see also: [[Hypertensive Emergency]] > [!references]- > - [Managing asymptomatic hypertension - video](https://www.youtube.com/watch?v=0TA02WMJ0ms&t=76s) > - [2024: The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association.](bookends://sonnysoftware.com/ref/DL/243859) > - Limitations: " The physical examination includes a focus on comparing bilateral pulses, auscultating the heart and lungs, and performing a fundoscopic examination. Further diagnostic investigations include a basic metabolic panel, a complete blood count, a chest radiograph, a 12-lead ECG including heart rate, and an assessment of volume status and risk of orthostasis." → most ED doctors do not perform fundoscopy and XR chest tends to be outdated approach to reviewing for aortic dissection > - [Heart foundation HTN guidelines](https://www.heartfoundation.org.au/for-professionals/hypertension) > - [Immediate Prescription of Oral Antihypertensive Agents in Hypertensive Urgency Patients and the Risk of Revisits with Elevated Blood Pressure](https://pmc.ncbi.nlm.nih.gov/articles/PMC7650220/) Open Access Emerg Med. 2020 > - "We have found no obvious evidence of benefit from oral antihypertensive agents in managing hypertensive urgencies in the ED. Oral hypertensive agents had no benefit in the reduction of blood pressure, no effect on reduction of ED length of stay, and blood pressure control within 2 weeks." > - JAMA Internal Med 2016 [Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting](https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2016.1509) > - SBP > 180 or diastolic >110 → no difference in MACE at 6 months referred to hospital vs discharged from GP (0.9% vs 0.8%) > - Retrospective study of 58 535 patients with (now-outdated) "hypertensive urgency," ED visits for hypertensive urgency were associated with an 8.2% rate of hospital admissions at 7 days vs 4.7% for patients sent home, a significant difference. Major cardiac events were rare, and two-thirds of patients still had uncontrolled hypertension at 6 months. > - The mean SBP was 182.5, with 10.2% of the patients having an SBP of at least 200 mm Hg. The mean DBP was 96.4 with 5.7% of the patients having a DBP of at least 120 mm Hg. We found a documented history of hypertension in 72.9% of patients, and 58.2% of patients were taking 2 or more antihypertensives > - ![[Pasted image 20250703180023.png]] > - Heart Lung 2020 [Hypertensive urgency or emergency? The use of intravenous medications in hospitalized hypertensive patients without organ dysfunction](https://pubmed.ncbi.nlm.nih.gov/33011460/) > - 80% of pts charted PRNs got IV anti-hypertensives (even though stable/asymptomatic) > - 4% hypotension, 35% bradycardia > - 2010 Weder : 60% of hospitalised pts recieved IV meds if had PRNs for BP > [!key points] > - New guidelines on asymptomatic markedly-elevated blood pressure mostly encourage avoiding intensive lowering of BP in the acute setting > - "Markedly Elevated Asymptomatic Hypertension = MEAH" ; this is NOT "hypertensive urgency" (outdated term) > - 2017 ACC/AHA/AAPA/ etc guideline note that for "hypertensive urgency" no indication for referral to ED, immediate reduction in BP in the ED, or hospitalisation > - it is **dangerous** to drop asymptomatic BP too quickly and can precipitate a stroke ## Step 0: correctly measure the BP ![[Pasted image 20250703164521.png]] - sitting in quiet room 3-5 minutes - empty bladder - calm - back supported ## Principles from 2024 AHA Scientific Statement on asymptomatic HTN ![[Pasted image 20250703153643.png]] ![[Pasted image 20250703153909.png]] ![[Pasted image 20250703153959.png]] ![[Pasted image 20250703154024.png]] ### ED Management - 2013 American College of Emergency Physicians clinical policy discourages antihypertensive medication for asymptomatic elevated inpatient BP in the ED, but initiating oral therapy in the ED at discharge to home is supported by the evidence for some patients. - Initiating antihypertensive treatment in the ED can help address health care disparities, particularly in disenfranchised groups who tend to experience poorer BP control and disproportionate rates of severe cardiovascular consequences, often lack primary medical care, and are more likely to present to the ED for care. - For patients with asymptomatic elevated BP presenting to the ED, engaging community health workers, implementing specific care pathways, and providing referral strategies, including harnessing alternative care models to facilitate primary care follow-up and ongoing BP management, are critical to ensuring appropriate and equitable management after ED discharge. ## Treatment choices - in pts with uncomplicated HTN, ACE-i, ARB, CCBs, and thiazide diuretics are all suitable first-line antihypertensive Rx - start with low-moderate recommended dose of a first-line drug. - pts with angina → CCBs and β blockers - heart failure → ACE-i (ARBs if ACE-i not tolerated) - older people → lowest dose > combinations to avoid: > - ACE + ARB → risk of renal failure > - verapamil + β blocker → risk of heart block ### Drug class contraindications | Class | contraindication | caution | | ---------- | ------------------------------------------------------------------------------------------- | ---------------------------------------------------------------- | | ACE or ARB | - pregnancy<br>- angioedema<br>- ↑ K<br>- bilat renal artery stenosis | - women child-bearing age | | CCB | | heart failure | | diuretic | - gout<br>- age (↑ risk diabetes) | - glucose intolerance<br>- metabolic syndrome<br>- ↑ Ca<br>- ↓ K | | β blocker | (NOT first line)<br>- asthma<br>- bradycardia<br>- AV block<br>- uncontrolled heart failure | - diabetes<br>- athletes<br>- COPD<br>- depression | ### Abbreviated treatment options table | Class | Drug | Dose | Comments | | ------------------- | -------------------- | --------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | ACE-i | Captopril | 12.5 - 50 mg BD | ***side effects:***<br>- cough<br>- ↑ K<br>- renal impairment (↑ with NSAIDs or ↓ volume)<br>- angioedema | | ACE-i | perindopril arginine | 5 - 10 mg od | | | ACE-i | perindopril erbumine | 4-8mg od | | | ACE-i | ramipril | 2.5 - 10 mg od in one or two doses | | | ARB | candesartan | 8 - 32mg od | - ↑ K<br>- renal impairment<br>- unlikely to have cough or angioedema | | ARB | irbesartan | 150mg - 300mg od | | | ARB | Losartan | 50 - 100mg od | | | ARB | olmesartan | 20 - 40mg od | | | ARB | valsartan | 80 - 320mg od | | | CCB | amlodipine | 2.5-10mg od | - prefer long acting once daily<br>- do not tx CCB-induced peripheral oedema with diuretics<br>- can cause peripheral vasodilation | | CCB | lercanidipine | 10 - 20mg od | | | CCB | Nifedipine | 10 - 40mg BD | | | CCB | diltiazem | 180 - 360mg od | non-dihydroyridine<br>- ↓ HR and contractility (verapamil more than tiltiazem)<br>- can cause constipation, AV block, heart failure, bradycardia | | CCB | verapamil | 80 - 160 mg BD | | | Thiazide | HCTZ | 12.5 - 25mg od | - ↓ K<br>- postural hypotension<br>- ↑ glucose<br>- ↓ Na<br>- ↑ urea | | Thiazide | indapamide | 1.5mg od | | | β - blocker | atenolol | 25 - 100mg od in 1-2 doses | | | β - blocker | many others | | | | alpha-2 agonist | methyldopa | 250 - 2000mg od in 2-4 doses | - not first-line<br>- mostly used for HTN in pregnancy<br>- sedating effects<br>- dizziness<br>- hepatitis<br>- positive [[Coombs test]] and haemolytic anaemia | | arterial vasodilaor | hydralazine | 50 - 100mg od in 2 doses | used for refractory HTN usually with β blocker and diuretic<br>- palpitations<br>- flushing<br>- tachycardia<br>- can exacerbate angina<br>- lupus-like syndrome (>100mg od for > 6 months) | | alpha2 agonist | moxonidine | 200-600mcg od in 1-2 doses. max single dose 400mcg | - need to withdraw over a few days<br>- dry mouth<br>- drowsiness<br>- bradycardia<br>- vasodilation | | alpha blocker | prazosin | 0.5mg BD for 3-7 days | - start at night in low dose ot reduce risk of first-dose hypotension<br>- can have profound postural hypotension<br>- caution in advanced age, volume depletion | ## Other tests and secondary HTN - ECHO → help dx LVH - carotid USS → rule out asymptomatic atherosclerosis in older adults - renal artery imaging/ renal artery duplex → ix renovascular causes of HTN (eg fibromuscular dysplasia in young females, older adults with atherosclerotic renal artery disease) - [[Ankle Brachial Index (ABI)]] → pts with risks of peripheral artery disease - plasma aldosterone/renin ration → [[Hyperaldosteronism|primary aldosteronism]] not excluded by normal serum potassium - metanephrine and normetanephrine excretion with creatinine and/or plasma catecholamine, metanephrine, and normetanephrine concentration, 24-hour urinary catechnolamine → if episodic catecholamine excess or episodic HTN suggestive of phaeochromocytoma - urinalysis (proteinuria) ## Example case: 52 year old woman, b/g HTN, hasn't taken meds in 3 years, took BP with friend and was 233/139, had CP 5 days ago none now, normal physical exam. ***Approach*** 1. Wait 20-30 min 2. Re-check BP (properly ) 1. in 33% of patients presenting with **asymptomatic maredly elevated BP**, leaving alone and re-checking will result in it decreasing without intervention 3. Do we need to do any "screening?" in asymptomatic patient 1. ACEP 2013: ECG (LVH) no benefit, CXR (cardiomegaly) no benefit, urinalysis (protein) no benefit, EUC (Cr for AKI) → *possible benefit* 2. Low evidence that ED treatment changes long term outcomes (see evidence in references section) *but* patients need *outpatient follow up within 1 month* 4. +/- start an oral agent 5. "Treat the patient, not the number"