Sunday, August 18, 2013

Asymptomatic Hypertension in the ED. What Should We Do?

Patient in his 50's shows up to the ED b/c his high blood pressure. He has no other complains, his wife made him come in (you know how it is). He gets an EKG in triage (protocol says you get one for showing up) and it has some mild LVH, but no acute changes. You do a physical exam and there is nothing besides the smell of bean burritos with lots of garlic. What do you do...? Do you screen for organ damage (EKG, UA, Creatinine, CXR)? Do you just begin treatment? Do you screen and treat depending on what you find? Do you advice him to continue checking his BP twice a day and follow up with his doctor this week? Or do you recommend him to stop eating Mexican food and eat tofu instead?

Asymptomatic hypertension is so common and the pressure to treat a high blood pressure is very high, this is a real pain in my existence. The nurses frequently ask for "something" to treat the BP, even when the patient has no complains. And how you like this one? "The nurses upstairs will not take the patient unless the BP is less than whatever (insert your favorite number here)", even though the patient has had poorly controlled HTN for the last 200 years. At that point I have two options, give in and write the order for something (insert your favorite fast acting anti-hypertensive) and risk overshooting causing an unsafe drop in the BP or just ignore it, let the team upstairs deal with it and make the nursing staff believe that I am an uncaring physician.

Fortunately in May of this year, ACEP published an update on their 2006 clinical policy on asymptomatic high BP in the ED. They did a pretty extensive review of the literature on the topic and provide good guidelines in this common dilemma. It is important to note, these guidelines do not apply for patients with high BP and signs/symptoms of target organ dysfunction, the so called hypertensive emergency (stroke, acute myocardial ischemia, pulmonary edema, encephalopathy), pregnant patients, ESRD or trauma. I know, it sounds obvious, but just in case.

I will now summarize with 3 key points of this document.

Definition of markedly elevated BP is in agreement with the JNC7 classification of stage 2 hypertension, which is SBP > 160 or DBP > 100.

Screening. In the ED, patients with asymptomatic HTN, routine screening for acute target organ injury (eg, creatinine, UA, EKG, CXR) is not required. However, in selected population (eg, poor follow up) screening with serum creatinine my identify kidney injury and affect disposition. Evidence level C.

ED treatment. In patients with asymptomatic markedly elevated BP, routine ED medical intervention is not required. These patients should be referred for outpatient follow up. But in selected groups (eg, poor follow up), the emergency physcian may treat and/or initiate therapy for long term control. Evidence level C.

Furthermore, this document cites evidence that up to 32% of hypertensive patients have reduction in their SBP of > 20 mmHg and DBP > 10 mmHg after 30 minutes of rest, and that acute lowering of the BP does not improve short term outcomes and it may actually  be detrimental. "It is generally accepted that the rapid lowering of markedly elevated blood pressure in the asymptomatic patient has the potential to do harm".
So... what should we do with the patient above? Well, that may depend of how "labby" you feel that day or how busy the ED is. But this guidelines should be enough to give you a point of reference and do what is best for your patients without clogging your department.

And for those who want to dive deeper into this guideline business, here is the reference for your reading pleasure.

Share this information with your colleagues, it may actually reach the people who make protocol decisions! 

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