Difference between revisions of "Asymptomatic hypertension"

(JNC-7 Classification)
(See Also)
 
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==Background==
 
==Background==
*JNC 7 recommends 2 or more properly measured, seated blood pressure readings on each of 2 or more office visits to establish the diagnosis of hypertension<ref>Chobanian AV, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - The JNC 7 Report. JAMA. 2003; 289(19):2560-2572.</ref>
+
{{Hypertension definition}}
  
 
==Clinical Features==
 
==Clinical Features==
=== JNC-7 Classification ===
+
*None (asymptomatic by definition)
{| style="width: 500px" border="1" cellpadding="1" cellspacing="1"
 
|-
 
| '''Class'''
 
| '''&nbsp;Systolic'''
 
| <br/>
 
| '''Diasolic'''
 
|-
 
| Normal
 
| <120
 
| and
 
| <80
 
|-
 
| Pre-hypertension
 
| 120-130
 
| or
 
| 80-89
 
|-
 
| Stage 1
 
| 140-150
 
| or
 
| 90-99
 
|-
 
| Stage 2
 
| ≥160
 
| or
 
| ≥100
 
|}
 
 
 
*JNC-8 Changes: In patients ≥60 yr the threshold has increased from <140/90 to <150/90<ref>James PA, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311(5):507-520.</ref>
 
 
 
== Work-Up ==
 
JNC 7 recommends chem 8, ECG, CXR, and UA prior to initiating therapy
 
*Upreg
 
*<120 diastolic --> home, outpt rx
 
*>210 systolic or >120-130 diastolic --> search end organ
 
**Chem 7 (creatinine)
 
**"No other diagnostic screening tests (e.g. UA, ECG) appear to be useful"<ref>Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. ACEP Clinical Policies Subcommittee on Ansymptomatic Hypertension. Annals of Emergency Medicine. Vol 62(1) July 2013 p59-63</ref>
 
 
 
*Screening
 
**Routine screening for acute target organ injury (e.g. creatinine, UA, ECG) is NOT required (Level C)<ref>Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. ACEP Clinical Policies Subcommittee on Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.</ref>
 
**In select patient populations, screening of creatinine may identify injury that affects disposition (Level C)<ref>Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. ACEP Clinical Policies Subcommittee on Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.</ref>
 
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
 
{{Hypertension DDX}}
 
{{Hypertension DDX}}
  
== Treatment ==
+
==Evaluation==
*Routine ED medical intervention is NOT required (Level C)<ref>Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. ACEP Clinical Policies Subcommittee on Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.</ref>
+
{{Asymptomatic hypertension evaluation}}
*In select patient populations, physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control (Level C)<ref>Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. ACEP Clinical Policies Subcommittee on Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.</ref>
 
**atients should be referred for outpatient follow up (Level C)<ref>Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. ACEP Clinical Policies Subcommittee on Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.</ref>
 
  
*First line for people without comorbidities
+
==Management==
**[[Hydrochlorothiazide]] 12.5mg, max 25mg
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{{Asymptomatic hypertension treatment}}
***Need labs before starting, does not work in people with CKD
 
*First line for people with [[DM]] and/or [[proteinuria]]
 
**[[ACEi]]/ARB: [[Lisinopril]] either Qday or BID
 
***Need Chem 10 before and after starting to check for [[hyperkalemia]] and creatinine
 
*Anyone with [[CAD]], [[CHF]]
 
**[[Beta-Blocker]] (don't need labs)
 
*[[Amlodipine]] for anyone, except for people with LE edema (don't need labs)
 
*[[Diltiazem]] for [[proteinuria]] in people unable to tolerate [[ACEi]] (don't need labs)
 
*[[Lasix]] for [[CHF]] and/or lower extremity edema secondary to [[proteinuria]]
 
  
'''JNC 8 Recommendations<ref>James PA, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311(5):507-520.</ref>'''
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{{Initial Outpatient Hypertension Medications}}
{| class="wikitable"
 
|-
 
! Population !! Non-black PTs !! Black PTs
 
|-
 
| General pop || thiazide, CCB, ACEI, or ARB || thiazide or CCB
 
|-
 
| CKD || ACEI or ARB || ACEI or ARB
 
|-
 
| DM || thiazide, CCB, ACEI, or ARB || thiazide or CCB
 
|}
 
  
==ACEP 2012 Clinical Policy on Asymptomatic Elevated BP<ref>Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. ACEP Clinical Policies Subcommittee on Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.</ref>==
+
==Disposition==
*Screening<ref>Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. ACEP Clinical Policies Subcommittee on Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.</ref>
+
*See workup, if no evidence of [[acute renal failure]] or [[hypertensive emergency]], '''patients should be referred for outpatient follow up (Level C)<ref name=ACEP2013 />'''
**Routine screening for acute target organ injury (e.g. creatinine, UA, ECG) is NOT required (Level C)
 
**In select patient populations, screening of creatinine may identify injury that affects disposition (Level C)
 
*Treatment<ref>Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. ACEP Clinical Policies Subcommittee on Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.</ref>
 
**Routine ED medical intervention is NOT required (Level C)
 
**In select patient populations, physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control (Level C)
 
**Patients should be referred for outpatient follow up (Level C)
 
  
 
==See Also==
 
==See Also==
*[[Hypertension (Main)]]
+
*[[Hypertension (main)]]
*[[Hypertensive emergency]]
+
 
*[[Hypertensive urgency]]
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==External Links==
 +
[https://www.acep.org/patient-care/clinical-policies/asymptomatic-elevated-blood-pressure/ ACEP Clinical Policy: Asymptomatic Elevated Blood Pressure]
  
==Sources==
+
==References==
 
<references/>
 
<references/>
  
[[Category:Cards]]
+
[[Category:Cardiology]]

Latest revision as of 21:34, 9 February 2021

Background

Classification of Hypertension

JNC-7 recommends 2 or more properly measured, seated blood pressure readings on each of 2 or more office visits to establish the diagnosis of hypertension [1]

Class Systolic Diasolic
Normal <120 and <80
Elevated Blood Pressure 120-129 and <80
Stage 1 130-139 or 80-89
Stage 2 ≥140 or ≥90
  • JNC-8 Changes:
    • In patients ≥60 yr the threshold has increased from <140/90 to <150/90[2]
    • Patients with diabetes mellitus (any age) and >140/90

Clinical Features

  • None (asymptomatic by definition)

Differential Diagnosis

Hypertension

Evaluation

Asymptomatic hypertension

  • Urine pregnancy in all women of child-bearing age (consider preeclampsia if positive)
Routine screening for acute target organ injury (e.g. creatinine, UA, ECG) is NOT required (Level C)[3]
In select patient populations, screening of creatinine may identify injury that affects disposition (Level C)[3]

Suggested algorithm:

  • <120 diastolic
    • No screening ED workup --> home with outpatient treatment
  • >210 systolic or >120-130 diastolic
    • Chem 7 (creatinine) --> home with outpatient treatment if no evidence of acute renal failure
      • "No other diagnostic screening tests (e.g. UA, ECG) appear to be useful"[3]

Management

Asymptomatic hypertension

Routine ED medical intervention is NOT required (Level C)[3]
  • In select patient populations, consider initiating or increasing outpatient therapy for long-term control (Level C)[3]

Initial outpatient hypertension medications

  • First line for people without comorbidities
    • Hydrochlorothiazide 12.5mg, max 25mg
      • Need labs before starting, does not work in people with CKD
  • First line for people with DM and/or proteinuria
    • ACEi/ARB: Lisinopril either Qday or BID
      • Need Chem 10 before and after starting to check for hyperkalemia and creatinine
      • Start 10mg lisinopril QD
  • Anyone with CAD, CHF
  • Amlodipine for anyone, except for people with LE edema (do not need labs)
    • Start amlodipine 5mg QD
  • Diltiazem for proteinuria in people unable to tolerate ACEi (do not need labs)
  • Lasix for CHF and/or lower extremity edema secondary to proteinuria

JNC 8 Recommendations[2]

Population Non-black Patients Black Patients
General population thiazide, CCB, ACEI, or ARB thiazide or CCB
CKD ACEI or ARB ACEI or ARB
DM thiazide, CCB, ACEI, or ARB thiazide or CCB

Disposition

See Also

External Links

ACEP Clinical Policy: Asymptomatic Elevated Blood Pressure

References

  1. Chobanian AV, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - The JNC 7 Report. JAMA. 2003; 289(19):2560-2572.
  2. 2.0 2.1 James PA, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311(5):507-520.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. ACEP Clinical Policies Subcommittee on Asymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.