Approach
• Must differentiate chronic elevations in BP from an acute elevation
• Must differentiate transient elevations (ie, from anxiety or pain) from other causes
• Search for life-threatening causes of elevations in BP, including e/o end-organ damage (see HTN emergency)
Definition (JAMA 2003;289:2560)
• HTN: SBP ≥140 or DBP ≥90
• HTN urgency: SBP ≥180 or DBP ≥110 w/ no acute organ damage; This term is also referred to as “hypertensive crisis” and has largely fallen out of favor
• HTN emergency: Elevated BP w/ acute organ damage (cardiac, CNS, renal)
History
• H/o CAD, CHF, TIA, stroke, peripheral a. dz, renal insufficiency, meds (sympathomimetics, cocaine, amphetamines), med noncompliance
Evaluation
• Check BP in both arms, check cuff/cuff size
• In ED pts w/ asymptomatic markedly elevated BP, routine screening for acute target organ injury (ie, serum Cr, US, ECG) is not required
• In select pt populations (ie, those w/ poor f/u), screening for an elevated Cr level may identify kidney injury that affects disposition
Treatment
• Goal BP <140/90 mmHg; if DM or renal dz goal is <130/80 mmHg
• Tx HTN results in 50% ↓ CHF, 40% ↓ stroke, 20–25% ↓ MI (Lancet 2000;356:1955)
• In pts w/ asymptomatic markedly elevated BP (ie, ≥180/≥110), routine ED medical intervention is not required
• In selected pt populations (ie, those w/ poor f/u), EPs may treat markedly elevated BP in the ED &/or initiate therapy for long-term control
• For initiation of long-term therapy, it may be reasonable to start a thiazide-type diuretic for most pts, but may consider ACEI, ARB, BB, CCB, or combination (Hypertension 2003:42:1206)
• In this situation, consider HCTZ 12.5–50 mg QD or Chlorthalidone 12.5–25 mg QD. Chlorthalidone may be superior to HCTZ (MRFIT, Circulation 1990;82(5):1616; SHEP, JAMA 1991;265;265(24):3255; ALLHAT, JAMA2002;288(23):2981)
Disposition
• Asymptomatic pts may be d/c home w/ PCP f/u
Pearls
• HTN in the ED is often a/w anxiety/pain. Always re√ BP once pt is calm & pain free
• Tx of pts w/ asymptomatic HTN in the ED is not necessary if outpt f/u is available
• In neonates, suspect renovascular dz, coarctation of the aorta, or kidney malformation
Hypertensive Emergency
Approach
• Look for e/o acute end-organ damage
• Neurologic: Encephalopathy, hemorrhagic or ischemic stroke, papilledema
• Cardiac: ACS, CHF, aortic dissection
• Renal: ARF
• Other: Preeclampsia–eclampsia
History
• Look for precipitants: Progression of essential HTN, medication noncompliance, rebound HTN (clonidine), worsening renal dz, pheochromocytoma, Cushing drug use (cocaine, amphetamines, MAOIs + tyramine), cerebral injury
• CP, dyspnea, HA, blurry vision, confusion, oliguria, hematuria
Findings
• Assess MS, e/o papilledema, visual acuity
Evaluation
• BUN/Cr, lytes, CBC, UA, ECG (e/o LVH), CXR, cardiac enzymes (if ischemia suspected), head CT (if ICH suspected)
Treatment
• ↓ MAP by 25% w/i 1–2 h using IV meds, then f/u w/ PO version
• Avoid tx HTN during acute stroke unless pt is getting lysed, has extreme HTN (>220/110), aortic dissection, active ischemia, or CHF (Stroke 2003;34:1056)
• Treat by underlying cause as noted above
Disposition
• True hypertensive emergencies require ICU admission for BP monitoring
Guideline: Wolf SJ, Lo B, Shi RD, et al. Clinical policy: Critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013;62:59–68.