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    Hypertension Beyond Emergency & Urgency

    Cardiovascular

    Last Updated Jan 19, 2022
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    By Nicholas Sparrow, Raman Ubhi

    Context

    • Many patients present with asymptomatic HTN (for symptomatic patients refer to point-of-care emergency clinical summary Hypertensive Emergency).
    • Some emergency physicians choose to initiate hypertension treatment in the ED on a case-by-case basis.2
    • There is lack of evidence based guidelines regarding initiating treatment for primary hypertension in the ED.
    • Recent review recommends considering treatment for marked hypertension (above 180/110) consistent with 2013 American College of Emergency Physicians’ Guidelines – based on expert panel consensus.3
    • It is also noted that studies have shown for many patients BP remains elevated on follow-up after ED visit.1,3,5

    Diagnostic Process

    • For patients not in hypertensive emergency or urgency, 2 or more readings should be taken during the visit before diagnosis.
    • Automated BP, preferably multiple measurements with patient alone in room to minimize white coat syndrome.
    • Hypertension can be diagnosed if mean BP greater than or equal to 180/110 during the visit.
    • Otherwise patient likely needs to follow up with an ambulatory BP device or home BP monitoring.
    • Patients diagnosed with new diagnosis of HTN should follow up with a provider within 1 week.
    • Focused history & physical regarding chronic target organ damage such as:
      • cardiovascular disease (e.g., angina, symptoms of heart failure).
      • peripheral vascular disease (e.g., claudication, lower extremity atrophy).
      • cerebrovascular disease (e.g., previous stroke/TIA, vascular dementia).
      • retinopathy.

    Ask about possibility of pregnancy (LMP, pregnancy planning).

    • Other tests to consider on initial diagnosis:
      • ECG
      • Urinalysis
      • Electrolytes
      • Kidney function
      • Consider diabetes screening and lipids
      • Consider pregnancy test

    Figure 1: Approach to non-emergent hypertension in Emergency3

    Figure 2: Hypertension Canada diagnostic algorithm4

    Recommended Treatment

    • Nonpharmacologic treatment4
      • Increase physical activity, provide exercise prescription: 30-60 minutes of moderate intensity exercise (walking, swimming, cycling) 4-7 days a week.
      • Weight reduction (target BMI 18.5-24.9 with target waist circumference <102cm men, <88cm women).
      • Decrease alcohol intake <2 drinks per day.
      • Diet such as DASH diet, increase fruits/vegetables.
      • Decrease sodium intake (<2g), consider increasing potassium.
      • Smoking cessation.
      • Relaxation therapy if stress is a factor.
    • Pharmacologic treatment (first line)4
      • Thiazide/thiazide like diuretic (long-acting such as chlorthalidone preferred)
      • ACE-I
      • ARB
      • Long acting CCB
      • Single pill combination (CCB+ACE-I, CCB+ARB, ARB+diuretic)
      • Beta blocker (not first line above 60yo)

    No ACE-I or ARB in pregnancy, avoid if planning pregnancy.

    ACE inhibitors favored when significant cardiovascular history, see hypertension highlights chart.

    Quality Of Evidence?

    Justification

    Recent review and metanalysis include many prospective and retrospective studies showing that hypertension seen in ED often persisted on follow-up1,3 and was not related to pain/anxiety.5

    However, the percentage of patients with true chronic HTN varied across studies in review, and individual studies were limited by design, e.g., poor patient follow-up.

    Low

    Related Information

    OTHER RELEVANT INFORMATION

    1. Hypertension highlights, includes Considerations in the Individualization of Pharmacological Therapy in Adults table https://guidelines.hypertension.ca/wp-content/uploads/2020/08/2020-22-HT-Guidelines-E-WEB_v3b.pdf

      Blood Pressure Action Plan for patients: https://guidelines.hypertension.ca/patient-resources


    Reference List

    1. Armitage LC, Whelan ME, Watkinson PJ, Farmer AJ. Screening for hypertension using emergency department blood pressure measurements can identify patients with undiagnosed hypertension: A systematic review with meta-analysis. J Clin Hypertens. 2019 Sep;21(9):1415-1425.


    2. Cho DD, Austin PC, Atzema CL. Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study. CJEM. 2015 Sep;17(5):523-31.


    3. Miller J, McNaughton C, Joyce K, Binz S, Levy P. Hypertension Management in Emergency Departments. Am J Hypertens. 2020 Oct 21;33(10):927-934.


    4. Rabi DM, McBrien KA, Sapir-Pichhadze R, et al. Hypertension Canada’s 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children. Can J Cardiol. 2020 May;36(5):596-624.


    5. Tanabe P, Persell SD, Adams JG, McCormick JC, Martinovich Z, Baker DW. Increased blood pressure in the emergency department: pain, anxiety, or undiagnosed hypertension? Ann Emerg Med. 2008 Mar;51(3):221-9.


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