EM@3AM – Asymptomatic Hypertension

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 42-year-old male, with a previous medical history of seasonal allergies (ranitidine), presents to the emergency department (ED) with a chief complaint of high blood pressure. The patient recently purchased a home blood pressure cuff and noted his readings as persistently elevated this afternoon (142/91 mmHg, 147/88 mmHg). Upon questioning, he denies headache, visual deficit, slurred speech, chest pain, shortness of breath, and decreased urine output.

The patient’s initial VS: BP 145/91, HR 63, T 99.7 Oral, RR 16, SpO2 98% on room air.

What’s the next step in your evaluation and treatment?

Answer: Asymptomatic Hypertension (HTN)^1-5

• Epidemiology: HTN is the most common cardiovascular disease in the U.S. (approximately 73 million individuals). Nearly 115 million annual ED visits are related to the treatment of HTN.^1,2
• Diagnosis, Evaluation, and Treatment:
  • According to the Eighth Joint National Committee (JNC): 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults³ and the ACEP Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients with Asymptomatic Hypertension in the Emergency Department:⁴
    • Diagnosis:
      • Two separate BP measurements in the ED are adequate for screening a patient with elevated BP readings.⁵
        • JNC recommends seated readings taken at least 5 minutes apart.
        • ED: evaluate confounders: pain and anxiety.
        • Requires readings > 140/90 mmHg in patients < age 60 and >150/90 in patients > age 60.³
    •  Evaluation:
      • Limited data on the utility of screening patients with asymptomatic hypertension:⁴
        • Perform a thorough H&P; look for signs and symptoms of end organ damage (vision changes, mild confusion, dyspnea on exertion, oliguria).
        • Consider laboratory studies (urinalysis, serum creatinine level, EKG) and imaging (CXR) => little data to validate the use of these evaluation modalities. If considering starting therapy, serum creatinine may be helpful (thiazides).
    •  Treatment:
      • JNC: “Elevated blood pressure alone, in the absence of symptoms and target organ damage, rarely requires emergency therapy…or hospitalization…but patients should receive oral antihypertensive therapy.”³
        • Currently there is no evidence to suggest that patients benefit from the rapid lowering of BP in the ED (several case studies identify poor outcomes: hypotension, MI, stroke, and death).⁴
      • JNC 8 Recommendations:³
        • BP Goals:
          • < 150/90 mmHg in patients > age 60.
          • < 140/90 mmHg in patients ages 18-59 without major co-morbidities, and in patients > age 60 with diabetes or chronic kidney disease (CKD).
        • Pharmacotherapy:
          • African American patients without CKD: calcium channel blockers (CCBs) and thiazides.
          • Patients with CKD: angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBS) first line.
          • Patients > 75 years of age with CKD: CCBs and thiazides – avoid ACEIs and ARBS due to the risk of hyperkalemia and further renal impairment.
          • All others: initiate a thiazide diuretic, CCB, ACEI or ARB.
•  Pearls:
  • 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.⁴

References:

1. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics–2009 update. A report from the American Heart Association Statistics Subcommittee. Circulation. 2009; 119:e21-e181.
2. Nawar E, Niska R, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data. 2007: 1-32.
3. James P, Oparil S, Carter B, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults. Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311(5):507-520.
4. Decker W, Godwin S, Hess E, Lenamond C, Jaboda A; American College of Emergency Physicians Clinical Policies Subcommittee on Asymptomatic Hypertension. Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department. Ann Emerg Med. 2006; 47(3): 237-249.
5. Marmon J, Green L, Levine D, et al. Using the emergency department as a screening site for high blood pressure. A method for improving hypertension detection and appropriate referral. Med Care. 1987; 25: 770-780.

For Additional Reading:

 Asymptomatic Hypertension:

Asymptomatic Hypertension