ACEP Guidelines: Asymptomatic Elevated Blood Pressure

Courtesy of Dr. Michael Jones @treatNstreetEM

Check out the latest revision of the ACEP Clinical Guideline on the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure:

http://www.acep.org/clinicalpolicies/

Bottom line — no good evidence on the topic!!!

So stop checking labs, urines, and ECG’s!  Discharge the patient with primary care followup.

 

The two questions addressed in this revision:

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

Patient Management Recommendations

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations.

(1) In ED patients with asymptomatic markedly elevated blood pressure, 
routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required.

(2) In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine may 
identify kidney injury that affects disposition (eg, hospital admission).
 

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

Patient Management Recommendations

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations.

(1) In patients with asymptomatic markedly elevated blood pressure, routine 


ED medical intervention is not required.

(2) 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. [Consensus recommendation]

(3) Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation]

3 Comments on "ACEP Guidelines: Asymptomatic Elevated Blood Pressure"

  • mike… i agree that acep finally has a more solid guideline for asymptomatic HTN and its eval in the ED. Mentioned this on “why we do what we do” column posted earlier. Friendly reminder to the residents, just as you posted, clear caveat is the 2nd bullet:
    (2) In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine may 
identify kidney injury that affects disposition (eg, hospital admission).
    (2) 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. [Consensus recommendation]

    So don’t just discharge the patients with no ED workup for their asymptomatic HTN if you cannot ensure primary care follow up.

  • These guidelines make me happy – but we recently had a case that made me think twice about their use…

    There was a pt recently @ Jacobi that was asymptomatically hypertensive to 200s/100s. According the above guidelines, this pt could have been started on an anti-hypertensive, given quick follow-up and sent home. In this case, the team decided to do an EKG and draw labs – he ended up having an NSTEMI w/ trops of 4.

    So is this the exception to the rule? Can you use these ACEP guidelines as “protection” if you have a bad outcome? (ie this pt was sent home and ended up dying from an MI, etc)

    Seasoned veterans, enlighten me!

  • Post that case! Get that follow up! Let’s have that discussion here.

    Want to know what happened to that guy? He got cathed. The cath showed some disease. So they stented some lesions, maybe one, maybe 2. He went home, now feeling no CP. (Oh, wait, he was asymptomatic to begin with.)

    Did he ever come back? Sure did. With occlusion of one his brand new stents. Still happy you got those labs? And here’s the kicker: Guess what his BP was when he returned? Still crappy, cause we all started looking for his lesions and feeding him ASA instead of Lisinopril. Cause he started following up with his interventional cardiologist instead of his PMD.

    But maybe I’m jaded and cynical. Maybe the idea that pts. who have no symptoms should get less intervention really isn’t a good way to balance risk and benefit. And maybe cardiology has already stopped stenting non-culprit lesions in your institutions. Sure.

    -pik

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