Is a patient with poorly controlled hypertension and elevated cholesterol fit for employment?

Work Fitness Assessment for Poorly Controlled Hypertension

This patient can be cleared for work with the condition that blood pressure control is optimized immediately and monitored closely, as poorly controlled hypertension poses significant cardiovascular risk that must be addressed before starting physically demanding employment. 1

Immediate Assessment of Work Fitness

Conditional clearance is appropriate with mandatory requirements for:

• Immediate optimization of antihypertensive therapy before December 1st start date 1
• Documented BP control to target <130/80 mmHg within 2-4 weeks 1
• Follow-up BP monitoring during initial employment period 1

The current BP of 142/87 mmHg represents Stage 2 hypertension (confirmed by previous reading of 156/96), which requires prompt pharmacological intervention rather than delayed clearance. 1

Critical Medication Non-Adherence Issue

The primary problem is medication non-compliance, not treatment resistance:

• Patient has 2 unopened packs of Losartan 100mg, indicating poor adherence 1
• This represents pseudo-resistant hypertension due to non-adherence rather than true treatment resistance 1
• Up to 25% of patients don't fill initial prescriptions, and adherence is a major barrier to BP control 1

Immediate interventions required:

• Direct counseling about cardiovascular risks of uncontrolled hypertension in the workplace 1
• Simplify regimen: once-daily dosing improves adherence 1
• Consider combination pills rather than separate medications 1
• Address barriers to medication taking (cost, side effects, understanding) 1

Optimization of Antihypertensive Therapy

Current regimen is inadequate due to non-adherence and likely insufficient for this patient's risk profile:

The patient requires intensified therapy given:

• CVD risk of 7% (moderate-high risk) 1
• Elevated cholesterol (total 5.1, LDL 3.4) 2, 3
• History of hypertension since June 2025 with poor control 1

Recommended treatment approach:

• Restart Losartan 100mg daily with witnessed first dose and adherence plan 4
• Add a thiazide-like diuretic (e.g., chlorthalidone 12.5-25mg daily) - diuretic therapy is consistently underutilized in resistant/poorly controlled hypertension 1
• Consider adding a calcium channel blocker if BP remains >140/90 after 2 weeks 1
• Target BP <130/80 mmHg given his cardiovascular risk profile 1

Management of Concurrent Hyperlipidemia

The elevated cholesterol significantly compounds cardiovascular risk and must be addressed simultaneously:

• Approximately 63.2% of adults with hypertension have concurrent hypercholesterolemia 2
• Combined hypertension and hyperlipidemia creates synergistic cardiovascular risk greater than either alone 2, 3, 5
• LDL 3.4 mmol/L is above target for his risk category 1

Lipid management recommendations:

• Initiate statin therapy (e.g., atorvastatin 20-40mg daily) targeting LDL <2.6 mmol/L (100 mg/dL) 1
• Losartan (ARB) does not adversely affect lipid profile, making it appropriate for this patient 6, 7
• Avoid beta-blockers and high-dose diuretics as initial therapy due to potential adverse lipid effects 6, 7

Workplace-Specific Considerations

Airport maintenance work presents specific concerns:

• Physical demands may acutely elevate BP 1
• Poorly controlled hypertension increases perioperative and acute cardiovascular event risk 1
• Electric shock accident history (September 2025) suggests potential for high-stress situations 1

Monitoring requirements for clearance:

• Home BP monitoring or repeat clinic measurements within 1-2 weeks 1
• Confirm BP <140/90 mmHg minimum before starting work 1
• Ideally achieve <130/80 mmHg target given his risk profile 1
• Recheck at 1 month after starting work to ensure maintained control 1

Cardiovascular Risk Stratification

This patient is at increased cardiovascular risk requiring aggressive management:

• 7% CVD risk score 1
• Multiple risk factors: hypertension, hyperlipidemia, former smoker, irregular exercise 3
• Poorly controlled hypertension "imparts a major level of cardiovascular risk" 1
• Combined presence of hypertension and hypercholesterolemia "increases considerably the risk for cardiovascular complications" 7

Lifestyle Modifications (Non-Negotiable)

Essential components for BP and lipid control:

• Sodium restriction to approximately 2g/day 1
• Weight reduction if overweight/obese 3
• Regular physical activity (minimum 30 minutes, 5 days/week) 3
• Maintain alcohol cessation (stopped 3 months ago) 1
• Complete smoking cessation (currently smokes when drinking) 1, 3

Common Pitfalls to Avoid

Do not delay work clearance indefinitely - this creates unnecessary employment barriers when conditional clearance with close monitoring is appropriate 1

Do not attribute poor control to "resistant hypertension" when the patient has unopened medication bottles - this is pseudo-resistance from non-adherence 1

Do not ignore the lipid disorder - treating only BP while ignoring elevated cholesterol leaves substantial residual cardiovascular risk unaddressed 2, 5, 8

Do not use beta-blockers as first-line therapy in this patient with hyperlipidemia, as they may worsen lipid profile 6, 7

Documentation for Employer

Provide written clearance stating:

• Patient is fit for work contingent upon documented BP control
• Current BP management plan is in place with close follow-up
• Recheck scheduled within 2-4 weeks
• Patient understands importance of medication adherence for workplace safety
• No restrictions on duties once BP controlled to target 1