Stuart Swadron, MD

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Foundations: Hypertension

Stuart Swadron, MD

Pearls:

  • Most people who present to the Urgent Care (UC) with elevated BP do not need aggressive intervention.

  • Focus on identifying those with hypertensive emergency, who require emergent lowering of the BP with IV drugs.

  • Hypertensive emergency occurs when there is high blood pressure that is associated with active, ongoing damage to the heart, brain, kidneys or eyes, that can be salvaged by reducing the blood pressure.

A history of hypertension:

  • The first modern studies demonstrating that elevated blood pressure was a problem were in the 1970s.  We began treating hypertension, and early on we considered any elevated blood pressure in the acute setting to be a problem that needed to be lowered immediately.

  • After years of experience, we now understand that for the vast majority of patients, lowering blood pressure acutely is not necessary and might actually be dangerous.  When patients have chronically elevated blood pressure, their brains get used to it.  If the blood pressure then drops precipitously, it is possible that the brain will not receive enough blood and the patient can suffer a watershed stroke.

  • Freis ED. The Veterans Administration Cooperative Study on Antihypertensive Agents. Implications for Stroke Prevention. Stroke. 1974;5:76-77. [Free open access link]

  • The same study that demonstrated the risk of chronically elevated blood pressure also offered evidence that very high blood pressures do not pose an acute risk to the patient.

  • Veterans with very high blood pressures were randomized to either receive treatment or receive no treatment.

  • Demonstrated that patients who were treated with medications had significantly longer lives.

  • The patients who were not treated did not have an immediate bad outcome, but rather experienced delayed consequences.  The first bad outcome in the cohort that did not receive medication to control BP was a stroke that occurred at 60+ days after the trial initiated.

  • Most patients that have high BP measurements in the UC setting do not need their BP emergently lowered.  However, there are rare instances when hypertension does need to be treated as an emergency.

  • Hypertensive emergency occurs when a patient with severely elevated blood pressure has evidence of acute end-organ damage.  The ACUTE is critical.

  • Blood pressure becomes an emergency when it is associated with ongoing damage to an internal organ like the heart, brain, kidneys or eyes and this damage can be stopped with reduction of blood pressure. This is a very narrow definition and these are the only people who need a trip to the ED to get on IV, titratable BP medication.

  • Everyone else requires very little from you in the UC setting.  They need an oral agent that will slowly reduce the blood pressure over the next 48-72 hours.

  • Note: The EKG of a patient with high blood pressure will likely show left ventricular hypertrophy that has been there for a long time and does not require treatment in the UC or ED.

True Hypertensive Emergencies

Very high BP +

Tx to consider

Acute coronary syndrome/myocardial infarction

Active chest pain

Morphine, nitroglycerin

Aortic dissection

Active chest pain

Morphine, nitroglycerin

Pulmonary edema

Shortness of breath, crackles

Nitroglycerin

Hypertensive encephalopathy

Headache, nausea, confusion

Subarachnoid hemorrhage/hemorrhagic stroke

Headache

Alpha-crisis

Recent cocaine, amphetamine, PCP use.

Benzos

Pre-eclampsia

Current or recent pregnancy

Headache

Note: the BPs in pre-eclampsia are often lower than other hypertensive emergencies and can be seen up to 6 weeks after delivery.

How should hypertensive emergencies be handled in the UC?

1. Call 911.

2. Put the patient on a monitor, start supplementary oxygen and move the crash cart very close to the patient.  Put the paddles on.

3. Instead of attacking the blood pressure immediately with BP agents, consider starting with the patient’s symptoms.

    • If the patient is very anxious, try 1mg lorazepam (Ativan).
    • If the patient has a lot of pain, consider morphine.
    • If the patient has chest pain consider nitroglycerin, but only after there is a good IV line than can be used to bolus fluids.
  1. Gain control over the BP with IV medications.  Oral agents are very difficult as you cannot control them or know when they have reached maximal effectiveness.

  2. Get a bolus ready in case the BP drops too low.

  3. Transfer the patient to the ED as soon as possible.

  • Hypertensive encephalopathy.  These patients have passed a threshold where their brain can no longer adapt to the high pressures it has been exposed to for a long time.  This usually occurs around the 230/140 range.  The brain can no longer protect itself from the high pressures, cells become damaged and there is cerebral edema. This is life threatening and can cause herniation syndromes, but it is very rare.  People that truly have hypertensive encephalopathy have a headache, nausea, vomiting and confusion.

  • A stroke often gets confused and misdiagnosed as hypertensive encephalopathy.  These two need to be differentiated because a patient with an infarct and elevated BP is going to be treated with permissive hypertension.  A person with hypertensive encephalopathy needs to have the BP lowered very quickly.  Consider sending these people to the ED without UC intervention where their BP can be controlled with IV meds.

  • What is the relationship between hypertension and benign headaches?  We do not need to worry about these headaches as long as the patient is clear that this headache is the same in nature and severity as their normal, chronic tension headaches.  If the patient reports there is anything new or different about this headache, evaluation for SAH/hypertensive emergency is required.

  • Consider the patient’s comorbidities when determining a disposition with hypertension.  A man who is otherwise healthy with no underlying conditions can probably go home and follow up with his PMD in a day to two for a BP recheck.  A man with a history of diabetes, ACS and CHF, is more likely to need some medical stabilization and it is worth considering sending the patient to the ED for a higher level of care.