Elevated Asymptomatic Hypertension: To Treat or Not to Treat?

21 Jul
July 21, 2014
Image obtained from idealbite.com

Image obtained from idealbite.com

As emergency physicians, we are constantly on the look out for elevated blood pressures and the potential devastating consequences. We are concerned about intracranial bleeds and acute pulmonary edema from heart failure. But what about the patient that comes in with high blood pressures, yet has no symptoms? Do we need to treat the number or the patient? In this post we will tackle this clinical dilemma of elevated asymptomatic hypertension: To treat or not to treat?

Clinical Scenario

A 47-year-old African American male presents to the ED complaining of a laceration to his finger he sustained while cooking. His tetanus is up to date, the bleeding is controlled, and you successfully repair the uncomplicated laceration. Prior to discharge, you review the patient’s vital signs and find a blood pressure of 190/115. The patient has no complaints. What needs to be done about this elevated blood pressure?

Epidemiology and Definitions

In 2008, it was estimated that approximately 30% of adults in the United States were affected with high blood pressure. Less than 50% of these patients reportedly were on appropriate pharmacological treatment. Keeping these statistics in mind, one can see how likely it will be that patients with poorly controlled blood pressure will be seen in the emergency department.

In July 2013, the American College of Emergency Physicians published a clinical policy, addressing patients presenting to the emergency department with asymptomatic elevated blood pressures. ACEP used the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) for the definition of hypertension (keep in mind JNC 8 was recently released in JAMA 2014). The policy considered markedly elevated blood pressure to be consistent with Stage 2 hypertension (SBP ≥ 160 mmHg, DBP ≥ 100 mmHg).

Image obtained from axialexchange.com

Image obtained from axialexchange.com

Clinical Policy (23842053)

The ACEP clinical policy addressed two separate questions. The first asked if screening for target organ injury reduces the rates of adverse outcomes. The second question asked if medical therapy in the ED reduced rates of adverse outcomes. The writing group “carefully” reviewed and critically analyzed the available medical literature. Level A recommendations are principles based on high degrees of clinical certainty. Level B recommendations identify particular strategies reflecting a moderate degree of clinical certainty. Level C recommendations are made based on panel consensus.

Screening for Target Organ Injury

With a Level C recommendation, ACEP states that routine screening for acute target organ injury (serum creatinine, urinalysis, ECG) is not required. JNC 7 recommends obtaining an ECG (for ischemia/LVH), chest x-ray (for pulmonary edema/cardiomegaly), serum creatinine (for renal dysfunction) and urinalysis (for proteinuria) in patients with hypertension. It must be remembered, however, that JNC 7, and subsequent editions, are geared for the primary care physician. Patients presenting to the ED are not addressed.

Medical Therapy in the ED

With another Level C recommendation, ACEP states that routine ED medical intervention for elevated blood pressure is not required. Select patients (i.e., poor follow up) may be treated and/or have therapy initiated for long-term control of their blood pressure. Whether or not treatment is started, all of these patients should be referred for outpatient follow up. “Longitudinal data continue to suggest that controlling blood pressure over time reduces the incidence of target organ damage, morbidity, and mortality.” (p. 63) It is also generally accepted that rapid lowering of blood pressure in asymptomatic patients has the potential to do harm.

Image obtained from sos03.com

Image obtained from sos03.com

Case Resolution

The patient reports he has been told in the past he has had high blood pressure by his doctor, but has not seen by his primary care provider (PCP) in over one year. You discuss with the patient the need for the patient to follow up with his doctor for repeat blood pressure measurement and give appropriate discharge instructions regarding both wound care and elevated blood pressure. The patient returns ten days later for suture removal and reports he has seen his doctor and was started on medication for his hypertension.

Clinical Bottom Line

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.

For the JNC 8 Update Summary Checkout:

Academic Life in Emergency Medicine (ALiEM): Blood Pressure Management in Adults (JNC8 and ACEP Clinical Policy)

Bibliography

The following two tabs change content below.

Matt Astin

Clinical Assistant Professor of Emergency Medicine/Internal Medicine at Medical Center of Central Georgia
REBEL EM Associate Editor and Author
Tags: , , , ,
10 replies
  1. Stucki, MD says:

    Thanks for the post. I’m a PGY3 right now. I had a pt the other day sent for HTN-asymptomatic. BP was 228/93. Is there and SBP level or DBP level that you would consider treating acutely? Even for just a goal of 10-20% reduction? I feel nervous when SBP is over 200 or DBP is over 120. Thanks!

    Reply
    • Matt Astin says:

      Thank you for the comment. Remember, this is just a guideline. Use your clinical gestalt. Personally, I look to see if the patient has a history of HTN and has been non-compliant. If truly asymptomatic, I don’t worry until the SBP gets above 220 or DBP above 120. Then, I try to give what they should be taking at home. On the other side, I had a patient today sent from home by an insurance nurse for elevated blood pressure. No known PMH and completely asymptomatic. Blood pressure was 203/91. He had no doctor. Therefore, I checked EKG, BMP, and UA. All of these were normal. I discharged him home on HCTZ with a list of primary care doctors. I personally feel comfortable with this due to my IM training, but “regular” EM should feel just as comfortable with a truly asymptomatic patient.

      Reply
    • Salim Rezaie says:

      Hello Stucki,
      In my practice….I don’t care what the number is. If the patient has no symptoms, I don’t treat acutely….Treat the patient NOT the numbers. If the pressure is that high, it has probably been that high for some time, so any acute dropping in blood pressure could cause stroke, or even syncope with other injuries. I will write for two PO prescriptions and discharge the patient home with them…..yes even with pressures >200 SBP and >100 DBP.

      Salim

      Reply
      • Pik says:

        This right here. In real life there is NO # at which no sx suddenly becomes an emergency. Screen for illness, tx pain, give usual meds po, send home.
        However for your case above: in real life if I let your PMD see you and decide what to put you on, what will they do when you roll in with the same # and no sx? Send you right back to me without a moments thought. So I’d get comfortable with Rx for BP meds.

        Reply
  2. Matt Lozano says:

    I had a pt involved in an assault with a negative work up. The highest his systolic got was 183 with his diastolic 117 the highest as well. He had a negative PMH and negative family history for HTN. We gave 20mg of Labetalol IV. His Systolic was in the low 160’s and diastolic had come down to around 100. What is the overall percentage to decrease overall BP?

    Reply
    • Matt Astin says:

      The generally accepted percentage decrease should be no more than 20-25%, in either the SBP or the DBP. The “overall” percentage has been discussed that much. In the patient you describe, those numbers would be sufficient. With no previous diagnosis and, presumable, no symptoms. He would need to follow up with his primary care physician for repeat blood pressure measurement, away from the stress of the assault, for definitive diagnosis and treatment.

      Reply
  3. John says:

    I will generally start people on anti-hypertensives at discharge and give a dose in the ED. I like norvasc 10mg because of its safety profile. With Lisinopril I feel I need to check a BMP before but not so with Norvasc.

    Reply
  4. Penny Wilson says:

    Great summary, thanks Matt!

    Can I also provide a perspective of the primary care doc who has to follow-up?

    Let’s remember that BP is only one component of long term risk. If a patient as elevated BP but normal lipids, non-smoker, no family history and is not diabetic, they may well be at low overall risk of cardiovascular events and therefore not need antihypertensives at all.

    Isolated hypertension is only considered to be a significant risk factor when it’s chronically >180/110 (ie more than one occasion – impossible to diagnose in a one off emergency presentation).

    The GP / primary care doctor is not going to thank you if you start their otherwise low risk patient on a long term medication who may just need lifestyle management, or careful follow-up. Trying to convince the patients that they need to stop taking the medication that the “smart hospital doctor” can be quite a challenge!

    Reply
    • Matt Astin says:

      So true. Thank you for this perspective. This all goes back to treating the patient, not the number. Another example of the “art” of medicine.

      Reply
  5. Matt Astin says:

    I agree, but it must also be pointed out that PCP’s need to take responsibility for their own patients. Fear mongering because you don’t know what to do is not an excuse.

    Reply

Leave a Reply

Want to join the discussion?
Feel free to contribute!

Leave a Reply

Your email address will not be published. Required fields are marked *

Time limit is exhausted. Please reload CAPTCHA.