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ED MANAGEMENT OF ASYMPTOMATIC HYPERTENSION

Nathaniel Shekem PA-CDepartment of Emergency Medicine

University of Iowa

DISCLOSURES

• None

OBJECTIVES• Discuss clinical importance of elevated BP in the ED

• Discuss definitions of hypertensive presentations

• Discuss an appropriate ED workup for asymptomatic hypertension

• Discuss potential harms of acute blood pressure lowering

• Discuss appropriate disposition for hypertensive ED patients

• Patient: “_______” told me to come to the emergency department because my blood pressure is too high and it needs to be lowered.

• Clinician: How do you feel?

• Patient: I feel fine. But ______ told me I’m going to have a stroke/brain bleed/heart attack/go on dialysis/die if I don’t lower it now.

• Chief Complaint

• Sent from pre-op anesthesia clinic due to high blood pressure. Patient was told not to take blood pressure medications due to surgery today. Patient has no complaints.

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IN A NUTSHELL…

• Don’t just do something, stand there!

HYPERTENSION

• Silent killer

• 30-50% of the US population has hypertension

• ED incidence of hypertension is 44%

• 27% in primary care setting

IS HYPERTENSIVE URGENCY A REAL THING?

• Blood pressure >180/120

• Implications of the term “urgency”

• 2013 ACEP Guidelines

• “Asymptomatic markedly elevated blood pressure”

Elevated Blood Pressure in the ED

End Organ Damage No End Organ Damage

Hypertensive Emergency Asymptomatic Markedly Elevated Blood Pressure

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WHAT INDICATES END ORGAN DYSFUNCTION?

• Strong indication for acutely lowering blood pressure

• PO or IV

EVIDENCE FOR ACUTE BP LOWERING

• “There is no RCT evidence demonstrating that antihypertensive drugs reduce mortality or morbidity in patients with hypertensive emergencies”

2013 ACEP GUIDELINES

• Level C

• Should I routinely perform tests to assess for end organ damage?

• NO

• Maybe serum creatinine

2013 ACEP GUIDELINES • Level C

• Should I routinely treat asymptomatic hypertension in the ED setting?

• NO

• Maybe start an oral antihypertensive

• Definitely arrange follow up

UTILITY OF “SCREENING” TESTS

• >58,000 patient met criteria for “hypertensive urgency”

• “Abnormal” test found in 5-7%

• Likely chronic rather than acute

POSSIBLE HARMS

• Acute BP lowering

• Autoregulation

• Poor perfusion to critical organs

• Risk of ischemia or infarction

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PRO TIP

• 30 minutes in a quiet calm room

• Blood pressure improved to mean of 160/89 mm Hg in 30% of patients

RISK AFTER DISCHARGE• 58,000 outpatients

• BP >180/100 mm Hg

• Asymptomatic

• Rates of major events

• Hospitalized vs outpatient

• <1% in both groups at 7 days, 30 days, and 6 months

RISK AFTER DISCHARGE• >200,000 ED visits in Ontario

• Primary diagnosis “hypertension”

• 8% hospitalized

• <1% rate of major events at 30 days

• Mortality

• 90 days <1%

• 1 year 2.5%

• 2 years 4.1%

SHOULD I START MY PATIENT ON A BP MEDICATION?

• Treatment options

• Thiazides and CCBs for all

• ACEi/ARB less effective in black population

• Restart prior medications

• How quickly?

• Goal <160/100

• Decrease MAP 20-25% over several days

HOW WE CAN MAKE A DIFFERENCE

• Recognize elevated blood pressure readings

• Patient education

• Ensure appropriate follow up

• Consider starting an antihypertensive