This is a presentation addressing the management of asymptomatic elevated blood pressures in the emergency room setting.

1. SEVERE ELEVATED HIGH
BLOOD PRESSURE AND
“NOTHING ELSE”
CLINICALLY, DOTHEY
NEED ADMISSION ?
Dr. Peter Andre Soltau
PGY 4.5 DM Emergency Medicine
UWI MONA

3. Case 1
■ 55 year old male patient presents to the triage department, after he presented
to the ophthalmology clinic for cataract surgery to the left eye. He was found to
have an elevated blood pressure and was therefore referred to A&E for further
management with a diagnosis of hypertensive urgency vs emergency.The
patient is a known hypertensive diabetic maintained on Nifedipine 30mg bd,
Enalapril 20mg bd and Metformin 500mg tid. He reports no SOB, leg swelling or
chest pain. He does however admit to waking from 5am to come to the hospital
for St.Thomas and did not take his medications
■ HisVitals at triage :T 95.7 P102 RR18b/min BP 190/115 U/A –prot+ , leu+, blood+
■ What is his triage designation?
■ How would you manage this patient?

5. Case 2
■ 78 year old female patient presents to the triage department for management of her
high blood pressure. She presented to the local health clinic two weeks prior for her
routine follow up and was told her blood pressure was very high 180/110. She notes
she had been having headaches at that time and was told by the doctor it was due to
her blood pressure. She was given a referral to the hospital, however she decided to
use home remedy “garlic” and watch the pressure.
■ Today she went to a health fair held at her church and the blood pressure was noted to
be 210/160. She decided to present because her headache is persistent and the BP just
wont go down.The patient is a known hypertensive maintained on Amlodipine 10mg
od and Enalapril 20mg bd. She reports forgetting where she puts her medications at
times but claims good compliance. She reports dizziness but no SOB, leg swelling,
chest pain or limb weakness.
■ Vitals at triage :T 96.2 P82 RR24b/min BP 240/150 U/A - NAD
■ How would you manage this patient?

7. What is Severe Elevated High Blood
Pressure ?
■ Severely elevated blood pressure is commonly
defined as a systolic blood pressure greater than or
equal to 180 mm Hg or diastolic blood pressure
greater than or equal to 110 mm Hg *
■ JNC 7 classified Stage 2 hypertension as systolic
blood pressure greater than or equal to 160 mm Hg
or diastolic blood pressure greater than or equal to
100 mm Hg
* Severely increased blood pressure in the emergency department.
Shayne PH, Pitts SR. Ann Emerg Med 2003 Apr;41(4):513-29.

8. What is a Hypertensive Emergency ?
■ 1) Is there acute end-organ dysfunction and/or damage?
■ 2) Is the dysfunction attributable to the elevated blood
pressure (or will the elevated BP likely to make the
dysfunction worse)?
■ 3) Is altering the BP necessary to improve the organ dysfunction?

9. Types Of Hypertensive Emergencies
■ Microvascular disorders:
characterized by small vessel dysregulation, with endothelial
damage and local inflammation (e.g. encephalopathy, pre-
eclampsia/eclampsia)
■ “Macro” vascular disorders:
(i.e. CHF, aortic dissection, stroke, subarachnoid hemorrhage)

10. Does triage BP correlate with outpatient
HTN?
■ For patients who present at triage with a high BP, an
elevated second measurement 60 to 80 minutes later
correlates highly with actual outpatient hypertension,
and does not correlate with the patient’s anxiety and/or
pain
Moderate-to-severe blood pressure elevation at ED entry: hypertension or normotension?
DieterleT, Schuurmans MM, StrobelW, Battegay EJ, Martina B Am J Emerg Med. 2005 Jul;23(4):474-9.

11. How CanWe Evaluate?
■ Clinical examination
(chest pain, dyspnoea,
neurological disorders, ECG,
retinal examination)
■ Laboratory tests (blood and
urine tests, cerebral imaging in
case of neurological disorders)

12. History
1) Does the patient have a history of hypertension?
2) Are they compliant with their medications? Any medication
changes?
3) Do they have a recent trigger (high salt diet, alcohol use, NSAID
use, steroids, cold meds)
4) Are they pregnant or are they postpartum?
5) When was the last time they had their BP checked (and is this
chronic hypertension that does not require acute management)?

13. History
■ CNS: Headache, nausea, vomiting, confusion, visual changes,
neurologic localizing symptoms
■ Cardiac: chest pain, shortness of breath, ankle swelling, orthopnea,
PND
■ Renal: polyuria, nocturia, hematuria
■ Secondary causes should be searched in patients who are younger
(<30), and have very high BP (renal artery stenosis). Also think
about Cushing syndrome, hyperaldosteronism,
pheochromocytoma, etc.

14. History

15. What diagnostic tests should we do for
patients with asymptomatic hypertension?
■ Karras et al show a 6– 7% rate of clinically meaningful findings:
Bloods : BMP 2%, CBC 2%
Urine analysis: 4%
ECG 2%
■ Consider screening tests on select patients (poor follow up and you
think that the result of the test will affect disposition (ie admission)
Karras DJ, et al: Utility of routine testing for patients with asymptomatic severe blood pressure elevation in the
emergency department. Ann Emerg Med 2008; 51:231

16. What diagnostic tests should we do for
patients with asymptomatic hypertension?
■ In JNC 7, routine laboratory testing, including an ECG for left ventricular
hypertrophy or ischemia, chest radiograph (CXR) for cardiomegaly or
pulmonary edema, serum creatinine level for renal dysfunction, and
urinalysis for proteinuria, is recommended before initiating therapy
■ ACEP 2013 guidelines suggest no workup is needed

17. ACEP 2013
■ “ Currently, there is very little evidence to guide the
practitioner about which patients to test who present to the
ED with asymptomatic elevated blood pressure. No current
study measured adverse outcomes on the basis of the
decision to test patients with asymptomatic elevated blood
pressure. Of the available evidence, ED screening for
creatinine level may identify a small group of patients with
renal dysfunction in the setting of asymptomatic markedly
elevated blood pressure.
However, it is unclear how this frequency compares with that
of patients who present with normal or near-normal blood
pressures. No other diagnostic screening tests appear to be
useful”

18. Treating Asymptomatic Hypertension
Should we treat patients with asymptomatic
hypertension in the ED?
■ Although there is a paucity of evidence for treatment of hypertension in the ED
affecting short term outcome, reducing BP will reduce risk of morbidity and
mortality over the longer term
■ How low and how fast should you go?
■ Do not drop BP rapidly, as it alters cerebral perfusion and puts patients at risk for
organ underperfusion (i.e. ischemic stroke), especially if their blood pressure
elevation has been chronic

19. Should we treat patients with
asymptomatic hypertension in the ED?
■ The ACEP Clinical Policy states there is no need to immediately reduce an
asymptomatic patient with high blood pressure
■ They can instead be referred back to their family physician for BP management
■ The Canadian Emergency Medicine Cardiac Research and Education Group
(EMREG) guidelines advise ED physicians to consider beginning
antihypertensive therapy for patients with BP of >180/110, and to initiate
treatment if BP > 200/130
■ These recommendations are based on limited evidence

20. Is there a target BP for asymptomatic
HTN?
■ There are no guidelines for the exact target BP that needs to be achieved before
discharge.
■ 2015: Study in Academic Emergency Medicine suggests that prescription of anti-
hypertensives in the ED may be safe and effective, at least in the short-term, for
patients with asymptomatic hypertension

21. Which drug is best for treatment of
asymptomatic hypertension?
■ Most patients can be started on a thiazide, an ACE-inhibitor or ARB, or a calcium-
channel blocker (CCB) according to the JNC 8 -
Exceptions:
■ 1. For patients with coronary artery disease, a B-blocker is first line
■ 2. For black patients, cardiac risk reduction is best achieved with a thiazide or a CCB
■ ** Contraindications for each agent.
ACEi orARBs are contraindicated in patients at risk for hyperkalemia
Do not use thiazides in patients with gout, and avoid B-blockers in patients with
COPD or asthma. **

22. Follow up for patients with
asymptomatic hypertension
■ Although there is a paucity of evidence, most clinicians recommend
follow up within 7 days, or more urgently for patients with severe
hypertension or comorbidities
■ CHEP guidelines are more liberal; they advise BP be rechecked within 1
month
■ However, patients started on an ACE or an ARB should follow up
sooner, and have their electrolytes checked within 1 week.

23. Discharge Education & Instructions
■ Have a conversation with the patient
■ Assure the patient that their BP won’t cause them any harm
■ Educate the patient that the damage from BP happens over
months to years to decades- not hours to days
■ Make sure that the patient understands that rapid BP
correction can harm them
■ Give good return precautions (chest pain, neuro sxs, etc.)
■ Give written discharge instructions regarding follow-up

24. Questions ?