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Asymptomatic Hypertension

Joe Martinez, MD, Mizuho Morrison, DO, and Matthew DeLaney, MD
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When a patient comes into your practice with blood pressures of 180/100 but they feel totally fine, what should you do? How much evaluation should they undergo? Should they be treated in the office? Or should they be referred to the ED? In this segment, Dr. Joseph Martinez chats with our own Mizuho Morrison and Matt DeLaney about the outpatient management of severe asymptomatic hypertension.

Pearls:

  • Blood pressure control is important, but it's most important in the longer term and patients can suffer adverse events if it is lowered too quickly.

 

Terminology:

  • Hypertensive emergency - hypertension which causes end organ damage:

    • ACS - STEMI/NSTEMI

    • Aortic dissection

    • Renal failure

    • Pulmonary edema

    • Encephalopathy or stroke

    • Eclampsia

  • Hypertensive urgency - patients with a systolic BP ≥180 or a diastolic ≥110 mmHg who are minimally symptomatic or asymptomatic and have no evidence of end organ damage.

 

Management

  • Patients who are truly asymptomatic and who are not at significant risk for developing rapidly progressive target organ damage should follow up with their PCP for blood pressure management.

  • Evaluate for potential causes of elevated hypertension such as  pain, substance withdrawal or rebound hypertension from stopping blood pressure medications.

  • The American College of Emergency Physicians states that for asymptomatic patients with markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) and routine ED medical intervention is not required.

  • There is overwhelming evidence that the short term risk of adverse events for patients with asymptomatic hypertension is exceptionally low and hospitalization is of no benefit:

    • A 2016 JAMA study found that patients who were sent to the hospital for hypertensive urgency had similar rates of major adverse cardiovascular events (MACE) compared to those that were sent home. The rates of MACE in both groups was extremely low as well at ~1% (Patel et al, 2016).

    • A study published by Masood et al. in 2016 in the Annals of Emergency Medicine found that in a retrospective cohort of patients that were sent to the ED with asymptomatic hypertension only 8% were admitted. The risk of mortality was similar between the group sent home versus those that were admitted ( 1% within 90 days, 2.5% within a year, 4% in 2 years).

  • In the entirety of the medical literature, there's never been a single study to show that abruptly reducing blood pressure is beneficial for patients that are asymptomatic, but there's been myriads of studies that show that it has the potential to cause harm.

Shaun S. -

I get the point of doing harm with rapid lowering
But questions still linger-

You say over the short term MACE is the same. But we don’t know how long these patients have been “urgently hypertensive.” When does it come a point when they aren’t short term and I send them home and they stroke. I mean who are the patients that have the stroke?

Just trying to sort this out. Why can’t I start them on HCTZ or Lisenopril in Irgent Care with follow up to their PCP?

Mike W., MD -

From Matt Delaney: That’s a really good question Shaun. You are correct that we have no way to know if someone has been hypertensive for years leading up to the day that they show up in the UC. Fortunately the majority of our patients are not going to leave and have a short term bad outcome, but your suggestion to start someone on oral antihypertensives and have them followup with their PCP is a very reasonable practice.
From Weinstock: Agree w Matt, it is OK to treat. I would add the caveat that we should confirm they actually have HTN and not just elevated BP and, as Tabor D points out above, that usually requires 2 BP elevations at 2 different visits. I also agree that we need to establish there is not a HTN emergency and if not, this is a good opportunity for shared decision making w the patient. A stroke or other longstanding HTN complication is years and years in the making - hard to imaging that a few days of weeks of low dose HCTZ or other anti-hypertensive would prevent these short term events!

Kateland K. -

Thank you for this topic. I come from a primary care background so I am inclined to start patients on anti-hypertensives, however my biggest concern is that where I practice there is a scarcity of PCPs. Patients often cannot afford the long wait times to be seen (greater than six months for new patients to establish) or simply don't want to follow up with anyone ("I feel fine!")

How would your recommendations change if there is no PCP practice to have the patient follow up with; would you still suggest starting therapy and if so, is there a liability there in starting a long term maintenance medication in an UC setting?

Mike W., MD -

wow, tough question. If 6 months that seems too long. If a month or two would be pretty reasonable to start. If it would be longer perhaps a recheck when you are working again (w your PCP background) for a recheck and if there are any required labs - this seems like a pretty reasonable and patient centered way to go!
M

Mike W., MD -

From a listener (with response by Matt Delaney below):
Thanks so much for the great content every month. I especially enjoyed Asymptomatic Hypertension as this confirmed my current practice for these types of pts. One wrinkle in this would be pts with BP 182/110 with a Headache. You see this pt that reports they always know when their blood pressure is "a little high" because they get a Headache. No other complaints. Exam completely benign. How would you approach this pt who looks well but has a high BP with a complaint which could be from end organ damage?

From Matt:
This is a common and somewhat messy clinical scenario. The literature seems to suggest that if a patient has a headache, hypertension, and a normal neuro exam they are unlikely to have any underlying damage to their neurologic "end organs." I will typically treat the patients discomfort and have found that many patients will have their BPs drop once we get their pain under control. Obviously if you're concerned about the patients headache and are worried that there may be an ominous cause (SAH, meningitis...) then I'd go down the normal headache pathway, but for the majority of these otherwise benign sounding folks with elevated BP's I don't often go down the imaging/abrupt BP reduction route.
Hope this helps,
MCD

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No...You Aren't Gonna Die! Full episode audio for MD edition 226:23 min - 106 MB - M4AUC RAP February 2019 Written Summary 353 KB - PDF

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