Asymptomatic hypertension

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

Clinical Features

JNC-7 Classification

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 PTs ≥60 yr the threshold has increased from <140/90 to <150/90

ACEP 2012 Clinical Policy on Asymptomatic Elevated BP

• Screening
  • 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
  • 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)

Work-Up

1. Upreg
2. <120 diastolic --> home, outpt rx
3. >210 systolic or >120-130 diastolic --> search end organ
   1. Chem 7 (creatinine)
   2. "No other diagnostic screening tests (e.g. UA, ECG) appear to be useful"

Treatment

1. First line for people without comorbidities
   1. HCTZ 12.5mg, max 25mg
      1. Need labs before starting, does not work in people with CKD
2. First line for people with DM and/or Proteinuria
   1. ACEi/ARB: Lisinopril either Qday or BID
      1. Need Chem 10 before and after starting to check for hyperK and Cr
3. Anyone with CAD, CHF
   1. Beta-Blocker (don't need labs)
4. Amlodipine for anyone, except for people with LE edema (don't need labs)
5. Diltiazem for proteinuria in people unable to tolerate ACEi (don't need labs)
6. Lasix for CHF and/or lower ext edema 2/2 proteinuria

See Also

• Hypertension (Main)