Asymptomatic hypertension: Difference between revisions
No edit summary |
|||
| Line 39: | Line 39: | ||
##Chem 7 (creatinine) | ##Chem 7 (creatinine) | ||
##"No other diagnostic screening tests (e.g. UA, ECG) appear to be useful"<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. Vol 62(1) July 2013 p59-63</ref> | ##"No other diagnostic screening tests (e.g. UA, ECG) appear to be useful"<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. Vol 62(1) July 2013 p59-63</ref> | ||
==Differential Diagnosis== | |||
{{Hypertension DDX}} | |||
== Treatment == | == Treatment == | ||
Revision as of 08:21, 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 |
Work-Up
JNC 7 recommends chem 8, ECG, CXR, and UA prior to initiating therapy
- Upreg
- <120 diastolic --> home, outpt rx
- >210 systolic or >120-130 diastolic --> search end organ
- Chem 7 (creatinine)
- "No other diagnostic screening tests (e.g. UA, ECG) appear to be useful"[2]
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
- HCTZ 12.5mg, max 25mg
- Need labs before starting, does not work in people with CKD
- HCTZ 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 hyperK and Cr
- 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 ext edema 2/2 proteinuria
JNC 8 Recommendations[3]
| 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 |
JNC-8 Changes
- In PTs ≥60 yr the threshold has increased from <140/90 to <150/90[4]
ACEP 2012 Clinical Policy on Asymptomatic Elevated BP[5]
- Screening
- Routine screening for acute target organ injury (e.g. creatinine, UA, ECG) is NOT required (Level C)
- In select patient populations, screening of creatinine may identify injury that affects disposition (Level C)
- Treatment
- Routine ED medical intervention is NOT required (Level C)
- In select patient populations, physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control (Level C)
- Patients should be referred for outpatient follow up (Level C)
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.
- ↑ 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
- ↑ 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.
- ↑ 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.