Clinical Scenario: 58 yo F with no significant PMH presents to the ED for high blood pressure. She reports having a BP of 190/110 at the pharmacy and came right to the ED. She denies HA, vision changes, chest pain, dyspnea, and oliguria. She last saw her PMD for her annual checkup many months ago, noted her BP was mildly elevated at that time, no medications were started then, and she is not currently taking any medications other than her vitamins.
Question: What is your workup for her? Should you go beyond an H&P? Do you start her on medications?
As per ACEP Clinical Policy from 2013, the term asymptomatic markedly elevated blood pressure includes the frequently used terms of asymptomatic hypertension and hypertensive urgency, which described markedly elevated high blood pressure without clinical evidence of acute end organ injury.
Under their 2013 policy, Level C recommendation is that: asymptomatic markedly elevated blood pressure in ED patients do not require routine screening for acute target organ injury (such as serum Cr, UA, EKG). Though in select patients, like those with poor follow-up, a screening for elevated Cr may identify kidney injury that changes disposition like admission.
Another Level C recommendation is that routine ED medical intervention is not required in these asymptomatic markedly elevated blood pressure patients. Consensus recommendation is that in select patients, like those with poor follow up, the ED physician may treat the BP in the ED and/or start long term therapy for BP control. Consensus recommendation is that patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up.
**So when do you treat the number acutely? Treat the clinical picture, not the elevated BP reading**
Want to read more?
https://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=429&inittopicdload=1
http://www.emdocs.net/em3am-asymptomatic-hypertension/
http://epmonthly.com/article/dont-let-hypertension-stress/
https://www.mdedge.com/emed-journal/article/114826/hematology/hypertension-ed
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. https://www.ncbi.nlm.nih.gov/pubmed/23842053