Asymptomatic Hypertension

UPPER BLOOD PRESSURE MANAGEMENT GOALS FOR ADMISSION TO OBS, ACUTE CARE, OR PCU

Background and Problem: There is a common misconception that a policy on upper blood pressure limits exits for patients who may be admitted to OBS, Acute Care, or PCU. A common belief is that without lowering of blood pressures to acceptable ranges, patients may not be transferred to these areas. Therefore, asymptomatic hypertension (hypertensive urgency) is often treated with aggressive IV medications in the Emergency Department to obtain rapid lowering of blood pressure prior to admission to the inpatient or observation areas of the hospital. However, no such policy exists at Sharp Memorial. The issue seems to stem from the routine holding orders that most physicians order upon admission to the hospital. The standard order set states, “Please call attending immediately if: SBP >180, DBP >110.” The expectation then becomes that immediate action will be taken given the urgency of this order, and therefore the patient should not leave the ED until this deficiency is corrected. However, immediate lowering of BP in patients without hypertensive emergency is difficult, time consuming, and potentially harmful. It hampers ED length of stay times and overall throughput from the ED. Furthermore, there is no benefit in patient oriented outcomes on either a short or long term scale.

Solution:

Educate all physician and nursing personnel on the difference between hypertensive emergency and asymptomatic hypertension (hypertensive urgency).

Eliminate the standard order “Please call attending immediately if: SBP >180, DBP >110” from all routine admission orders, specifically from all cases in which there is no evidence of hypertensive emergency. Attending physicians can add upper blood pressure notification requirements on a case-by-case basis should they determine that upper blood pressure notification is warranted.

Eliminate any notion of upper blood pressure limits as a potential barrier to admission for all OBS/Acute Care/PCU admissions.

Educate all physician and nursing personnel regarding the new changes.

Data and Guidelines

What defines hypertensive emergency vs asymptomatic hypertension (hypertensive urgency)?
- “Hypertensive emergencies are characterized by severe elevations in BP (􏰁180/120 mm Hg) complicated by evidence of impending or progressive target organ dysfunction. They require immediate BP reduction (not necessarily to normal) to prevent or limit target organ damage. Examples include hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, acute left ventricular failure with pulmonary edema, unstable angina pectoris, dissecting aortic aneurysm, or eclampsia.”
- “Hypertensive urgencies are those situations associated with severe elevations in BP without progressive target organ dysfunction. Examples include upper levels of stage II hypertension associated with severe headache, shortness of breath, epistaxis, or severe anxiety. The majority of these patients present as noncompliant or inadequately treated hypertensives, often with little or no evidence of target organ damage.”
  - JNC 7, Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003 Dec;42(6):1206-52. Epub 2003 Dec 1. PMID: 14656957
- Does rapid lowering of the blood pressure help patients with asymptomatic hypertension (hypertensive urgency)?
  - “Rapid reduction of severe asymptomatic hypertension with orally administered antihypertensive medication has become a common emergency department practice. … In view of the small but reported risk of antihypertensive loading and the burden and expense of prolonged emergency department therapy, these results suggest that the common practice of acute oral antihypertensive loading to treat severe, asymptomatic hypertension should be reconsidered.”
    - Rapid reduction of severe asymptomatic hypertension. A prospective, controlled trial. Arch Intern Med. 1989;149(10):2186. PMID 2679473
  - “In the office setting, however, very high blood pressure readings may also be perceived as posing an immediate risk of acute coronary syndrome or stroke, perhaps prompting hospital referral. To date, however, no study has indicated that hypertensive urgency portends acute risk.”
    - CONCLUSIONS AND RELEVANCE: Hypertensive urgency is common, but the rate of MACE in asymptomatic patients is very low. Visits to the ED were associated with more hospitalizations, but not improved outcomes. Most patients still had uncontrolled hypertension 6 months later.
      - Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA Intern Med. 2016;176(7):981. PMID 27294333
    - Does rapid lowering of blood pressure in cases of asymptomatic hypertension (hypertensive urgency) cause harm?
      - “There are a number of case studies and case reports of patients with poor outcomes, including hypotension, myocardial ischemia and infarction, strokes, and death, precipitated by rapidly lowering elevated blood pressures in asymptomatic patients.”
        
        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. PMID: 16492490
        
        Referencing the following studies
        
        Shayne PH, Pitts SR. Severely increased blood pressure in the emergency department. Ann Emerg Med. 2003;41:513-529.
        
        Gallagher EJ. Hypertensive urgencies: treating the mercury? Ann Emerg Med. 2003;41:530-531.
        
        Ram CV. Immediate management of severe hypertension. Cardiol Clin. 1995;13:579-591.
        
        Wachter RM. Symptomatic hypotension induced by nifedipine in the acute treatment of severe hypertension. Arch Intern Med. 1987;147:556-558.
        
        O’Mailia JJ, Sander GE, Giles TD. Nifedipine-associated myocardial ischemia or infarction in the treatment of hypertensive urgencies. Ann Intern Med. 1987;107:185-186.
        
        What do the established clinical practice guidelines state on the topic?
        
        Regarding urgency – “there is no evidence to suggest that failure to aggressively lower BP in the emergency room is associated with any increased short-term risk to the patient who presents with severe hypertension.”
        
        JNC 7, Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003 Dec;42(6):1206-52. Epub 2003 Dec 1. PMID: 14656957
        
        “In contrast, hypertensive urgencies are situations associated with severe BP elevation in otherwise stable patients without acute or impending change in target organ damage or dysfunction. Many of these patients have withdrawn from or are noncompliant with antihypertensive therapy and do not have clinical or laboratory evidence of acute target organ damage. These patients should not be considered as having a hypertensive emergency and instead are treated by reinstitution or intensification of antihypertensive drug therapy and treatment of anxiety as applicable. There is no indication for referral to the emergency department, immediate reduction in BP in the emergency department, or hospitalization for such patients.
        
        2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71(6):e13-e115. PMID: 29133356
        
        “In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes?… In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required.”… “It is generally accepted that the rapid lowering of markedly elevated blood pressure in the asymptomatic patient has the potential to do harm”
        
        Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013 Jul;62(1):59-68. PMID: 23842053

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