Asymptomatic hypertension: Difference between revisions
(/* ACEP 2012 Clinical Policy on Asymptomatic Elevated BPClinical 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 An...) |
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== Treatment == | == Treatment == | ||
*First line for people without comorbidities | *First line for people without comorbidities | ||
**[[Hydrochlorothiazide]] 12.5mg, max 25mg | **[[Hydrochlorothiazide]] 12.5mg, max 25mg | ||
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| DM || thiazide, CCB, ACEI, or ARB || thiazide or CCB | | DM || thiazide, CCB, ACEI, or ARB || thiazide or CCB | ||
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;Routine ED medical intervention is NOT required (Level C)<ref>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 Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.</ref> | |||
;In select patient populations, physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control (Level C)<ref>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 Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.</ref> | |||
;Patients should be referred for outpatient follow up (Level C)<ref>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 Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.</ref> | |||
==See Also== | ==See Also== | ||
Revision as of 11:20, 22 February 2015
Background
- 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]
Clinical Features
JNC-7 Classification
| 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]
Work-Up
- Upreg
- <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"[3]
- Chem 7 (creatinine) --> home with outpatient treatment if no evidence of acute renal failure
- 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)[5]
Differential Diagnosis
Hypertension
- Hypertensive emergency
- Stroke
- Sympathetic crashing acute pulmonary edema
- Ischemic stroke
- Intracranial hemorrhage
- Preeclampsia/Eclampsia
- Autonomic dysreflexia
- Scleroderma renal crisis
- Acute glomerulonephritis
- Type- I myocardial infarction
- Volume overload
- Urinary obstruction
- Drug use or overdose (e.g stimulants, especially alcohol, cocaine, or Synthroid)
- Renal Artery Stenosis
- Nephritic and nephrotic syndrome
- Polycystic kidney disease
- Tyramine reaction
- Cushing's syndrome
- Obstructive sleep apnea
- Pheochromocytoma
- Hyperaldosteronism
- Hyperthyroidism
- Anxiety
- Pain
- Oral contraceptive use
Treatment
- First line for people without comorbidities
- Hydrochlorothiazide 12.5mg, max 25mg
- Need labs before starting, does not work in people with CKD
- Hydrochlorothiazide 12.5mg, max 25mg
- 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
- ACEi/ARB: Lisinopril either Qday or BID
- Anyone with CAD, CHF
- Beta-Blocker (don't need labs)
- Amlodipine for anyone, except for people with LE edema (don't need labs)
- Diltiazem for proteinuria in people unable to tolerate ACEi (don't need labs)
- Lasix for CHF and/or lower extremity edema secondary to proteinuria
JNC 8 Recommendations[6]
| Population | Non-black PTs | Black PTs |
|---|---|---|
| General pop | thiazide, CCB, ACEI, or ARB | thiazide or CCB |
| CKD | ACEI or ARB | ACEI or ARB |
| DM | thiazide, CCB, ACEI, or ARB | thiazide or CCB |
- Routine ED medical intervention is NOT required (Level C)[7]
- In select patient populations, physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control (Level C)[8]
- Patients should be referred for outpatient follow up (Level C)[9]
See Also
Sources
- ↑ 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.
- ↑ 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.
- ↑ 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 Ansymptomatic Hypertension. Annals of Emergency Medicine. Vol 62(1) July 2013 p59-63
- ↑ 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 Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.
- ↑ 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 Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.
- ↑ 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.
- ↑ 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 Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.
- ↑ 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 Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.
- ↑ 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 Ansymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.