Cite this post as:
Scott Weingart, MD FCCM. Practical Evidence 013 – ACEP Management of Asymptomatic Blood Pressure 2013. EMCrit Blog. Published on October 22, 2013. Accessed on September 18th 2024. Available at [https://emcrit.org/emcrit/2013-acep-management-of-asymptomatic-htn/ ].
Financial Disclosures:
The course director, Dr. Scott D. Weingart MD FCCM, reports no relevant financial relationships with ineligible companies. This episode’s speaker(s) report no relevant financial relationships with ineligible companies unless listed above.
CME Review
Original Release: October 22, 2013
Date of Most Recent Review: Jul 1, 2024
Termination Date: Jul 1, 2027
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Scott,
Great Podcast as usual!
A few comments:
1. Regarding the utility of obtaining serum Cre for pts with poor follow up – one point is that once a pt has ESRD, they magically get on Medicare, so there may be some benefit to testing and admitting those pts.
2. Regarding initiation of treatment in the ED – I am actually a research fellow, and this is my big project – keep an eye out – I might have an answer for you in a couple of years!
Aaron
Sounds good my friend
Fist of all, I’m a huge fan. I absolutely love driving to work now, listening to your podcasts – and the ones by Jeffrey Guy. I am a veterinarian and specialize in emergency and critical care and I have learned so much already listening to your podcasts. I would to comment on the one about asymptomatic hypertension. I was a bit taken back by the fact that there is a lack of recommendation to treat asymptomatic hypertension. If someone has a pressure of 260/110, aren’t you just waiting for disaster to strike if you don’t treat? In cats we also… Read more »
Thanks Roger. Hypertension absolutely needs treatment, just not emergent treatment. In fact the only way to screw up an asymptomatic patient is to bring their bp down too quickly. If they are sitting comfortably at 260/110 it means they’ve been there for a long time. Acute lowering leads to ischemia. This was discovered when folks thought it clever to break open nifedipine capsules to use sublingually. Strokes resulted.
Hi Scott,
thanks for the reply. It totally makes sense what you said and I actually would not admit them for treatment, either. The only drug we usually have for this is nitroprusside and I would not use it in an asymptomatic cat, either. I would just script out some amlodipine (our treatment of choice for hypertension in cats) and this is generally safe and well tolerated.
I think this problem will increase as we see more iPhone apps and such capable of measuring BP. It makes me think: What is the cutoff for having a symptom? In my experience some patients say “I feel a little strange” and are not able to narrow it down. I try to convey to the students that this warrants treatment, observation and Cr as well as the clinical examination. I worry that innocent appearing symptoms, that are poorly quantified by the patient is interpreted as no symptoms.
Symptoms in this regard are not subtle. In hypertensive emergency the patient looks like crap. When the studies have looked at ?s like can elevated BP cause headache or other vague symptoms, the answer turns out to be that the headache was much more likely to have caused the BP elevation than vice versa.
I have been looking into this recently and have not found good data regarding the vague symptoms. Do you have any pubmed links handy?
Alex
EM/IM resident
Hey Scott, Let me start with the obligatory sunshine blow: I love your stuff and thanks to the unaware masses not catching on to the impact of amazingly current and high-yield FOAM (especially EmCrit) I look a little smarter each day. Now on to the practical question. As a committed, albeit junior, academician I struggle with balancing EBM, efficiency, and medico-legal issues on a daily basis. Your review of the Management of Asymptomatic HTN nicely epitomizes one of those challenges. I think there are many from the “recently trained” community who recognize the party-line statement that we should resist the… Read more »
I will do a podcast on hypertensive emergencies just for you brother (and not just b/c you have good taste in beer).
Solid podcast – like the addition of the practical evidence (and beer) to the emcrit feed. Love everything evil twin does – they’re actually a “gypsy brewer” from Denmark that sets up shop in other breweries and puts out collaboration beers, they used to be with Westbrook brewing back home in charleston, sc … would love for them to follow me to residency in chi-town!
beautiful info on Evil Twins!
Hey Scott,
In your hypertensive emergencies discussion I hope you touch on what type/degree of renal impairment should mandate admission/intervention.
Example, Pt rolls in with the usual drug store hypertension and really does have a BP of 220/140, asymptomatic, repeatedly elevated in the ED. Hasn’t seen a primary doc in a few years. Creatinine 1.8 or 2.4 or 3.8 or 5? I’m never sure what to do with this, especially if arranging follow up is not easily obtainable.
Look forward to hearing the Htnsive episode
Mike.
Mike, I think it is dealer’s choice on these guys. If you want to admit or can’t get them f/u locked in within a short time (3-5 days), admit. If you can get them f/u (in an office that has the ability to get them all the tests they need–renal uts, rapid return blood tests, etc.). In my county trauma center, we would admit all of these guys and we’d get paid for it.
Great summary of this paper Scott. While the literature doesn’t support universal screening for asymptomatic hypertension, most of these patients will rule in for essential hypertension in the outpatient setting, and many of these patients will have significant renal dysfunction, so getting a quick Creatinine I think is reasonable. If the patient follows up as an outpaitent armed with an elevated Creatinine they will be more likely to be treated appropriately. Just like we have a responsibility for screening for abuse, we have a responsibility for screening for kidney dz in patients with markedly elevated BP in the ED. We’ll… Read more »
I don’t disagree, but the ? pit docs want to know is can they get the pt out right away, and the answer is yes. They’ve prob. been sitting in the dpet for some repeat measurements by the time the doc picks up their chart and they can get d/ced within minutes after that in the right circumstance.
What if you send a asymptomatic patient home with BP of 250/110 without treatment and next day his BP goes further up and then he comes back with brian bleed or MI or aortic dissection ? Bomb will blast if pressure keeps on going up. Everyone knows that BP should not be corrected quickly in these set of patients but I am not sure discharging these people completely untreated is a good idea. If things can go wrong they will go wrong on occasions.
Hey Scott, Great podcast, great refresher. You wondered about why 3 months as the cutoff for adverse outcomes (~7:30 in podcast): From the ACEP rec: “A Class III study, the VA Cooperative Trial of 1967, was a randomized placebo-controlled trial of 143 male patients with diastolic blood pressure of 115 mm Hg to 130 mm Hg. No adverse outcomes in either group were demonstrated during the initial 3 months of enrollment. Four of 70 patients in the placebo group (6%; 95% CI 2% to 14%) versus 0 of 73 patients in the treatment group (0%; 95% CI 0% to 5%)… Read more »
will give it a shot!