Clinical Controversies

Figure: EM best practice, hypertension, hypertensive urgencyFigureAbout 30 percent of U.S. adults have hypertension, with millions not even knowing it. Asymptomatic hypertension is elevated blood pressure without any signs or symptoms of end-organ damage. Severe hypertension is often defined as 180/120 mm Hg or higher, and any number above this typically triggers a visit to the ED. Many of these patients are referred from a clinic or pharmacy or after using an at-home blood pressure monitor. Of course, our job as emergency physicians means we ask the right questions and perform a thorough physical exam to rule out end-organ damage. Mild headaches and lightheadedness do not necessarily mean end-organ damage or automatically warrant a workup. Discharge is appropriate without further testing for patients with no concerning symptoms or signs. This is supported by several studies and a clinical policy. (ACEP. April 2018; https://bit.ly/3ceyAVV.) Broad workups, including ECGs, chest x-rays, chemistry panels, blood counts, urinalyses, and even troponins, are unnecessary in most patients. Two prospective, observational studies at urban EDs found only five to seven percent of patients had a meaningful unanticipated abnormality on screening tests. No patients had findings of hypertensive emergency. (Ann Emerg Med. 2008;51[3]:231; Am J Emerg Med. 2010;28[2]:235.) Perhaps the most damning was a large retrospective study that measured 58,535 clinic patients referred to the ED. These patients all had asymptomatic hypertension (≥ 180/110 mm Hg), and the study found no major adverse events at seven days, eight to 30 days, or even six months. Only 2.1 percent had evidence of end-organ injury on their lab results, but the investigators did not elaborate on what that entailed. None of the head or chest CTs was abnormal (0/60). (JAMA Intern Med. 2016;176[7]:981.) Multiple other studies prefer outpatient testing and follow-up instead of ED management, and this is the right move for patients who have a primary care physician for follow-up. It is not unreasonable to initiate antihypertensive therapy in the ED depending on patient factors and ease of follow-up. That decision, however, should be made case by case and should not use a one-size-fits-all approach. Hypertensive Urgency Lowering blood pressure in the ED in those with asymptomatic hypertension does not change outcome. An excellent retrospective cohort study of 1016 patients found similar revisits and mortality where 435 received antihypertensive therapy for asymptomatic hypertension and the rest were not treated. (Am J Emerg Med. 2015;33[9]:1219.) Perhaps the most controversial portion of this discussion is related to hypertensive urgency. Frankly, it is difficult to define what hypertensive urgency actually is. I frequently ask residents and colleagues what they consider to be hypertensive urgency. The long pause followed by a variety of answers and head scratches tells me no one really knows. Nearly every major journal or textbook defines hypertensive urgency as a marked elevation in blood pressure without evidence of target organ damage. (StatPearls. Aug. 27, 2021; https://bit.ly/3o6INX3.) UpToDate mentions that asymptomatic hypertension is “sometimes called hypertensive urgency.” (Nov. 17, 2021; https://bit.ly/3z9sdw9.) So, which is it? Similar conclusions can be reached about hypertensive “urgency” if studies continue to show no major benefit in working up and treating asymptomatic hypertension. Either the definition of hypertensive urgency needs to be more specific or go away entirely. Guidelines currently do not recommend rapidly lowering blood pressure in most patients, even in those with hypertensive urgency. Only UpToDate suggests that patients with a history of aortic or intracranial aneurysms may need to have their blood pressure lowered over a period of hours. They do not provide any policies or research to support this statement nor any details about what period of lowering is required. Multiple studies and task force statements are clearly of no proven benefit and may even cause harm if blood pressure reduction is too aggressive. (J Hypertens. 2013;31[10]:1925.) And no clear cutoff has delineated what blood pressure is too high and requires lowering. (J Am Osteopath Assoc. 2013;113[9]:664; https://bit.ly/3cgvO2q.) Better Definition Needed One study in 2008 showed that those with hypertensive urgency had a higher risk of subsequent cardiovascular events, but it only defined hypertensive urgency as blood pressure above 220 systolic and/or diastolic above 120 mm Hg. (J Hypertens. 2008;26[4]:657.) Again, what separates these patients from those with a systolic blood pressure of, say, 200 or 210 is simply arbitrary. Many of our ED patients have elevated blood pressure. Some have blood pressures of ≥180/≥110 mm Hg daily and have no clue. These people are certainly at risk for cardiac and renal complications in the long run, but our current definitions are insufficient to address the problem. Asymptomatic patients with elevated blood pressure should not be labeled as hypertensive urgency. Instead, focus on what makes a difference. Do a solid history and physical exam, identify those who are at risk for hypertensive emergencies, and order further studies from there. Arrange close primary care follow-up and weigh the risks and benefits of prescribing an antihypertensive if the patient is not already on one for the majority of patients you send home. Patients with blood pressure too high for you to feel comfortable about discharging them can rest in a quiet, dark room for 30 minutes with their cellphone on silent to minimize distractions. You will find that this strategy is quite effective in lowering their blood pressure and is supported by research. (J Clin Hypertens [Greenwich]. 2008;10[9]:662; https://bit.ly/3o6XjOQ.) We should demand a more detailed definition of hypertensive urgency to reduce crowding in our waiting rooms, decrease confusion, and provide safe, optimal blood pressure reduction for our patients. Call it like it is: Hypertensive urgency is not immediately urgent. Dr. Briggsis an assistant professor of emergency medicine at the University of South Alabama in Mobile. He is the founder, podcast co-host, and editor-in-chief of EM Board Bombs (https://www.emboardbombs.com), a multiplatform educational tool designed to provide board prep and focus on what you need to know for the practice of emergency medicine. Follow him on Twitter@blakebriggsmd.