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Severely Elevated Blood Pressure in the ED

In the ACEP clinical policy, the term “asymptomatic severely elevated blood pressure” replaces the term “hypertensive urgency.” Although ACEP’s definition of asymptomatic markedly elevated blood pressure suggests that a patient must be “asymptomatic,” this is not the case. ACEP’s clinical policy, along with other guidelines, state only that the patient should have no symptoms of end organ dysfunction, not that the patient must be entirely asymptomatic.

If the history and physical are not concerning for end organ dysfunction, acute testing and treatment in the ED is not routinely necessary. Should the patient lack outpatient follow up, one may elect to start an oral antihypertensive…

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Featured

  Slow Medicine: Is 'Hypertensive Urgency' Outdated?

First, hypertensive urgency is common and rates of major adverse cardiovascular events within a 6-month period are low. We should not over-react to this common diagnosis, despite the somewhat alarming terminology. Perhaps it is time for another change in nomenclature, e.g., simply: "stage II hypertension."

 Elevated Asymptomatic Hypertension: To Treat or Not to Treat?

Patients with markedly elevated blood pressure (SBP ≥ 160 mmHg, DBP ≥ 100 mmHg) require neither screening diagnostic studies nor acute treatment in the emergency department, as long as they are asymptomatic. Initiation of therapy may be considered in special patient populations, such as those with poor follow up.

 Hypertensive emergency

#1 most common mistake = overdiagnosis of hypertensive emergency among patients with scary high Bp but no target organ damage. This isn't a hypertensive emergency...

 Non-emergent Hypertension

Regardless of whether you call it hypertensive urgency, non-emergent or asymptomatic hypertension, severe, uncomplicated BP or markedly elevated BP, all of the guidelines have the same general recommendations: do NOT acutely lower these patients’ blood pressure unless you have another reason to do so, and especially avoid the use of short term IV antihypertensives.

Articles of Interest

Episode 40: Asymptomatic Hypertension

The literature is thin in this area, and there are many controversies... The Canadian Emergency Medicine Cardiac Research and Education Group (EMREG) guidelines advise ED physicians to consider beginning antihypertensive therapy for patients with BP of >180/110, and to initiate treatment if BP > 200/130 (11). These recommendations are based on limited evidence. Furthermore, there are no guidelines for the exact target BP that needs to be achieved before discharge.

Acute Treatment of Hypertensive Urgency

Although patients with hypertensive urgency are often treated with medications to acutely lower their blood pressure, there is no evidence to support this practice, and a strong pathophysiologic basis suggests that harm may result.

An Evidence-Based Approach To Managing Asymptomatic Elevated Blood Pressure In The Emergency Department

In patients without end-organ hypertension symptoms or signs, discharge from the ED with follow-up for elevated blood pressure is appropriate. It is not advisable to treat these patients in the ED with parenteral or oral therapy to which they are naïve, simply to improve their vital signs while in the department. Drugs such as clonidine are not considered first-line therapy for hypertensive urgency. In patients who may have chronically elevated blood pressure, they can cause a significant drop in blood pressure, leading to a decrease in cerebral blood flow, with consequent syncope or even stroke

Asymptomatic Hypertension

Depending on patient-specific factors and ease of accessibility to follow-up, it may be reasonable to initiate oral anti-hypertensives in the emergency department. Initial therapy recommendations for non-Black individuals are a thiazide diuretic, an ACE-inhibitor or a calcium channel blocker. Initial therapy recommendations for Black individuals are a thiazide diuretic and/or calcium channel blocker. Patients with chronic kidney disease should have an ACE-inhibitor or angiotensin receptor blocker started, regardless of race or diabetic status.

Asymptomatic Hypertension (Deep Dive R23)

Make SURE the patient isn’t having symptoms of end organ dysfunction, which could make this hypertensive emergency (confusion, severe headache, blurry vision, weakness, chest pain, shortness of breath, seizures during pregnancy, etc). ACEP clinical policy states, that in the patient with true asymptomatic hypertension who presents to the emergency department, no routine testing or treatments are indicated.

Blood Pressure Management in Adults

Hypertension is one of the most common conditions seen in primary care clinics and emergency departments (EDs). Frequently, patients are found to have asymptomatic hypertension and referred to EDs for management, despite the fact that rapidly lowering blood pressure is not necessary and may be harmful. Yet many clinics still refer these patients for emergent management.

EM@3AM – Asymptomatic Hypertension

Currently, there is no evidence that delineates the appropriate ED management of asymptomatic hypertension: role of the ED physician => identify the patient with an elevated blood pressure, initiate oral antihypertensive therapy as appropriate, and refer for prompt follow-up.

Evaluation and Treatment of Asymptomatic Hypertension

Special consideration should be given to patients with poor access to follow-up, and brief screening for renal failure and initiation of long-term antihypertensive therapy may be considered in such cases. Acute lowering of blood pressure should be avoided, however, and primary care follow-up for long-term blood pressure management should be the primary goal in the vast majority of cases.

How should asymptomatic hypertension be managed in the hospital?

Management of asymptomatic hypertension in the hospital begins with addressing contributing factors, reviewing held home medications – and rarely – urgent oral pharmacotherapy.

Hypertensive Emergencies - Dr. Godfrey

Asx HTN <220/120 without complaints... When to treat asx HTN? If BP >165/105 + Cr >2, start two agents. or >220/>120 without any dysfunction, two agents. If 140-165: Controversial, but at the very least, tell the pt and Fast-track them. *Social intervention*.

Hypertensive emergency

#1 most common mistake = overdiagnosis of hypertensive emergency among patients with scary high Bp but no target organ damage. This isn't a hypertensive emergency...

Hypertensive Emergency and Urgency

Oral medication to bring down BP over 24-48 hours. Start with uptitrating home regimen (or giving missed dose).

Management Of Asymptomatic Hypertension

Aside from Hypertensive Emergency, Lowering BP in the ED/UR is not Required or Indicated...

Management of Hypertensive Urgency and Emergency

Allow period of rest (30min) and recheck blood pressure. – This will fix up to a third of patients. (Grassi, et. al., Park, et.al.) • If bp remains elevated, consider augmenting or beginning home anti-hypertensive regimen. • Typically felt that outpatient follow-up within 1 week is sufficient.

POTD: Asymptomatic Hypertension in the ED

**So when do you treat the number acutely? Treat the clinical picture, not the elevated BP reading**

Resources

EM Basic

The patient’s blood pressure is 190/80 but they feel fine…how do we treat these patients in the ED? Labs? EKG? BP meds? Admission???…but they are here for an ankle sprain! Asymptomatic hypertension is a challenging complaint to deal with in the ED because of so many conflicting opinions and worries but it doesn’t have to be difficult.

ACEP

In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required.