Asymptomatic hypertension

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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[1]
  • JNC-8 Changes
    • In PTs ≥60 yr the threshold has increased from <140/90 to <150/90[2]

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

Work-Up

JNC 7 recommends chem 8, ECG, CXR, and UA prior to initiating therapy

  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"[3]

Differential Diagnosis

Hypertension

Treatment

JNC 8 Recommendations[4]

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[5]

  • Screening[6]
    • 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[7]
    • 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

Sources

  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. 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. 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
  4. 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.
  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 Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.
  6. 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.
  7. 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.