Hypertension (main)

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Background

Categorization of Hypertension[1]

^Many emergency physicians do not use the diagnosis of "hypertensive urgency," but utilize instead only hypertensive emergency (signs of end organ dysfunction) or asymptomatic hypertension (all others)

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 [2]

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[3]
    • Patients with diabetes mellitus (any age) and >140/90

Clinical Features

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)[4]
In select patient populations, screening of creatinine may identify injury that affects disposition (Level C)[4]

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"[4]

Management

Disposition

  • Hypertensive emergency --> admission
  • Otherwise, normally discharged home with a follow up appointment with the primary care physician

References

  1. Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.
  2. 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.
  3. 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.
  4. 4.0 4.1 4.2 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.