Non-emergent Hypertension

“Doctor, this patient’s blood pressure is 184/101, do you want to do anything about it?”

1 of every 3 adults in the United States has high blood pressure.¹ Because of this, hypertension is something we see constantly in the ED, from incidentally noted hypertension in patients presenting with other complaints to patients coming to the ED because of their blood pressure reading at home or in an outpatient clinic. But what happens when a patient’s blood pressure is “too high”?

In 2003, the JNC 7 guidelines divided hypertensive crises into two categories: hypertensive emergency and hypertensive urgency.

Hypertensive emergency was defined as “severe elevations in BP (>180/120 mmHg) complicated by evidence of impending or progressive target-organ dysfunction”², including:

• Neuro:  encephalopathy, intracranial hemorrhage and CVA
• CV: acute pulmonary edema, acute heart failure and acute MI
• Renal: Acute renal failure
• Vasculature: aortic dissection and eclampsia

This category was easy to define, not because of the blood pressure numbers but rather because of the clinical picture. These hypertensive emergencies look like true emergencies, regardless of the patient’s blood pressure and are all disease processes an emergency medicine physician should be able to recognize as emergencies. With some exceptions (including aortic dissection, intracranial hemorrhage and eclampsia), the treatment of blood pressure in these hypertensive emergencies is the same:

First, reduce mean arterial pressure by no more than 25% within the first hour

Then, if stable, reduction to 160/100-110 within next 2-6 hours

Then, if this BP is well tolerated and the patient is clinically stable, further gradual reduction towards a normal BP can be implemented in the next 24-48 hours  

I will not go into specific antihypertensives recommended and treatment goals for each of these disease processes, but you can find good reviews here:

https://www.acepnow.com/article/hypertensive-emergencies/?singlepage=1

https://www.accp.com/docs/bookstore/ccsap/ccsap2018b1_sample.pdf

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Clinical practice has varied far more significantly for the category labeled “hypertensive urgencies”, truly better referred to as asymptomatic hypertension or severe, uncomplicated hypertension. What is most important about this category is not necessarily the blood pressure number itself, but rather the lack of target-organ dysfunction. This does not mean that the patients are completely asymptomatic – they may be complaining of a mild headache, anxiety or epistaxis – but they are not experiencing any of the true emergencies that would place them into the “hypertensive emergency” category.

Even in 2003, the JNC 7 noted that “there is no evidence to suggest that failure to aggressively lower BP in the ER is associated with any increased short-term risk to the patient who presents with severe hypertension”². Instead, they note that most of these patients are noncompliant with their home antihypertensive regimen. They suggested that we review and reinstate these patients’ home antihypertensive if necessary, adjust their home antihypertensive regimen as needed and most importantly, help these patients arrange appropriate and timely outpatient follow-up.

But the word “urgency” tends to scare providers and has, unfortunately, led to overly aggressive and inappropriate treatment of many patients with severe, uncomplicated hypertension with rapid-acting oral or even intravenous antihypertensives. This is not without harm as acutely lowering blood pressure by too much or too quickly can lead to relative hypotension causing ischemic strokes, TIAs and MIs. In fact, many studies have shown that we actually do more harm than good by treating these blood pressures acutely^3,4. This has been recognized as such a problem that JNC 8, the latest JNC guidelines, doesn’t even mention hypertensive urgencies. Similarly, the 2017 American College of Cardiology/American Heart Association guidelines state “…there is no indication for referral to the emergency department, immediate reduction in BP in the emergency department, or hospitalization for [patients with hypertensive urgency].”⁵

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. What CAN you do to lower these patients’ blood pressure and provide them greater risk reduction in the long term?

• Use appropriate equipment and positioning of patients when checking BP in the ED
• Treat underlying causes of acute hypertension (pain, nausea, anxiety, toxidromes)
• Let patients rest in a quiet, dark room for 30 minutes prior to rechecking BP
• Review home antihypertensive medications and compliance
• Educate patients on importance of adherence to home medications
• Adjust or re-institute home antihypertensives as necessary
• Finally, and most importantly, do your best to help these patients get timely outpatient primary care physician follow up

References:

1. Go A. S., Mozaffarian D., Roger V. L., et al. Heart disease and stroke statistics-2013 update. Circulation. 2013;127(1):e6–e245.
2. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA. 2003;289(19):2560–2571.
3. Fischberg GM, Lozano E, Rajamani K, et al. Stroke precipitated by moderate blood pressure reduction. J Emerg Med. 2000;19:339–46.
4. Brooks TW, Finch CK, Lobo BL, et al. Blood pressure management in acute hypertensive emergency. Am J Health Syst Pharm. 2007;64(24):2579–2582
5. Breu AC, Axon RN. Acute Treatment of Hypertensive Urgency. J Hosp Med. 2018;12:860-862.
6. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018; 138:e484–e594.