UMEM Educational Pearls

Title: Asymptomatic markedly elevated blood pressure in the ED

Keywords: Hypertension (PubMed Search)

Posted: 9/1/2013 by Ali Farzad, MD (Updated: 3/10/2014)
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Adult ED patients are commonly found to have markedly elevated blood pressures (>160/100) without any signs or symptoms of acute organ injury (ie, cardiovascular, renal, or neurological).

A recently revised ACEP clinical policy aims to guide emergency physicians in the evaluation and management of such patients.

They make the following recommendations (Level C):

Routine screening tests (ie, CXR, ECG, UA, BMP) do not reduce adverse outcomes and are not required from the ED.
Initiation of medical treatment does not reduce adverse outcomes and is not required in the ED.
Patients with persistently elevated blood pressure should be referred for primary care follow-up.
In select patient populations (eg. poor access to care), a screening creatinine level may identify renal injury that may alter disposition.
If medication is started in the ED, the goal should be to facilitate gradual long-term control. Rapidly lowering blood pressure may be harmful.

Bottom-line:

There's little evidence to guide the decision of which patients with markedly elevated blood pressures to test or treat in the ED. This new clinical policy suggests that routine screening and treatment is not required. Asymptomatic patients should be referred for close follow-up, but consider a BMP in patients with poor follow up.

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References

Wolf SJ, Lo B, Shih RD, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. Ann Emerg Med. 2013;62(1):59–68.

Attachments

1309011328_Ann_Emerg_Med_2013_Wolf.pdf (186 Kb)