Hypertension (main)

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Background

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[1]

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
  • JNC-8 Changes: In patients ≥60 yr the threshold has increased from <140/90 to <150/90[2]
  • Any age with diabetes mellitus and >140/90

Categorization of Hypertension[3]

^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)

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]

Hypertensive emergency

Management

Asymptomatic hypertension

Routine ED medical intervention is NOT required (Level C)[4]
  • In select patient populations, consider initiating or increasing outpatient therapy for long-term control (Level C)[4]

Initial outpatient hypertension medications

  • First line for people without comorbidities
    • Hydrochlorothiazide 12.5mg, max 25mg
      • Need labs before starting, does not work in people with CKD
  • First line for people with DM and/or proteinuria
    • ACEi/ARB: Lisinopril either Qday or BID
      • Need Chem 10 before and after starting to check for hyperkalemia and creatinine
      • Start 10mg lisinopril QD
  • Anyone with CAD, CHF
  • Amlodipine for anyone, except for people with LE edema (do not need labs)
    • Start amlodipine 5mg QD
  • Diltiazem for proteinuria in people unable to tolerate ACEi (do not need labs)
  • Lasix for CHF and/or lower extremity edema secondary to proteinuria

JNC 8 Recommendations[2]

Population Non-black Patients Black Patients
General population thiazide, CCB, ACEI, or ARB thiazide or CCB
CKD ACEI or ARB ACEI or ARB
DM thiazide, CCB, ACEI, or ARB thiazide or CCB

Hypertensive emergency

Disposition

  • Hypertensive emergency → admission
  • Otherwise, discharged home with a follow up appointment with the primary care physician (Level C)[4]

References

  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. 2.0 2.1 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. Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 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 Asymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.

Authors

Neil Young