Severe Hypertension: Does This Patient Need to Go to the … · Severe Hypertension: Does This Patient Need to Go to the ER? ... •Severely increased BP •High-risk for rapidly

Severe Hypertension: Does This Patient Need to Go to the ER?

Joseph P. Martinez, MD, FACEP, FAAEM

Associate Professor of Emergency Medicine and Medicine

Assistant Dean for Student Affairs

University of Maryland School of Medicine

Baltimore, Maryland

Scary numbers

Scary numbers

Scary numbers

Cases

• Case 1

• 68 yo presents to office with BP 220/140

• Complains of “ripping” pain between shoulder blades

• Options

• No medications, have patient start BP log

• Start medication and see in one week

• Have family take patient to ER

• Have EMS take patient to ER

Aortic Dissection

Cases

• Case 2


• Complains of acute onset severe headache

• Altered mental status, not moving one side

• Options





Hypertensive ICH

Cases

• Case 3


• Complains of dyspnea, PND, orthopnea

• Saturations 78% in office, tachypneic, pink sputum

• Options

• No medications, have start BP log




Acute Pulmonary Edema

Some Decisions in Medicine are Easy!

• Case 4


• No complaints

• Options





Cases

• Case 5


• No complaints

• Recently started TID ibuprofen for arthritis pain

• Options





Cases

• Case 6


• Complains of mild frontal headache; “I get it

when my pressure is up”

• Options





Cases

Objectives

• Discuss terminology of hypertension

• Discuss whether nonspecific symptoms still count

as “asymptomatic”

• Describe an effective office approach to

asymptomatic HTN

• Deliberate about the pros and cons of rapidly

lowering BP

Demographics

• 35 million office visits yearly

• Affects 25% of population

• 50 million in the US

• 1 billion worldwide

• 30% don’t know they have it

• Control rates fall short in 50%

From JNC VII

“The risk of CVD, beginning at 115/75 mm Hg,

doubles with each increment of 20/10 mm Hg”

JNC 8

Hypertension

• Accurate (appropriate cuff, repeated measurements)

• Regression to the mean

• Reactive (pain, anxiety, withdrawal, drugs)

How Quickly to Treat?

From JNC VII

• “Elevated blood pressure alone, in the absence of

symptoms or new or progressive target organ

damage, rarely requires emergency therapy”

From JNC VII

• “Elevated blood pressure without target organ

damage does not require hospitalization but should

receive immediate combination oral therapy”

• (No references)

Terminology

Classic Terminology

Hypertensive Urgency?

• Is it really urgent?

• Framing phenomenon

• Education• Patients

• Nurses

New Terminology

Hypertensive Urgency

• Severely increased BP

• High-risk for rapidly progressive end-organ

damage

• CHF

• CAD

• Renal disease

• TIA/CVA

Hypertensive Urgency

• Increased level of scrutiny

What is Asymptomatic?

• 26% of patients with elevated BP will have a

complaint of a “hypertension” symptom

• Nearly 68% will have them if prompted

• No correlation between symptoms and level

of blood pressure elevation

• History

• Physical

• Labs

• Follow-up

How to approach these patients

• History



• History

• Previous diagnosis

• Previous medications

• Compliance

• Perturbers

• Symptoms

Perturbers

• Illness

• Pain

• Anxiety

• Ingestions• Illicits

• Sympathomimetics

• MAO-I

• NSAIDs

• History

• Physical

• Labs

• Follow-up


• Physical


• Physical

• Mental status

• Cardiopulmonary examination

• Neurological examination

• FUNDUS


Fundus

Fundus

Fundus

Fundus


• History

• Physical

• Labs

• Follow-up


• Labs

Labs

• JNC VII

• EKG, UA, Glucose, Hematocrit, Potassium,

Creatinine, Calcium, Fasting Lipid Profile

• CXR and EKG not helpful

• 116 patients

• 2/116 had interventions based on tests

• None influenced BP management

Labs

• Renal function is important to know

• 167 asymptomatic patients

• 7.2% had abnormal BMP requiring admission

• Urinalysis instead of blood work

• All patients with significantly elevated creatinine had

hematuria or proteinuria

• Specificity improved with 1+ proteinuria

Labs

Treatment

• VA Cooperative Trial

•NO adverse events in the first three months

among patients with DBP 115-129 irrespective of

whether they received treatment or placebo

• Zeller 1989: DBPs 116-139; randomized to:

• Clonidine load to decrease BP

• Hourly placebo x 4

• Immediate discharge

• All received prescription on discharge

• No difference in outcomes or BP control at 3

months

Treatment

• VALUE trial

• Valsartan vs. amlodipine

• Increased cardiovascular events in 6 months when BP

not controlled

• Difference in events diminished as control became

similar

• BP control is important in relatively short time

• Months NOT days

Treatment

• What’s the downside to treating aggressively?

Treatment

• No studies have definitively shown benefit to

acutely lowering blood pressure in asymptomatic

patients

• Multiple studies demonstrate HARM

JAMA. 1996;276:1328-1331

Treatment

• Follow-up is the key!

• This is where PCPs have the advantage

• If known HTN, restart/adjust meds

• If newly diagnosed, recheck in 24-48 hours

• Can initiate treatment if very high

• Look for perturbers!

Treatment

Send to ED?

• Hypertensive emergencies

• YES!

• Severe asymptomatic hypertension

• Almost never

• Hypertensive urgency (new definition)

• Probably not, but on occasion

What usually happens in ED

• Waiting and waiting and waiting

• History and physical

• Labs

• Observation

• Likely discharge home with large bill

What might happen in ED

• Waiting and waiting and waiting


• Labs

• Admit to hospital

• Started on meds and discharged with larger

bill

• Waiting and waiting and

waiting


• Labs

• Someone panics over the

numbers and gives IV

Hydralazine

What could happen in ED

Summary

• Severe hypertension is common

• Try to get away from the term “hypertensive urgency”

• Blood pressure needs treatment!• Weeks to months NOT hours to days

• Numbers are scary• Educate patients, nurses, other providers

• Stop practicing “eminence-based medicine”

Documents

Severe Hypertension: Does This Patient Need to Go to the … · Severe Hypertension: Does This Patient Need to Go to the ER? ... •Severely increased BP •High-risk for rapidly