Difference between revisions of "Asymptomatic hypertension"

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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. [http://hyper.ahajournals.org/content/42/6/1206.full.pdf JAMA. 2003; 289(19):2560-2572.]</ref>
+
{{Hypertension definition}}
 
 
===JNC-7 Classification===
 
{| class="wikitable"
 
|-
 
| '''Class'''
 
| '''Systolic'''
 
|
 
| '''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 name=JNC8>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). [http://jama.jamanetwork.com/article.aspx?articleid=1791497 JAMA. 2014; 311(5):507-520.]</ref>
 
  
 
==Clinical Features==
 
==Clinical Features==
Line 40: Line 9:
  
 
==Evaluation==
 
==Evaluation==
*Upreg
+
{{Asymptomatic hypertension evaluation}}
*<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"<ref name=ACEP2013>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.</ref>
 
 
 
;Routine screening for acute target organ injury (e.g. creatinine, UA, ECG) is NOT required (Level C)<ref name=ACEP2013 />
 
;In select patient populations, screening of creatinine may identify injury that affects disposition (Level C)<ref name=ACEP2013 />
 
  
 
==Management==
 
==Management==
*First line for people without comorbidities
+
{{Asymptomatic hypertension treatment}}
**[[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]]
 
**[[Beta-Blocker]] (do not need labs)
 
*[[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<ref name=JNC8 />'''
+
{{Initial Outpatient Hypertension Medications}}
{| class="wikitable"
 
|-
 
! 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
 
|}
 
 
 
;Routine ED medical intervention is NOT required (Level C)<ref name=ACEP2013 />
 
;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 name=ACEP2013 />
 
;Patients should be referred for outpatient follow up (Level C)<ref name=ACEP2013 />
 
  
 
==Disposition==
 
==Disposition==
*See workup, if no evidence of [[acute renal failure]], outpatient treatment
+
*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 />'''
  
 
==See Also==
 
==See Also==
 
*[[Hypertension (main)]]
 
*[[Hypertension (main)]]
 +
 +
==External Links==
 +
[https://www.acep.org/patient-care/clinical-policies/asymptomatic-elevated-blood-pressure/ ACEP Clinical Policy: Asymptomatic Elevated Blood Pressure]
  
 
==References==
 
==References==

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.