November 2013: ED Management of Asymptomatic Hypertension

This month JC will be looking at the management of patient’s with asymptomatic hypertension in the ED.  There is limited data particularly data that addresses important patient outcomes as those described in the PICO below. I have included two widely cited articles as well as a Clinical Policy Statement from ACEP. Most of us find this a challenging issue particularly when we first hear about the patient’s BP at the time of discharge from the ED. Should we give the nurse a friendly eye-roll and tell them no intervention necessary or should we be more aggressive advocates regarding screening and management in our local patient population. Should make for an interesting JC.

PICO Question

Population: Patients presenting to the emergency department (ED) with severely elevated BP and no signs or symptoms concerning for end-organ damage  

Intervention: Laboratory testing, electrocardiogram (ECG), chest x-ray, or rapid reduction in blood pressure                                                                               

Comparison: Outpatient referral for evaluation and initiation of antihypertensive therapy 

Outcome: Stroke, MI, renal failure, dialysis, death

Nishijima DK, Paladino L, Sinert R. Routine testing in patients with asymptomatic elevated blood pressure in the ED. AM J Emerg Med. 2010 Feb;28(2):235-42.

Karras DJ, Kruus LK, Heilpern KL. Utility of routine testing for patients with asymptomatic severe blood pressure elevation in the emergency department. Ann Emerg Med. 2008 Mar;51(3):231-9.

Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Asymptomatic Hypertension in the ED. Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department. Ann Emerg Med.2006 Mar;47(3);237-49.