Written by Laura Murphy
Spoon Feed
This article emphasizes the difference between hypertensive emergency and asymptomatic elevated blood pressure (BP). While hypertensive emergency requires prompt treatment to lower BP, treatment of asymptomatic elevated BP in acute care settings may be harmful.
Asymptomatic elevated BP? Less is more.
This article shifts focus from the use of terms hypertensive urgency and hypertensive crisis to the presence of target-organ damage (hypertensive emergency) to determine need for acute treatment of hypertension. While patients with hypertensive emergency require immediate, acute treatment, often with parenteral medications, those with asymptomatic elevated BP likely do not.
The authors emphasize the importance of proper techniques for measurement of BP, such as frequently calibrated devices. Prior to treatment, it is best to focus on accurate re-measurement and circumstantial factors such as pain, anxiety, stress, illness-related factors, etc., as well as medications or substances that may increase BP (e.g. stimulants, NSAIDs, corticosteroids). When treating asymptomatic elevated BP, evidence supports restarting home medications over intensifying or adding additional medications.
Observational studies have shown that pharmacologic treatment of asymptomatic elevated BP (especially with IV medications) can cause harm, including hypotension or rapid lowering of BP, as well as myocardial injury, kidney injury, and death*. It is likely more important to treat markedly elevated blood pressure in patients who are in the ED or being admitted for cardiovascular conditions. Permissive hypertension for other patients with acute illness is likely safer given alterations in physiology and autoregulation.
Finally, the article acknowledges that the ED is a key (sometimes, only) source of care for many patients who do not have access to reliable outpatient care. In addition to emphasizing lifestyle modifications, initiating antihypertensive therapy at ED discharge in appropriate patients who have persistently elevated or markedly elevated BP is appropriate. Addressing barriers to outpatient treatment and referring patients to outpatient care and follow-up is also pivotal.
How will this change my practice?
In patients who do not have symptoms or evidence of target-organ damage, I will continue with a “less is more” approach and emphasize the importance of monitoring in the outpatient setting. That said, my personal practice is to start antihypertensive medications in appropriate patients who may have limited access to outpatient care, particularly those who present solely for elevated BP from other settings or with symptoms that may be related to cardiovascular disease.
Another Spoonful
See original 2017 AHA Guidelines for Management of High Blood Pressure here, the AHA Guidelines Made Simple, and the JournalFeed summary for treatment guidelines for hypertension. We need to be aware of these given the prevalence of this disease!
*See summary of relevant studies in article.
Source
The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association. Hypertension. 2024 Aug;81(8):e94-e106. doi: 10.1161/HYP.0000000000000238. Epub 2024 May 28. PMID: 38804130.
Very Nice & Interesting Article. I am for the less is more approach whenever necessary.
I am curious what your approach will be to a patient who comes in with Asymptomatic markedly elevated BP despite taking their regular home med. Do you add on an oral agent and monitor them in the ED ?