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Asymptomatic Hypertension

January 28, 2019
Sam Ashoo
Definition of hypertension:1
  • Normal: 120/80 or less
  • Pre-hypertension: 120-139/80-89
  • Stage 1: 140-149/90-99
  • Stage 2:  >160/>100
Is there evidence to suggest that immediate and rapid blood pressure reduction is beneficial in patients with hypertension and NO other symptoms ? JNC-71
  • “However, 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.”
  • “Unfortunately, the term “urgency” has led to overly aggressive management of many patients with severe, uncomplicated hypertension. Aggressive dosing with intravenous drugs or even oral agents, to rapidly lower BP is not without risk. Oral loading doses of antihypertensive agents can lead to cumulative effects causing hypotension, sometimes following discharge from the ER.”
In ED patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce rates of adverse outcomes? ACEP2
  1. In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required.
  2. In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission).”
In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes? ACEP2
  1. In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required.
  2. In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control. [Consensus recommendation]
  3. Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation]
If I choose to treat the patient’s hypertension, what should I use? JNC-71
  • Stage 1 – Thiazide Diuretic (hydrochlorothiazide 25-50mg, chlorthalidone 12.5-25mg)
  • Stage 2 – Thiazide + ACE-I (or ARB, BB, CCB)
  • Special Populations: See Table Below (Page 33, JNC-71)
 DiureticBBACE-ICCBAldosterone Antagonist
Heart FailureXXXX
Post MIXXX
High Coronary Disease RiskXXXX
DiabetesXXXX
Chronic Kidney DiseaseX
Recurrent Stroke PreventionXX
Why should my patient care about lowering blood pressure ? JNC-71
In clinical trials, antihypertensive therapy has been associated with reductions in
  1. stroke incidence, averaging 35–40 %
  2. myocardial infarction (MI), averaging 20–25 %
  3. HF, averaging >50 %
“It is estimated that in patients with stage 1 hypertension and additional cardiovascular risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated. In the added presence of CVD or target organ damage, only nine patients would require such BP reduction to prevent one death.”

 

References and further reading:
  1. 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):2560-72. PubMed , Full Text
  2. Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM. 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(1):59-68. PubMed , Full Text
  3. Gauer R. Severe Asymptomatic Hypertension: Evaluation and Treatment. Am Fam Physician. 2017;95(8):492-500. PubMed PubMed , Full Text
  4. Yang JY, Chiu S, Krouss M. Overtreatment of Asymptomatic Hypertension-Urgency Is Not an Emergency: A Teachable Moment. JAMA Intern Med. 2018; PubMed PubMed

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