Hypertension

How to read this summary

• Canadian sources come first, US sources second. Each point has a source tag like ^[S1] or ^[U1]. The full list of tags is at the end.
• "WARNING" marks a conflict or an old document. "Unconfirmed" means it could not be verified in the sources used. Never trust an unconfirmed item without checking.
• PEBC follows Canada. When Canada and the US differ, the Canadian answer is the exam answer.
• IMPORTANT: Canada has two guideline layers. The newest is the Hypertension Canada 2025 primary-care guideline ^[S1]. The older 2020 comprehensive guideline ^[S5] is still the only Canadian source for many special situations (diabetes, kidney disease, stroke, pregnancy, resistant hypertension work-up). Where they differ, this summary shows both and says so.
• Page numbers: S1 and S5 use the printed journal page numbers (S1 starts at E549, S5 at 596). Drug labels use the page of the monograph.

1. What is high blood pressure? (the garden hose)

• Blood pressure (BP) is the force of blood pushing on the walls of your blood vessels. It is written as two numbers, for example 120/80 mmHg. The top number is systolic (when the heart squeezes). The bottom number is diastolic (when the heart rests) ^{[S4 p2]}.
• Daily-life picture: think of a garden hose. If you open the tap too hard, the hose is under too much pressure. Over years the hose wall gets damaged. High BP does the same to blood vessels ^{[S4 p2 compares it to pumping too much air into a tire or balloon]}.
• Why it matters: high BP raises the risk of stroke, heart attack, eye problems, dementia, kidney disease, heart failure and erectile dysfunction ^{[S4 p2]}. Hypertension is the most common modifiable risk factor for heart and blood vessel disease and death, and about 1 in 4 adults in Canada has it ^{[S1 p.E549]}.
• Most people do not feel it, so many do not know they have it ^{[S4 p2]}.
• Most hypertension is managed in primary care. The 2025 guideline is written for family doctors, nurse practitioners, nurses and pharmacists ^{[S1 p.E549-E550]}.
• The 2025 guideline is not meant for children or for pregnancy ^{[S2 diagnosis; S1 p.E559 Figure 3 note]}.

2. Measuring BP and making the diagnosis

2.1 How to measure BP properly

• Use a validated automated (oscillometric) device and a standard method. Automated devices are easier, make fewer human mistakes and give more repeatable numbers than a manual cuff with a stethoscope ^{[S2 diagnosis; S1 p.E550]}.
• Manual (auscultatory) measurement is better when the patient has an ongoing or high load of irregular heartbeat (arrhythmia), or when the device has not been validated for the group (for example children, pregnant people) ^{[S2 diagnosis]}.
• "Validated" matters: in Canada about 90% of BP devices sold in pharmacies are validated, but only about 45% of devices sold by online retailers ^{[S2 diagnosis]}. Patients can check the Hypertension Canada website or ask a pharmacist ^{[S4 p5]}.
• A non-standard office reading is on average 5-10 mmHg higher than a standard one ^{[S2 diagnosis]}.
• The protocol used in recent trials and in the patient tool: 5 minutes of seated rest, then 3 readings 1 minute apart, averaged ^{[S2 diagnosis; S4 p5]}. The 2025 guideline Figure 1 says to rest 1-5 minutes if feasible, then take 3 readings 1 minute apart ^{[S1 p.E552]}.
• Patient technique (Hypertension Canada patient tool; 2025 Figure 1) ^{[S4 p5; S1 p.E552]}:
• Sit with the back supported, feet flat on the floor, legs uncrossed.
• Arm bare and supported, middle of the cuff at heart level, lower edge of the cuff 3 cm above the elbow crease.
• Use a cuff that fits the arm. Do not talk or move.
• Quiet room, 5-minute rest. No caffeine, tobacco or exercise in the 30 minutes before.
• At home: measure twice, twice a day, for several days, ideally in the week before the clinic visit (read from the patient tool; image text, partly unverified).
• Memory trick: "5-3-1" = 5 minutes rest, 3 readings, 1 minute apart. (Trick written by MapleRxPrep; the numbers come from ^{[S2 diagnosis]}.)
• Daily-life example: measuring BP right after climbing the stairs or after a coffee is like weighing yourself with your shoes and a heavy coat on. The number is wrong.

2.2 The 2025 Canadian definition and diagnosis (Canada, newest)

• Hypertension in adults is defined as BP of 130/80 mmHg or higher, measured with a validated device under good conditions ^{[S1 p.E550; S2 recommendations]}.
• Out-of-office BP is recommended to confirm the diagnosis, and to find white-coat and masked hypertension ^{[S2 recommendations]}.
• Ambulatory BP monitoring (ABPM) measures BP every 20-30 minutes, day and night ^{[S2 diagnosis]}.
• Home BP monitoring (HBPM): measure in duplicate, twice a day, for a week ^{[S2 diagnosis]}.
• White-coat hypertension = high in the office, normal outside. Found in 15-30% of people with a high office BP ^{[S2 diagnosis]}.
• Masked hypertension = normal in the office, high outside. Found in 10-15% ^{[S2 diagnosis]}.
• The 2025 algorithm (Figure 2) ^{[S1 p.E558]}: suspected hypertension (office, pharmacy or home) -> standard office BP -> if 130/80 or higher -> out-of-office check (daytime ABPM or HBPM) -> mean 130/80 or higher = hypertension; below that = white-coat hypertension (keep yearly or opportunistic checks). If the office BP is below 130/80 = no hypertension (yearly or opportunistic checks, and test out of office if masked hypertension is suspected).
• If out-of-office BP is not possible (cost, access, training), repeat the standard office BP at another visit to confirm ^{[S1 p.E551; S2 diagnosis]}.
• In adults with confirmed hypertension, do routine tests to check heart and blood vessel risk and signs of organ damage ^{[S2 diagnosis]}. The exact list is in the 2025 Appendix 1 (not downloaded; see unconfirmed). The 2020 guideline list is in section 3.
• The single threshold for office, ambulatory and home readings is 130/80 in the 2025 guideline ^{[S3 p1-2]}.
• Daily-life example: a person whose BP is 150/90 at the clinic only (nervous in the white coat) may be normal at home. Home checks prevent giving a pill that is not needed.

⚠️ WARNING: The older 2020 Canadian guideline ^{[S5 p600-602]} used different numbers: automated office BP 135/85 or more is high; office (manual) BP 140/90 or more is high; ABPM daytime 135/85 or 24-hour 130/80; home BP 135/85. A first-visit mean systolic of 180 or more, or diastolic of 110 or more, already means hypertension. Know both sets; the 2025 definition (130/80) is the newest Canadian one.

2.3 US categories (second)

• US 2025 AHA/ACC guideline keeps the 2017 groups: normal below 120/80; elevated 120-129 (and below 80); stage 1 130-139 or 80-89; stage 2 140 or higher, or 90 or higher ^[U1].
• US: home (HBPM) and ambulatory (ABPM) monitoring are recommended to confirm the diagnosis ^[U3].

3. Baseline tests after diagnosis

• 2020 Canadian list for all patients with hypertension ^{[S5 p604]}:
• urinalysis; blood sodium, potassium and creatinine; fasting glucose and/or A1c; cholesterol (total, LDL, HDL, non-HDL) and triglycerides (fasting or not); 12-lead ECG.
• People with diabetes: also check urine albumin.
• Routine echocardiogram for everyone is NOT recommended. Use an echo when left ventricular hypertrophy (LVH), left ventricular dysfunction or coronary disease is suspected, and use an objective EF check (echo or nuclear scan) if heart failure is present ^{[S5 p604]}.
• A pregnancy test should be considered before starting lifestyle changes or drugs in women who can become pregnant ^{[S5 p604]}.
• US 2025: urine albumin-to-creatinine ratio is now recommended for all patients with high BP (it was optional in 2017) ^[U1].
• Check for things that raise BP: some drugs and substances (see section 9.4) ^{[S5 p611 Table 11]}.

4. Who should be treated, and the BP target (Canada 2025)

4.1 Treatment thresholds

• Healthy lifestyle changes are recommended for all adults with hypertension ^{[S2 recommendations]}.
• Start drugs when BP is 140/90 or higher, OR when systolic BP is 130-139 and the person is at high cardiovascular risk ^{[S2 treatment]}.
• High-risk conditions (Box 1) ^{[S2 treatment; S1 p.E554]}: established cardiovascular disease (coronary artery disease, heart failure, stroke or similar, peripheral artery disease); diabetes (type 1 or 2); chronic kidney disease (eGFR below 60 mL/min/1.73 m2 or albuminuria 3 mg/mmol or more); 10-year Framingham risk score 20% or more; age 75 years or older.
• Systolic 130-139 and NOT high risk: use healthy lifestyle changes alone and recheck in 3-6 months; if still 130-139 and not high risk, recheck every 6-12 months ^{[S2 treatment]}.
• Drugs go together with lifestyle, never instead of it. Good lifestyle change may later allow lower doses or stopping a drug ^{[S2 treatment]}.
• Daily-life example: two neighbours both have 135/82. One has diabetes (high risk): start a pill and lifestyle. The other is healthy with no risk conditions: try diet, salt and exercise first and recheck in 3-6 months.

4.2 Treatment target

• Target systolic BP below 130 mmHg if the treatment is well tolerated ^{[S2 recommendations]}.
• No separate diastolic target: when systolic is below 130, the risk stays low even if the diastolic is 70-90 ^{[S2 treatment; S3 p2]}.
• Exceptions: goals of care, frailty, fall risk and orthostatic hypotension. In these people aim as low as reasonably achievable, case by case ^{[S2 treatment]}.
• Age alone is not a reason to set a higher target. Most older adults still benefit from BP control; judge by frailty, fall risk, symptomatic orthostatic hypotension, goals of care and other diseases ^{[S3 p2]}.
• Good measurements are about 5-10 mmHg lower than casual office readings, which is why the target is 130 and not 120 ^{[S2 treatment]}.
• Possible harms of tight control are uncommon (low blood pressure, fainting, falls, electrolyte problems, kidney injury) ^{[S2 treatment]}. Ask about dizziness, and check kidney function and electrolytes.
• People already well controlled on their current medicines do not need to be switched to the new algorithm ^{[S3 p3]}.

⚠️ WARNING: The 2020 Canadian guideline ^{[S5 p606-609]} had different thresholds and targets: low risk 160/100 to start, target below 140/90; high risk (clinical or subclinical cardiovascular disease, CKD, 10-year Framingham 15% or more, or age 75+; for intensive management age 50 or older, measured with automated office BP) start at SBP 130 or more with intensive target below 120; diabetes target below 130/80; most others below 140/90. The 2025 guideline replaces this with one simple target (SBP below 130). The 2020 text says patients can still be treated to below 120 if that suits them ^{[S3 p3]}.

4.3 US second

• US 2025: BP goal below 130/80 for all adults (and as close to 120/80 as possible for many); medicines are started at 130/80 or higher for people with cardiovascular disease, diabetes, CKD or 10-year risk 7.5% or more (PREVENT calculator); for lower risk, start a drug if 3-6 months of lifestyle does not bring BP below 130/80 ^{[U1; U3; U2]}.
• US stage 2 (140/90 or higher): start two drugs at once, preferably in a single pill ^[U1].

5. Lifestyle (non-drug) treatment

Healthy lifestyle is the base of treatment for everyone ^{[S2 treatment]}.

• Salt substitutes: the 2025 guideline cites a trial in people aged 60+ with hypertension and prior stroke where a potassium salt substitute lowered major cardiovascular events (13%) and deaths (12%); but potassium must be monitored with kidney disease or potassium-raising drugs, and the spironolactone label says avoid salt substitutes ^{[S2 treatment; S11 p5]}.
• Calcium and magnesium supplements are not recommended to prevent or treat hypertension ^{[S5 p606]}.
• Stress management can be considered when stress may be driving BP ^{[S5 p606]}.
• Aspirin for primary prevention (no heart disease yet) is no longer recommended in people with hypertension ^{[S5 p604-605]}.
• Statin: decide by global risk as in CCS Lipids 2021: statin for FRS 20% or more, or FRS 10-19.9% with LDL-C 3.5 mmol/L or more (or non-HDL-C 4.2 or more, apoB 1.05 or more, or men 50+/women 60+ with one more risk factor), and for statin-indicated conditions (ASCVD, diabetes with age 40+, CKD, AAA). The older Hypertension Canada 2020 rule was 3 or more risk factors after age 40 ^{[S5 p605; CCS Lipids 2021]}.
• Daily-life tip: a home-made soup is easy to salt; a can of soup, deli meat and chips already hold most of the day's sodium. Patient rule of thumb: pick foods labelled 5% daily value of sodium or less (patient tool; this figure could not be verified from the extracted text, unconfirmed) ^{[S4 p3]}.

US second: sodium under 2300 mg a day (1500 mg is the ideal); alcohol ideally none, and if used no more than 2 drinks a day for men and 1 for women; exercise 75-150 minutes a week of aerobic and/or resistance; lose at least 5% of weight if overweight; DASH-type diet ^[U1].

6. Drug treatment (Canada 2025 first)

6.1 The big picture

• The three first-line classes are: ACE inhibitors or ARBs, thiazide or thiazide-like diuretics, and long-acting dihydropyridine calcium channel blockers (CCBs). They lower BP and protect the heart about equally well ^{[S1 p.E555]}.
• Start low-dose COMBINATION treatment (two of the three classes), ideally in one pill (single-pill combination, SPC), for everyone who needs drugs ^{[S2 recommendations]}.
• About 70% of adults with hypertension need more than one class to reach target ^{[S1 p.E555]}.
• Why a single pill: better adherence than free-drug combinations (odds ratio about 1.21), BP control in about 65% versus 48% on single-drug treatment, and it cuts "therapeutic inertia" (doctors leaving people on one drug too long). Dizziness is a bit more common than with single-drug treatment ^{[S1 p.E555]}.
• Beta-blockers are NOT first-line unless there is a specific reason: heart failure, angina, after a heart attack, or heart rate or rhythm control. Reason: less stroke protection and more people stop them for side effects ^{[S1 p.E555; S3 p5]}.
• ACE inhibitor plus ARB together: never. More hyperkalemia, kidney injury, low BP and fainting with no added benefit ^{[S1 p.E556]}.
• ACEi and ARBs are teratogenic. Avoid or stop them in anyone who is pregnant or trying to become pregnant, and counsel all people who can become pregnant ^{[S1 p.E555]}.
• Memory trick: "A-C-D" = A: ACE inhibitor or ARB (Angiotensin-Converting Enzyme inhibitor / Angiotensin II Receptor Blocker); C: Calcium channel blocker (the long-acting dihydropyridine, name ends in "-pine"); D: thiazide-type Diuretic. Pick two of A, C, D to start.
• Another trick: ACEi names often end in "-pril" (ramipril) and ARBs in "-sartan" (irbesartan).
• Daily-life example: lowering BP with two small pills is like turning two taps down a little instead of closing one tap completely; each class works in a different way and the side effects stay small.

6.2 The 2025 step ladder (primary-care algorithm)

BP is checked every 1-3 months until at target, then every 6-12 months ^{[S1 p.E559 Figure 3]}.

• One tablet holding two drugs is preferred when it is available and covered. If not, give 2 separate pills; prefer a long-acting thiazide-like diuretic to a thiazide diuretic. If the patient is at high risk of symptomatic low BP, starting with one drug is reasonable ^{[S1 p.E559 footnote]}.
• Alternative single-pill combinations available in Canada ^{[S1 p.E560 Table 3]}:
• ARB + thiazide/thiazide-like: irbesartan-HCTZ, telmisartan-HCTZ, olmesartan-HCTZ, candesartan-HCTZ.
• ACEi + thiazide/thiazide-like: lisinopril-HCTZ, perindopril-indapamide.
• ARB + long-acting dihydropyridine CCB: telmisartan-amlodipine.
• Irbesartan/HCTZ was picked for the algorithm because of effect, tolerability, cost, coverage, supply and because the pill can be split in half (an uncoated pill without extended release can be cut) ^{[S3 p4]}.
• A one-pill triple combination (ACEi/ARB + thiazide + CCB) works but was not available in Canada when the guideline was written ^{[S2 treatment]}.
• Resistant hypertension: BP above target on an ACEi/ARB + thiazide/thiazide-like + CCB at the highest doses the patient can tolerate. Add spironolactone (conditional advice) ^{[S2 treatment]}.
• Spironolactone details ^{[S2 treatment]}:
• In the PATHWAY-2 trial (people with resistant hypertension) spironolactone lowered systolic BP more than placebo (by 8.7 mmHg), more than doxazosin (by 4.0 mmHg) and more than bisoprolol (by 4.5 mmHg).
• Check serum potassium 2-4 weeks after starting and after each dose change. Risk is higher with CKD and with other drugs that raise potassium (ACEi, ARB).
• Counsel males about breast enlargement (gynecomastia). In a heart failure trial (RALES, 25 mg) 10% of males on spironolactone developed it, versus 1% on placebo.
• Screen for primary aldosteronism with aldosterone and renin levels, ideally before spironolactone is started. Consider referral and a search for secondary causes.
• Referral for secondary hypertension is suggested when there is unexplained sudden worsening, low potassium, adrenal nodule, abdominal bruit, kidney injury after starting treatment, severe or malignant hypertension, hypertension at a young age, or resistant hypertension ^{[S1 p.E559 Figure 3 footnote]}.
• Memory trick for the ladder: "Half, Whole, Amlodipine, Spironolactone" (Step 1 half tablet, Step 2 whole tablet, Step 3 amlodipine, Step 4 spironolactone).

⚠️ WARNING: The 2020 Canadian guideline ^{[S5 p607-608]} allowed single-drug start OR a single-pill combination, and preferred longer-acting thiazide-like diuretics (chlorthalidone, indapamide) over HCTZ. The 2025 guideline says HCTZ and thiazide-like diuretics seem interchangeable for cardiovascular protection, with more low potassium on chlorthalidone (6.0% vs 4.4%) ^{[S1 p.E555; S3 p5]}. Even so, the 2025 algorithm footnote and Appendix 2 still prefer a long-acting thiazide-like diuretic when two separate pills are used ^{[S1 p.E559; S3 p5]}. Both versions say: do not combine ACEi with ARB.

6.3 Drug classes in short (labels first)

Each row uses Health Canada product monographs unless noted.

How they work (from the labels): - ACE inhibitor (ramipril): lowers angiotensin II, so blood vessels squeeze less and less aldosterone is made; this can raise potassium a little ^{[S7 p21]}. - ARB (irbesartan): blocks angiotensin II at its AT1 receptor ^{[S6 p25]}. - Dihydropyridine CCB (amlodipine): blocks calcium from entering blood vessel and heart muscle cells, so the vessel muscle relaxes ^{[S8 p17]}. - Thiazide (hydrochlorothiazide): a diuretic ("water pill"); the label says the exact way it lowers BP is unknown ^{[S9 p14]}. - MRA (spironolactone): blocks aldosterone, so more sodium and water leave the body and potassium is kept ^{[S11 p17]}.

• Daily-life example for an ACE inhibitor: a new cough that started 3 weeks after starting ramipril is not "a cold". Tell the prescriber; the ACEi may need to be changed to an ARB. (Dry cough is listed in the label ^{[S7 p5]}; switching to an ARB is the usual teaching, not directly stated in the label: unconfirmed.)

7. Special situations (mostly Canada 2020)

⚠️ WARNING: The 2025 guideline is for uncomplicated primary-care hypertension. Details for special groups below come from the 2020 guideline ^{[S5 p607-611]}, unless noted. Hypertension Canada says a full updated guideline is being released topic by topic, so newer topic updates may exist and were not checked.

• Secondary clues (renovascular disease) - 2 or more of: sudden onset or worsening at age over 55 or under 30; abdominal bruit; resistant to 3 or more drugs; creatinine rise of 30% or more on an ACEi or ARB; other atherosclerosis; repeated flash lung edema ^{[S5 p612]}.
• Resistant hypertension (2020 and 2025 agree on the idea): BP above target on 3 or more drugs at best doses, ideally including a diuretic. First rule out "apparent" resistance: bad technique, white-coat effect, poor adherence, substances that raise BP, and secondary causes ^{[S5 p611-612; S2 treatment]}. Sleep apnea should be assessed ^{[S5 p611 Table 10]}.
• Primary aldosteronism testing (2020) ^{[S5 p614]}: take blood in the morning after the patient has been up for at least 2 hours and seated 5-15 minutes; fix low potassium first; stop aldosterone antagonists and potassium-affecting diuretics 4-6 weeks before. US 2025: hold MRAs at least 4 weeks and screen all with resistant hypertension ^[U3].
• In 2020, other add-on drugs that lowered BP in resistant hypertension were eplerenone, amiloride, bisoprolol, doxazosin and clonidine, with spironolactone lowering BP the most ^{[S5 p611-612]}.
• Daily-life example: a patient says "my BP pills do not work". First ask: are you taking them, is the cuff correct, do you take ibuprofen or a decongestant?

8. Pregnancy and breastfeeding

• Canada (Hypertension Canada 2020, includes 2018 pregnancy advice) ^{[S5 p618-620]}:
• Ask women of childbearing age about pregnancy at regular visits; consider a pregnancy test before starting treatment. Preconception counselling is recommended for women with high BP before pregnancy; consider stopping ACEi and ARBs in women who are planning pregnancy.
• Treat when average BP is 140/90 or higher (chronic, gestational or preeclampsia). Target diastolic 85 mmHg.
• The 2020 text says the best time to stop an ACEi or ARB (before conception or in early pregnancy) has not been established, and advises caution; the Avalide label is stricter: patients planning pregnancy should be changed to an alternative with an established pregnancy safety record ^{[S5 p618-619; S6 p11]}.
• First-line oral drugs in pregnancy: labetalol, methyldopa, long-acting nifedipine, other oral beta-blockers (acebutolol, metoprolol, pindolol, propranolol). Second-line: clonidine, hydralazine, thiazide diuretics.
• ACE inhibitors and ARBs must NOT be used in pregnancy (fetal kidney toxicity).
• BP of 160/110 or higher in pregnancy or after delivery is an obstetrical emergency needing urgent treatment.
• Breastfeeding: labetalol, methyldopa, long-acting nifedipine, enalapril or captopril can be used.
• Health Canada labels: ACE inhibitor (ramipril) and ARB (Avalide) labels have a boxed warning about fetal injury and death and are contraindicated in pregnancy; stop when pregnancy is found ^{[S7 p5; S6 p5]}. Ramipril and Avalide labels also list nursing women as a contraindication ^{[S7 p4; S6 p4]}. Amlodipine: no clinical experience in pregnancy; use only if benefit outweighs risk; contraindicated in breast-feeding ^{[S8 p4, p8]}. Indapamide: contraindicated in pregnancy and lactation ^{[S10 p3]}.
• Daily-life example: a woman of 30 on lisinopril or ramipril who is trying to become pregnant should talk to her prescriber before conception, not after the test turns positive.
• US 2025: treat chronic hypertension in pregnancy at 140/90 or higher; counsel on low-dose aspirin 81 mg a day for preeclampsia prevention ^[U1]. Goal below 140/90; ACEi, ARB, MRA and atenolol are on the avoid list ^[U3].

9. Drug safety, interactions and counselling

9.1 Pharmacist checks at the counter

• Check the whole list for: ACEi + ARB (never), ACEi/ARB with potassium supplements or salt substitutes, spironolactone with ACEi/ARB, NSAIDs, lithium, and sacubitril/valsartan.
• Look at the patient: pregnancy (ACEi, ARB), history of angioedema, sulfa allergy (thiazides), gout, asthma (beta-blocker), skin cancer history (HCTZ), low BP, dehydration.
• Ask about home BP numbers, dizziness, cough, ankle swelling, vision changes and skin changes.

9.2 Interactions from the labels

• NSAIDs (including COX-2 inhibitors) weaken the BP-lowering effect of ARBs and diuretics, and with an ARB can worsen kidney function in elderly, volume-depleted (including those on diuretics) or kidney-impaired patients ^{[S6 p24]}. Daily-life example: a patient on irbesartan/HCTZ takes ibuprofen every day for knee pain and the BP creeps up; a pharmacist should notice.
• Lithium: thiazides and ARBs raise lithium levels. Thiazide with lithium is generally not recommended; if unavoidable, lower the lithium dose by 50% and check levels ^{[S6 p23; S9 p5]}.
• Digoxin: low potassium from thiazides raises digoxin toxicity risk ^{[S9 p5, p10]}.
• Aliskiren with an ACEi or ARB: contraindicated in diabetes or eGFR below 60 ^{[S6 p4; S7 p4]}.
• ACEi and sacubitril/valsartan: contraindicated together; keep 36 hours apart either way ^{[S7 p4]}.
• Amlodipine: avoid strong CYP3A4 inhibitors (ketoconazole, clarithromycin, ritonavir). In older people clarithromycin with amlodipine was linked to more kidney injury hospital stays than azithromycin ^{[S8 p7]}.
• Potassium: MRA or ACEi/ARB with potassium supplements, salt substitutes or other potassium-raising drugs can cause hyperkalemia ^{[S11 p5; S1 p.E555]}.

9.3 Side effects to counsel

• ACEi: dry cough; swelling of face, lips, tongue or throat is an emergency ^{[S7 p8]}.
• ARB/ACEi: dizziness when standing, especially after the first doses; do not drive if dizzy ^{[S7 p5]}.
• Thiazide: pass more urine; low potassium or sodium (weakness, cramps, thirst); gout flare; sun sensitivity; check skin for new or changing marks; wear sunscreen SPF 30 or higher, a hat and clothes; sudden eye pain or loss of vision needs urgent care ^{[S9 p4-7]}.
• Amlodipine: ankle swelling (dose-related), headache ^{[S8 p7, p9-10]}.
• Spironolactone: breast enlargement in men; high potassium; avoid salt substitutes ^{[S11 p5, p8]}.
• Beta-blocker: tired, slow pulse; never stop suddenly ^{[S12 p5]}.
• Missed dose (Avalide label): take the next dose at the usual time; never take two doses at once ^{[S6 p6]}.
• Adherence (2020) ^{[S5 p613]}: once-daily dosing, single pill, tailoring pill time to daily habits, packaging aids such as blister packs, phone follow-up especially in the first 3 months, and pharmacy refill checks. Review adherence and lifestyle before raising doses.

9.4 Things that can raise BP

• 2020 list ^{[S5 p611 Table 11]}: calcineurin inhibitors, licorice, erythropoietin, tyrosine kinase inhibitors, NSAIDs, cocaine, amphetamines, oral contraceptives, sympathomimetics and corticosteroids. Remove or reduce when possible.
• Daily-life example: cold remedies with a decongestant (a sympathomimetic) can push BP up. Ask before recommending them.

9.5 Home BP monitoring (2020 and 2025)

• HBPM should be considered for people not at target, with diabetes, CKD, suspected non-adherence, a white-coat effect or masked hypertension; patients need proper training ^{[S5 p604]}.
• Home BP is high at 130/80 or higher (2025 patient tool) ^{[S4 p4]}; the 2020 guideline used 135/85 for HBPM ^{[S5 p601]}.

10. Hypertensive urgency or emergency

• At the first visit a patient with features of urgency or emergency must be treated at once and counts as hypertensive ^{[S5 p601]}. The 2020 supplemental table with the list of features was not read; treat severe symptoms (chest pain, severe headache, confusion, weakness, vision problems) as an emergency and send for urgent care. (The symptom list is general teaching, unconfirmed in the sources used.)
• At a first-visit mean systolic of 180 or more, or diastolic of 110 or more, the 2020 guideline diagnoses hypertension (no wait for out-of-office checks) ^{[S5 p601]}.

11. Pharmacist role

• The 2025 guideline names pharmacists as target users and says team-based care is part of the approach (HEARTS framework: Healthy-lifestyle counselling, Evidence-based treatment protocols, Access to essential medicines and technology, Risk-based cardiovascular disease management, Team-based care, Systems for monitoring) ^{[S1 p.E549-E550]}.
• Tasks: check BP correctly, teach home BP, check devices, review the medicine list and interactions, screen for adherence problems, counsel on lifestyle, watch for side effects, help find reasons for a poor response, and refer when needed (secondary causes, resistant hypertension, pregnancy, severe BP).
• Pharmacist authority to prescribe, adjust or monitor BP varies by province: not checked in the sources used (unconfirmed).

12. Canada vs US and label vs guideline

12.1 Canada vs US (Canada wins on the exam)

12.2 Label vs guideline (both are shown; none of these points is used in the quiz)

• Exam tip: for dose and contraindication questions use the Health Canada label. For first-step treatment choices, use the Hypertension Canada guideline. The guideline numbers for spironolactone and HCTZ are lower than the older label doses.

13. Easy memory tricks in one place

• 5-3-1: 5 minutes rest, 3 readings, 1 minute apart.
• A-C-D: ACE inhibitor / ARB, Calcium channel blocker, thiazide-type Diuretic. Start with two.
• Names: "-pril" = ACE inhibitor, "-sartan" = ARB, "-pine" = dihydropyridine CCB (amlodipine).
• Ladder: Half, Whole, Amlodipine, Spironolactone.
• 130 is the line: 130/80 defines hypertension; aim for systolic under 130.
• Thiazide: low potassium, low sodium, gout, sun and skin cancer, sulfa allergy.
• Pregnancy: stop "-pril" and "-sartan".
• Spironolactone: potassium-sparing. Check potassium 2-4 weeks after starting.

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14. Ten original practice MCQs

Blueprint area for all: 1A Clinical Care. Likely exam angle is shown in each answer.

Q1. A pharmacist uses a validated device. After 5 minutes of seated rest, how many readings about 1 minute apart should be taken and averaged? - A. 1 - B. 2 - C. 3 - D. 6

Q2. Which pair of BP drugs should never be used together? - A. ACE inhibitor and thiazide diuretic - B. ACE inhibitor and ARB - C. ARB and dihydropyridine calcium channel blocker - D. ARB and thiazide diuretic

Q3. A healthy 45-year-old has repeated standardized readings of 136/84 mmHg and no risk condition (no diabetes, kidney disease, heart disease, age under 75, Framingham risk under 20%). What is the best 2025 Canadian advice? - A. Emphasize healthy lifestyle changes and recheck in 3-6 months - B. Start spironolactone today - C. Start two drugs at once - D. No follow-up is needed

Q4. A patient starts ramipril and weeks later has a dry, persistent cough with no signs of infection. What is the best action? - A. Double the ramipril dose - B. Start an antibiotic - C. Tell him to ignore it - D. Tell the prescriber; dry cough is a known ACE inhibitor effect

Q5. According to the 2025 Hypertension Canada guideline, when should potassium be checked after starting spironolactone for resistant hypertension? - A. After 1 year - B. Only if the patient feels weak - C. 2-4 weeks after starting and after each dose change - D. Never, because spironolactone lowers potassium

Q6. Which advice fits a patient starting hydrochlorothiazide? - A. Use indoor tanning beds, since they are safer than the sun - B. Limit sun exposure, use sunscreen SPF 30 or higher and check the skin for new marks - C. Take a daily potassium supplement - D. No special advice is needed

Q7. A woman taking irbesartan/hydrochlorothiazide plans a pregnancy. What is the best advice? - A. Keep taking it until a positive pregnancy test - B. Take half the usual tablet - C. Switch to an ACE inhibitor - D. Talk to the prescriber now; ARBs are contraindicated in pregnancy

Q8. Which side effect of amlodipine is the most common and depends on the dose? - A. Ankle swelling (peripheral edema) - B. Dry cough - C. Breast enlargement - D. High potassium

Q9. A patient on bisoprolol wants to stop it suddenly because he feels well. What is the best advice? - A. He may stop it at any time - B. He may stop it for a few days - C. Do not stop suddenly; call the prescriber, because stopping fast can worsen angina or cause arrhythmia - D. Beta-blockers have no withdrawal problems

Q10. A cardiologist switches ramipril to sacubitril/valsartan. How long after the last ramipril dose should the first sacubitril/valsartan dose wait? - A. At least 36 hours - B. 12 hours - C. 6 hours - D. No wait is needed

15. Answers and explanations

1. C. The standard protocol is 5 minutes of seated rest, then 3 readings 1 minute apart, averaged ^{[S2 diagnosis]}. Likely exam angle: BP technique.
2. B. ACE inhibitor plus ARB: more hyperkalemia, kidney injury and low BP without extra benefit ^{[S1 p.E556; S5 p608]}.
3. A. SBP 130-139 and not high risk: lifestyle alone and recheck in 3-6 months ^{[S2 treatment]}.
4. D. Dry cough is a labelled ACE inhibitor effect and usually settles after a dose cut or stopping ^{[S7 p5]}.
5. C. Potassium is checked 2-4 weeks after starting spironolactone and after each dose change ^{[S2 treatment]}.
6. B. Thiazide photosensitivity and skin cancer risk ^{[S9 p4, p7]}.
7. D. ARBs carry a boxed warning for fetal injury and are contraindicated in pregnancy ^{[S6 p5, p11; S5 p620]}.
8. A. Peripheral edema is the most common and dose-dependent effect ^{[S8 p7]}.
9. C. Abrupt stopping of a beta-blocker can cause worse angina, heart attack or arrhythmia ^{[S12 p5]}.
10. A. At least 36 hours between an ACE inhibitor and sacubitril/valsartan ^{[S7 p4]}.

16. Sources (accessed 2026-10-24; Canada first, then US)

Canada

• S1. Goupil R, Tsuyuki RT, Santesso N, et al. Hypertension Canada guideline for the diagnosis and treatment of hypertension in adults in primary care. CMAJ 2025;197(20):E549-E564 (May 26, 2025). doi:10.1503/cmaj.241770. Library file: canada/guidelines/hypertension/Hypertension-Canada-2025-Primary-Care-Guideline-CMAJ-2025.pdf.
• S2. Hypertension Canada 2025 primary-care guideline web pages (Recommendations, Diagnosis, Treatment), retrieved 2026-10-24. https://hypertension.ca/guidelines/recommendations , https://hypertension.ca/guidelines/diagnosis , https://hypertension.ca/guidelines/treatment .
• S3. Appendix 2: responses to frequent questions, 2025 guideline (CMAJ 2025). Library file: Hypertension-Canada-2025-Guideline-Appendix2-CMAJ-2025.pdf.
• S4. Appendix 4: Understanding and measuring your blood pressure (patient tool), Hypertension Canada 2025. Library file: Hypertension-Canada-2025-Guideline-Appendix4-CMAJ-2025.pdf.
• S5. Rabi DM, McBrien KA, Sapir-Pichhadze R, et al. Hypertension Canada's 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children. Can J Cardiol 2020;36(5):596-624. https://guidelines.hypertension.ca/wp-content/uploads/2022/09//Hypertension-Canada-2020-Comprehensive-Guidelines-for-Prevention-Diagnosis-Risk-Assessment-and-Treatment-of-Hypertension-in-Adults-and-Children.pdf . Older guideline, partly replaced by S1.
• S6. Avalide (irbesartan/hydrochlorothiazide) Product Monograph, sanofi-aventis Canada, date of authorization 2025-07-25. https://pdf.hres.ca/dpd_pm/00081257.PDF
• S7. Teva-Ramipril Product Monograph, revision 2020-10-20. https://pdf.hres.ca/dpd_pm/00058445.PDF (older label; no newer ramipril label checked).
• S8. Norvasc (amlodipine) Product Monograph, Upjohn Canada ULC, revision 2023-02-23. https://pdf.hres.ca/dpd_pm/00069708.PDF
• S9. Hydrochlorothiazide Product Monograph, Sanis Health, 2026-03-18. https://pdf.hres.ca/dpd_pm/00083924.PDF
• S10. Lozide (indapamide) Product Monograph, Servier Canada, revision 2020-06-11. https://pdf.hres.ca/dpd_pm/00056817.PDF
• S11. Aldactone (spironolactone) Product Monograph, Pfizer Canada, 2025-11-07. https://pdf.hres.ca/dpd_pm/00082356.PDF
• S12. Apo-Bisoprolol Product Monograph, 2026-04-08. https://pdf.hres.ca/dpd_pm/ (library copy: Apo-Bisoprolol_PM_2026-04-08.pdf).

United States (secondary summaries; the primary guideline could not be opened)

• U1. American College of Cardiology press release, "New High Blood Pressure Guideline Emphasizes Prevention, Early Treatment to Reduce CVD Risk", Aug 14, 2025 (summary of the 2025 AHA/ACC multi-society guideline). https://www.acc.org/about-acc/press-releases/2025/08/13/20/03/new-high-blood-pressure-guideline-emphasizes-prevention-early-treatment-to-reduce-cvd-risk
• U2. ACC, "New in Clinical Guidance: High Blood Pressure Focus of New ACC/AHA Guideline", Oct 1, 2025. https://www.acc.org/latest-in-cardiology/articles/2025/10/01/01/new-in-clinical-guidance-hbp
• U3. Brown, Clark, Jones. Updates in the 2025 AHA/ACC Hypertension Guideline. Curr Hypertens Rep 2026;28(1):19 (review of the guideline, not the guideline itself). https://pmc.ncbi.nlm.nih.gov/articles/PMC12995957/
• Primary US guideline (could not be opened, access blocked): 2025 AHA/ACC/multi-society Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. https://www.ahajournals.org/doi/10.1161/HYP.0000000000000249

PEBC reference: PEBC Pharmacist Qualifying Examination Blueprint Ver. 03-2026 (area names only): https://pebc.ca/wp-content/uploads/pdfs/Qual%20EN/Pharmacist_Qualifying_Exam_Blueprint.pdf

17. Unconfirmed / check yourself

• The primary 2025 AHA/ACC guideline could not be opened (access blocked). US points come from an ACC press release, an ACC summary and a 2026 review. Use them as secondary.
• 2025 Hypertension Canada Appendix 1 (the table of routine tests and the source-guideline tables) and Appendix 5 were not downloaded; the baseline test list in section 3 is from the 2020 guideline. Figure 1 (BP technique, S1 p.E552) was only partly checked; the Appendix 4 patient tool is mostly images, so the 5% daily value sodium tip and the home-BP schedule are unconfirmed.
• Hypertension Canada says topic-by-topic updates of the comprehensive guideline will follow the 2025 primary-care guideline. Newer topic pages were not searched.
• The 2020 list of features of hypertensive urgency/emergency (Supplemental Table S2) was not read.
• Whether a 300/25 mg irbesartan/HCTZ tablet is currently sold in Canada is unconfirmed (label strength table shows 150/12.5 and 300/12.5).
• Label dose for chlorthalidone and indapamide were not fully read; the indapamide label gives a maximum of 2.5 mg a day. Ramipril label is from 2020 (older).
• Switching from an ACE inhibitor to an ARB after cough is common teaching, not a statement in the ramipril label.
• Lab monitoring schedule after starting an ACEi or ARB (when to check potassium and creatinine) was not found in the labels read, except the 30% creatinine-rise clue in 2020 and the spironolactone 2-4 week advice in 2025.
• Pharmacist scope of practice for BP in each province, and the symptom list for hypertensive emergency, were not checked in the sources.
• Diabetes Canada 2018 chapter on hypertension (in the library) and the CCS/Canadian Stroke guidance were not used.
• US points not on U1 (PREVENT 7.5% threshold, MRA hold of 4 weeks, goal below 130/80, as close to 120/80 as possible, drugs to avoid in pregnancy, one drug first for stage 1) rest on U2/U3 only (secondary). A single-pill triple combination was "not yet available" when the 2025 guideline was written; today's status is unconfirmed. Advice such as "rise slowly", "call the prescriber promptly" and the hypertensive-emergency symptom list is general teaching.
• Doses are for exam study only, not for real patients. Not affiliated with or endorsed by PEBC.

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