Cardiovascular Disease

Hypertension

The relationship between blood pressure (BP) and risk of CVD events (heart attacks, strokes, heart failure, etc.) is continuous, consistent, and independent of other risk factors.³ Therefore, BP must be monitored on an annual basis following the procedures outlined by the American Heart Association^4,5 (see Appendix A).

Self (home) and ambulatory BP measurements are useful for monitoring CVD.⁶ However, given the LEO’s possible conflicting interests, clinic or office readings must be used to determine duty status. In addition, LEOs on anti-hypertensive medications must be evaluated and questioned about any possible job-impairing side effects, such as electrolyte disturbances or orthostatic hypotension (see LEO chapter on Medications). The association between increasing BP and cardiovascular events rises with the presence of additional CVD risk factors and end-organ damage due to hypertension.^5,7-17 Therefore, all LEOs with hypertension should be screened for: a) other CVD risk factors (diabetes mellitus, smoking, hyperlipidemia, obesity, and lack of exercise); and b) hypertensive renal, cardiovascular or eye damage (see Appendix B).

The following discussion addresses work restrictions and frequency of monitoring for three stages of hypertension. It is important to note that the criteria used are from the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-6),³ rather than the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7),⁷ or the Eighth Joint National Committee (JNC-8) because criteria relevant for job restrictions is found under Stage 3 in JNC-6.³

Stage I (Mild): Systolic 140-159 millimeters of mercury (mmHg) or diastolic 90-99 mmHg.

• No restrictions.
• Screen for other CVD risk factors (age, sex, total cholesterol, high-density cholesterol, systolic BP, use of anti-hypertensive therapy, diabetes, and current smoking). For the LEO ≥40 years of age, use this information to estimate a 2-year or 10-year risk for atherosclerotic cardiovascular disease (ASCVD) defined as coronary death, fatal stroke, nonfatal myocardial infarction, or nonfatal stroke. LEOs assessed at intermediate or high risk (>2% ASCVD risk over the next 2 years or ≥10% ASCVD risk over the next 10 years) should be restricted until a symptom-limiting exercise stress test (EST) to 12 metabolic equivalents (METs) can be performed (see section on Coronary Artery Disease).^18,19
• Screen for end-organ damage – if end-organ damage is present (see Appendix B), an EST to 12 METs should be performed (see section on Coronary Artery Disease).^8-17
• Referral to treating physician for evaluation and treatment.
• Recheck BP and 2-year or 10-year risk for ASCVD ¹⁹
• Screen for end-organ damage annually if hypertension persists.⁹

Stage II (Moderate): Systolic 160-179 mmHg or diastolic 100-109 mmHg

• No restrictions.
• Screen for other CVD risk factors (age, sex, total cholesterol, high-density cholesterol, systolic BP, use of anti-hypertensive therapy, diabetes, and current smoking). For the LEO ≥40 years of age, use this information to estimate a 2-year or 10-year risk for atherosclerotic cardiovascular disease (ASCVD) defined as coronary death, fatal stroke, nonfatal myocardial infarction, or nonfatal stroke. LEOs assessed at intermediate or high risk (>2% ASCVD risk over the next 2 years or ≥10% ASCVD risk over the next 10 years) should be restricted until a symptom-limiting EST to 12 METs can be performed (see section on coronary artery disease).^18,19
• Screen for end-organ damage – if end-organ damage is present (see Appendix B), an EST test to 12 METs should be performed (see section on coronary artery disease).^8-17,19
• Referral to treating physician for evaluation and treatment.
• Recheck BP in 1 month:
  • If BP is <140/90 mmHg, then no restriction and recheck BP every 3 months for 1 year.
  • If BP is reduced to Stage I, then no restriction and, recheck BP in 1 month (see section on Stage I for further evaluation). If BP remains in Stage II, provide restrictions until blood pressure is reduced to Stage I or below.

Stage III (Severe): Systolic ≥180 mmHg or diastolic ≥110 mmHg

• Provide restrictions.
• Screen for other CVD risk factors (age, sex, total cholesterol, high-density cholesterol, systolic BP, use of anti-hypertensive therapy, diabetes, and current smoking). For LEOs ≥40 years of age, use this information to estimate a 2- and 10-year risk for atherosclerotic cardiovascular disease (ASCVD) defined as coronary death, fatal stroke, nonfatal myocardial infarction, or nonfatal stroke. LEOs assessed at intermediate or high risk (>2% ASCVD risk over the next 2 years or ≥10% ASCVD risk over the next 10 years) should be restricted until a symptom-limiting EST to 12 METs can be performed (see section on coronary artery disease).^18,19

• Screen for end-organ damage – if end-organ damage is present (see Appendix B), an EST to 12 METs should be performed (see section on coronary artery disease).^8-17,19
  • Refer to treating physician for evaluation and treatment.
  • On recheck:
    • If BP is <140/90 mmHg, then no restrictions and recheck BP every 3 months.
  • If BP is in Stage I, then no restrictions, and recheck BP in 1 month (see section on Stage I for further evaluation).
    • If BP is in Stage II or III, provide restrictions until blood pressure is reduced to Stage I or ^a,5,20-23

Appendix A: AHA-ACC Blood Pressure (BP) Measurement

BP measurements in the office or clinic setting as adapted from Pickering et al.,⁴ and Black et al.⁵

• Caffeine, exercise, and smoking should be avoided for at least 30 minutes prior to measurement.
• The patient should be seated comfortably for 5 minutes with the back supported and the upper arm bared without constrictive clothing. The legs should not be crossed.
• The arm should be supported at heart level and the bladder of the cuff should encircle at least 80% of the arm circumference.
• The mercury column should be deflated at 2 to 3 mm/s, and the first and last audible sounds should be taken as systolic and diastolic pressure. At least two measurements should be measured 1 minute apart with the averaged recorded. If there is >5 mm Hg difference between the first and second readings, additional (1 or 2) readings should be obtained and then the average of these multiple readings is used.
• Neither the patient nor the observer should talk during the measurement.

Appendix B: Screening Test for End-Organ Damage Due to Hypertension

Kidneys^9,10

• Spot serum creatinine to estimate the glomerular filtration rate using the 2009 CKD-EPI or MDRD calculation method (see http://touchcalc.com/e_gfr).

AND

• Spot urine albumin to creatinine ratio.

Chronic kidney disease (one type of end organ damage) is diagnosed if, over a period of 3 months, the LEO has either of the following^9,10:

• an estimated glomerular filtration rate <60 mL/min/1.73m²;

OR

• a urine albumin to creatinine ratio of >30 mg/g.

Chronic kidney disease is associated with increased rates of both fatal and non-fatal cardiovascular events.^9-16 This CVD risk is a graded association; the more severe the kidney disease, the higher the CVD risk.¹⁶ For patients with mild to moderate chronic kidney disease (an estimated glomerular filtration rate between 45-60 mL/min/1.73m²), the CVD risk is 20% higher than those with an estimated glomerular filtration rate >60 mL/min/1.73m².¹⁶ The TG considers the CVD risk of an LEO with chronic kidney disease, even those with mild to moderate chronic kidney disease, to warrant a symptom-limiting exercise stress test (see EST section).

Cardiovascular

1. Symptoms (e.g., dyspnea, fatigue) or signs (e.g., fluid retention, reduce left ventricular ejection fraction) of heart failure.
2. Tests for left ventricular hypertrophy (LVH). While an electrocardiogram (ECG) can detect LVH, echocardiography or cardiac magnetic resonance imaging (MRI) are more sensitive tools.⁵
3. Symptoms consistent with transient ischemic attacks (TIAs).
4. Heart failure, LVH, or TIAs are all complications (end organ damage) of chronic hypertension. All three are associated with an increased risk of fatal and non-fatal cardiovascular events. LEO with any of these cardiovascular complications of hypertension warrant a symptom-limiting exercise stress test (see EST section).

Ophthalmologic

Dilated eye examinations for retinopathy

For the purposes of this document, Grade 3 or higher retinopathy (using the Modified Scheie Classification of Hypertensive Retinopathy – see http://eyewiki.aao.org/Hypertensive_retinopathy) is considered positive for end-organ damage and is associated with increased cardiovascular risk.^8,17