Asymptomatic Hypertension

Asymptomatic hypertension is a frequent presenting complaint to the emergency department. Often, patients may be sent in by their primary care provider for work-up or evaluation. ACEP has developed a guideline in order to assist us with the management of this complaint, which can be varied depending on your training. A concise, practical summary of their recommendations for patient management is provided below.

Question 1: Should we screen for end-organ damage in patients who present with asymptomatic elevated blood pressure?

While there is no great evidence for this question, ACEP has two recommendations. In general, ACEP recommends that no screening is indicated for routine patients that present with asymptomatic hypertension. They state that physicians may screen for elevated creatinine in specific populations, such as patients that have poor or no follow-up. Based on three studies, there is a relatively high rate of incidental abnormal findings that may require addressing, and few true positives that altered management, although there were a few cases that did result in admission for renal insufficiency. They also recommend that screening for anything other creatinine does not appear useful, including obtaining an EKG.

Question 2: Should we intervene on patients with asymptomatic elevated blood pressure?

Again, no great evidence exists for this question, but ACEP has three Level C recommendations. They recommend no intervention based on the limited available data. There is evidence that the rapid lowering of blood pressure outside of a hypertensive emergency can worsen outcomes. A study done by Grassi et al (cited by the guidelines) found that of patients who presented with asymptomatic hypertension, 32% had a decrease in blood pressure within 30 minutes without intervention. This finding can lead to some questioning the utility of acting on our blood pressure readings in this patient population.

Consensus opinion recommends that for patients with poor follow-up, treatment can be started. They also recommend that all patients should be referred for outpatient follow-up. ACEP does suggest that for limited patient populations, such as those with no follow-up, treatment can be initiated, but they also report that many patients’ blood pressures will improve within 90 minutes without intervention, based on previous studies.

One should interpret their guidelines as evidence that we should only intervene in very limited circumstances in patients who present with asymptomatic blood pressure. If a patient has a primary care doctor, they can be referred to them for follow-up. In the case of extreme hypertension in a patient with no follow-up, we can consider screening for renal insufficiency and potentially even starting treatment, but the most important aspect is that we should ensure adequate follow-up for the patient.

Further Reading