Black tonometer and heart isolated on whiteHypertension is one of the most common conditions seen in primary care clinics and emergency departments (EDs).  Frequently, patients are found to have asymptomatic hypertension and referred to EDs for management, despite the fact that rapidly lowering blood pressure is not necessary and may be harmful.  Yet many clinics still refer these patients for emergent management. In December 2013, the Eighth Joint National Committee (JNC 8) published a new, open-access, evidence-based hypertension guideline in JAMA.  They only cited randomized clinical control trials to answer three questions:

  1. Does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
  2. Does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
  3. Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

 What was included in this review?

  • Adults aged 18 years or older
  • Randomized controlled trials with 100 patients or more and at least one year or more of follow up

What are the strengths of recommendation?

  • A = Strong Recommendation
  • B = Moderate Recommendation
  • C = Weak Recommendation
  • D = Recommendation Against
  • E = Expert Opinion
  • N = No Recommendation For or Against

 What were the recommendations made? 1

  • Recommendations 1 – 5 address thresholds and goals for blood pressure treatment
  • Recommendations 6 – 8 address the selection of antihypertensive medications
  • Recommendation 9 addresses a summary of strategies for starting and adding antihypertensive medications

Recommendation 1

  • Grade A: In the general population age ≥ 60 years, initiate pharmacologic treatment to lower BP if ≥ 150/90 mmHg
  • Grade E: In the general population age ≥ 60 years, if pharmacologic treatment results in BP ≤ 140/90 mmHg, and no adverse effects, treatment does not need to be adjusted

Recommendation 2

  •  In the general population age < 60 years, initiate pharmacologic treatment to lower DBP if ≥ 90 mmHg
      • Grade A: Ages 30 – 59 years
    • Grade E: Ages 18 – 29 years

Recommendation 3

  • Grade E: In the general population age <60 years, initiate pharmacologic treatment to lower SBP if ≥ 140 mmHg

Recommendation 4

  • Grade E: In patients < 70 years with chronic kidney disease (GFR < 60 mL/min/1.73 m2), initiate pharmacologic treatment to lower BP if ≥ 140/90 mmHg
  • No recommendation could be made based on current evidence in patients ≥ 70 years with CKD (GFR < 60 mL/min/1.73 m2)

Recommendation 5

  • Grade E: In patients with diabetes mellitus, initiate pharmacologic treatment to lower BP if ≥ 140/90 mmHg

Recommendation 6

  • Grade B: In the non-African American population, including patients with diabetes mellitus, initial hypertensive treatment should include:
    • Thiazide diuretic,
    • Calcium channel blocker (CCB),
    • Angiotensin-converting enzyme inhibitor (ACEI), or
    • Angiotensin receptor blocker (ARB)

Recommendation 7

  • In the African American population, initial anti-hypertensive treatment should include a thiazide diuretic or a CCB
    • Grade B: General African American population
    • Grade C: African American population with diabetes mellitus

Recommendation 8

  • Grade B: In the general population with CKD and hypertension, initial anti-hypertensive (or add-on) treatment with an ACEI or ARB improves kidney outcomes

Recommendation 9

  • Grade E: The main objective of hypertension treatment is to attain and maintain goal BP.  If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes recommended above.

Take Home Points:

  • Age ≥ 60 years: Goal BP is < 150/90 mmHg
  • Age < 60 years, CKD, DM, regardless of race: Goal BP < 140/90 mmHg
  • These are are 1 month goals and not acute goals to be managed in the ED

What does the 2013 ACEP Clinical Policy say on this topic?

  • ACEP Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure, July 2013.

In patients with asymptomatic elevated BP, does screening for target organ injury reduce rates of adverse outcomes?

  • Level C: “Routine screening for acute target organ injury is not required but in select patient populations (i.e, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition.”

In patients with asymptomatic markedly elevated BP, does ED medical intervention reduce rates of adverse outcomes?

  • Level C : “In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required.”
  • Consensus Recommendations:
    • “In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control.”
    • “Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up.”

Take Home Points:

  • Patients with asymptomatic elevated BP do not need screening labs and can be referred for outpatient management.

Bottom Line

Patients referred to the ED with asymptomatic hypertension DO NOT need immediate blood pressure management or lab screening, but do need referral to a primary care physician for repeat blood pressure checks and initiation of pharmacologic therapy if needed.

1.
James P, Oparil S, Carter B, 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. [PubMed]
Salim Rezaie, MD

Salim Rezaie, MD

ALiEM Associate Editor Clinical Assistant Professor of EM and IM University of Texas Health Science Center at San Antonio Founder, Editor, Author of R.E.B.E.L. EM and REBEL Reviews
Salim Rezaie, MD

@srrezaie

EM/IM Doc; Founder of REBEL EM & REBEL Cast; Doing my Part to Cut Down on KT Time; Viva #FOAMed #FOAMcc (Tweets are opinion only)