Hypertension (main): Difference between revisions
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==Background== | ==Background== | ||
{{Hypertension definition}} | |||
{{Hypertension categories}} | {{Hypertension categories}} | ||
==Clinical Features== | ==Clinical Features== |
Revision as of 12:03, 4 December 2016
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 |
Elevated Blood Pressure | 120-129 | and | <80 |
Stage 1 | 130-139 | or | 80-89 |
Stage 2 | ≥140 | or | ≥90 |
- JNC-8 Changes:
- In patients ≥60 yr the threshold has increased from <140/90 to <150/90[2]
- Patients with diabetes mellitus (any age) and >140/90
Categorization of Hypertension[3]
- Asymptomatic hypertension
- Systolic BP 140-179 or diastolic BP 90-109
- Asymptomatic
- Hypertensive urgency^
- Systolic BP ≥ 180 or diastolic BP ≥ 110
- No evidence of end-organ dysfunction
- Hypertensive emergency
- Systolic BP ≥ 180 or diastolic BP ≥ 110
- Evidence of end-organ dysfunction
^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
- Most hypertension is asymptomatic
- End organ damage may result in chest pain, altered mental status, blurred vision or signs of acute kidney failure
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
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]
- Chem 7 (creatinine) --> home with outpatient treatment if no evidence of acute renal failure
Management
Disposition
- Hypertensive emergency --> admission
- Otherwise, normally discharged home with a follow up appointment with the primary care physician
References
- ↑ 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.
- ↑ Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.
- ↑ 4.0 4.1 4.2 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.