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1. Project: Ghana Emergency Medicine Collaborative
Document Title: Hypertensive Urgency and Emergency
Author(s): Keith Kocher (University of Michigan), M.D. MPH 2010
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2

3. Hypertensive Urgency and
Emergencies
Keith Kocher, MD MPH
University of Michigan
Department of Emergency Medicine
August 11th, 2010
3

4. Objectives
n Know how to evaluate someone who is
hypertensive (which may mean doing nothing)
n Know how to distinguish between hypertensive
emergencies and non-emergencies—and how to
manage them
n Competently be able to appropriately disposition
patients over the range of hypertension problems—
from someone with an elevated blood pressure to
hypertensive emergencies
4

5. Outline
n Background
n Small group discussion
n Evidence based lecture
n Final thoughts and questions/comments
5

6. Lecture/Topic Boundaries
n Lecture confined to evaluation
and management of
hypertension within the ED
setting
n Adults
n Will touch on several disease
processes, but not the definitive
lecture on managing the entire
range of hypertensive
emergencies
Medisave UK 2013 (Flickr)
6

7. Lecture/Topic Boundaries
n I want to specifically encourage interruptions,
questions, and discussion during my talk
n You will find that there is a lack of evidence based
medicine support for many of these issues
n You will find that there are many ways of managing
these patients
n You will find there may be local/regional and
generational differences in physician (PCP and EP)
management 7

8. Definitions
n Elevated blood pressure
n Hypertension without an
underlying diagnosis of
hypertension
n Hypertension
n The disease of chronically
elevated blood pressure
n Essential hypertension
(90%)
n Hypertension without a
specific secondary cause
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7). National Heart, Lung, and Blood Institute,
n Secondary hypertension
(10%)
n Hypertension related to an
underlying pathologic
process (adrenal disease,
renal disease, etc)
8

9. Definitions
n Hypertensive
crisis
n A hypertensive
urgency or
emergency
n Hypertensive
urgency
n Severe elevations
in BP without
progressive target
organ dysfunction
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7). National Heart, Lung, and Blood Institute,
n Hypertensive emergency
n Characterized by severe elevations
in BP (>180/120) complicated by
evidence of impending or
progressive target organ dysfunction
n Malignant hypertension
n Old term, varying definitions,
unlikely to find in recent guidelines
n Severely elevated blood pressure
with retinal hemorrhages or
papilledema vs. encehalopathy or
acute nephropathy
9

10. Definitions
n Target organ dysfunction
or end organ damage:
n Brain
n Retina
n Heart
n Arteries
n Kidney
n Then decide what it means
to have “dysfunction” or
“damage”?
n Headache vs. hemorrhage
n Chest pain vs. CHF
The Seventh Report of the Joint National
Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood
Pressure (JNC 7). National Heart, Lung,
and Blood Institute, 2003.
(chronic
conditions)
10

11. Epidemiology
n Why do we care about treating hypertension?
n Major public health problem
n Represents a huge burden of disease:
n Affects ~30% of population over age 20
n More than half of people 60–69 years of age and approximately three-
fourths of those 70 years of age and older are affected
n The relationship between BP and risk of cardiovascular events is
continuous, consistent, and independent of other risk factors
n The higher the BP, the greater the chance of heart attack, heart failure,
stroke, and kidney diseases
n For every 20 mmHg systolic or 10 mmHg diastolic increase in BP, there is a
doubling of mortality from both ischemic heart disease and stroke
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7). National Heart, Lung, and Blood Institute,11

12. n From the National
Hospital Ambulatory
Medical Care Survey
(NHAMCS)
n CDC database
tracking ED specific
information starting
in 1992
n Codes for up to three
reasons for visit
n Often associated
with other
complaints:
headache, chest
pain, vertigo/
dizziness, dyspnea,
abdominal pain,
palpitations,
epistaxis
0.0%
0.1%
0.2%
0.3%
0.4%
0.5%
0.6%
0.7%
0.8%
0.9%
1.0%
0
200
400
600
800
1,000
1,200
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
in100,000visits
National Trends in Hypertension as Presentation to
the ED: 1998-2007
Total number of ED visits (left axis)
Percentage of ED visits with hypertension as any of three recorded reasons for presentation
(right axis)
Percentage of ED visits with hypertension as primary reason for presentation (right axis)
NHAMCS
12

13. n From NHAMCS
n Database began
recording vital signs
starting in 2001
n Adults defined as
age ≥ 18
n Almost 50% of adult
ED patients present
with elevated blood
pressures in the
range of “stage 1”
hypertension
n Almost 10% of adult
ED patients present
with elevated blood
pressures in the
hypertensive crisis
range
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
100
200
300
400
500
600
700
800
900
1,000
2001 2002 2003 2004 2005 2006 2007
in100,000visits
National Trends in Elevated Blood Pressure
for Adults at Time of Presentation to the ED: 2001-2007
Total number of adult ED visits (left axis)
Percentage of adult ED visits with elevated blood pressures at presentation, systolic bp ≥ 140 or
diastolic bp ≥ 90 (right axis)
Percentage of adult ED visits with extremely elevated blood pressures at presentation, systolic
bp ≥ 180 or diastolic bp ≥ 120 (right axis)NHAMCS
13

14. n From NHAMCS
n For patients
presenting to
ED with blood
pressure or
hypertension as
any of the 3
reasons for visit
n Trends in
testing:
n Any blood test
(~60%)
n EKG (~50%)
n UA (~20%)
n No testing
done (~30%)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0.0%
0.1%
0.2%
0.3%
0.4%
0.5%
0.6%
0.7%
0.8%
0.9%
1.0%
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
National Trends in Testing for ED Presentations of
Hypertension: 1998-2007
Percentage of ED visits with hypertension as any of three recorded reasons for presentation (right axis)
Percentage of those ED visits in which any blood test ordered (right axis)
Percentage of those ED visits in which EKG ordered (right axis)
Percentage of those ED visits in which no testing done (right axis)
Percentage of those ED visits in which urinalysis ordered (right axis)NHAMCS
14

15. n From NHAMCS
n For those with any
of 3 final diagnoses
with specific
hypertensive related
diagnosis
n Includes following
diagnoses (based on
ICD-9 codes):
n Elevated blood
pressure reading
without diagnosis of
hypertension (code
796.2)
n Hypertensive
disease (codes
401-405)
n Excludes:
n Specific disease
processes in which
hypertension may be
aspect of care
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
National Trends in Hypertension Diagnoses and
Disposition in the ED: 1998-2007
Percentage of ED visits with any type of hypertensive diagnosis (left axis)
Percentage of these admitted/transferred (right axis)NHAMCS
15

16. Outline
n Background
n Small group discussion
n Evidence based lecture
n Final thoughts and questions/comments
16

17. Rules
n Groups of 4-5
n Mix of experience
n Some junior level residents, some senior
level residents, faculty spread around
n Elect a spokesperson
n Will report back to the group
17

18. Rules
n 2 Cases
n Specifically I want you to discuss:
n How evaluate (labs, other testing, do
nothing)
n How manage (treatment options,
consultants)
n How to disposition (admit ICU, admit,
discharge, outpatient treatment, follow up
instructions)
18

19. Case #1
A 53 year old man with a history of
hyperlipidemia presents to your ED with a
complaint of “high blood pressure.” He
was scheduled to undergo a dental
procedure today. However his dentist
noted his blood pressure to be 175/100 and
therefore cancelled the procedure and sent
him to the ED. Initial vital signs are: bp
180/105, pulse 90, temp 37.5, sat 99% on
RA. He otherwise has no complaints.
Specifically he denies chest pain, shortness
of breath, headache or focal neurologic
symptoms. Physical exam is normal. He
denies any known diagnosis of
hypertension.
Case #2
Questions:
1. What do you want to do
diagnostically?, therapeutically?
2. What is your disposition plan?
A 57 year old woman with a history of
hypertension presents with confusion. She
is brought in by her husband. Initial vital
signs are: bp 210/130, pulse 103, temp 37.5,
sat 99% on RA. She is able to provide some
history. She notes a headache but no focal
neurologic complaints. No fever, neck
pain, or rash. No chest pain, abdominal
pain, back/flank pain, or shortness of
breath. No trauma. Her husband states
she became gradually more disoriented
since yesterday and missed taking her usual
anti-hypertensive medications. Physical
exam is normal except she is disoriented to
time and place. Head CT is negative.
Questions:
1. What additionally do you want to do
diagnostically?, therapeutically?
2. What is your disposition?
19

20. Outline
n Background
n Small group discussion
n Evidence based lecture
n Final thoughts and questions/comments
20

21. Maxim 1
Hypertension in the ED is
a spectrum of disease
LESSON: You need to determine the
underlying process
21

22. Teaching Point
n Spectrum of disease:
inaccurate measurement → isolated elevated blood
pressure → hypertensive urgency → hypertensive
emergency
n When confronted with an elevated blood pressure, you
need to determine what is the underlying process
n How you treat may be radically different based on your
assessment
n A patient could have a blood pressure of 180/110 and be
experiencing any of the above clinical scenarios 22

23. Inaccurate BP measurement
n The accurate measurement of BP is the “sine qua
non for successful management”
n The equipment should be regularly inspected and validated
n The operator should be trained and regularly retrained in the standardized
technique
n The patient must be properly prepared and positioned
n The auscultatory method of BP measurement should be used
n Persons should be seated quietly for at least 5 minutes in a chair (rather than
on an exam table), with feet on the floor, and arm supported at heart level
n Caffeine, exercise, and smoking should be avoided for at least 30 minutes
prior to measurement
n An appropriately sized cuff (cuff bladder encircling at least 80 percent of the
arm) should be used to ensure accuracy
n At least two measurements should be made and the average recorded
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7). National Heart, Lung, and Blood Institute,23

24. Maxim 2
Asymptomatic
Hypertension in the ED
LESSON: Don’t just do
something…stand there
24

25. Isolated elevated blood pressure
n As an emergency
physician, what is
your responsibility?
n Is this one of our
public health
missions?—to screen
for hypertension
n We are not primary
care physicians.
n We do not regular
manage chronic
hypertension.
The Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (JNC 7). National Heart, Lung, and Blood
Institute, 2003.
25

26. Isolated elevated blood pressure
n Does an elevated blood
pressure in the ED mean
anything? And what level
of elevation is significant?
n People are anxious, in
pain, we don’t always get
accurate blood pressure
measurements—
especially when trying to
apply these to the
diagnosis of a chronic
condition
n Study in Kaiser system
n Included 407 patients without
diagnosis of hypertension
n Noted elevated BP in ED
n Followed up in clinic
n 70% continued to have an
elevated BP…more likely
with initially higher BPs in
the ED
n No difference between those
with/without pain
complaints or between those
seen in ED vs urgent care
Backer HD, et al. Reproducibility of Increased
Blood Pressure During an Emergency
Department or Urgent Care Visit. Annals of
Emergency Medicine, 2003;41(4):507-12.26

27. Inaccurate BP measurement
n How many BP
measurements would
be helpful to be able
to detect previously
undiagnosed
hypertension in an
ED patient?
Mamon J, et al. Using the ED as a Screening Site for High
Blood Pressure. Medical Care, 1987 25(8):770-80.
n Conducted in adult
ED at Johns Hopkins
n Patients presenting to
non-urgent side of ED
n 203 patients
n Found that important to
include 2 readings as first
was generally higher
n Using 3 readings did not
significantly improve
capture of patients with
hypertension
27

28. Isolated elevated blood pressure
n Testing
n Recommendations from JNC 7 for
outpatient setting:
n EKG
n UA, CBC, basic, cholesterol panel
n More extensive testing for causes of
secondary hypertension not necessary
n Not specifically addressed by ACEP
n If we are ad hoc PCP’s for some
patients, what is our
responsibility to do testing?
n Timing of these tests?
The Seventh Report of the Joint
National Committee on Prevention,
Detection, Evaluation, and Treatment
of High Blood Pressure (JNC 7).
National Heart, Lung, and Blood
Institute, 2003.
Laboratory Tests and Other Diagnostic Procedures
• Routine lab tests recommended before initiating
therapy: 12-lead electrocardiogram; urinalysis, blood
glucose and hematocrit; serum potassium, creatinine,
calcium^-66, and a lipoprotein profile that includes
high-density lipoprotein cholesterol, low-density
lipoprotein cholesterol, and triglycerides
• Optional tests: measurement of urinary albumin
excretion or albumin/ creatinine ratio (ACR) except for
those with diabetes or kidney disease where annual
measurements should be made. More extensive testing
for identifiable causes is not generally indicated unless
BP control is not achieved or the clinical and routine
lab evaluation strongly suggests an identifiable
secondary cause
28

29. Isolated elevated blood pressure
n Treatment?
n Lower blood pressure in ED
n Discharge with script to start an
anti-hypertensive
n Discuss with PCP over phone and
mutually decide on anti-
hypertensive to discharge with
n Refer to PCP to decide what to do
n Do nothing
n Rapidly lowering
an elevated BP
may cause harm
n Some patients
with elevated BP
in the ED may not
have elevation on
follow up in clinic
Decker WW, et al. Clinical Policy: Critical
Issues in the Evaluation and Management
of Adult Patients with Asymptomatic
Hypertension in the ED. Annals of
Emergency Medicine, 2006;47(3):237-49.29

30. Isolated elevated BP: ACEP
n “Rapidly lowering blood pressure in asymptomatic patients in
the ED is unnecessary and may be harmful in some
patients.” (Level B evidence)
n “Initiating treatment for asymptomatic hypertension in the
ED is not necessary when patients have follow-up.” (Level B
evidence)
n “When ED treatment for asymptomatic hypertension is
initiated, blood pressure management should attempt to
gradually lower blood pressure and should not be expected to
be normalized during the initial ED visit.” (Level B evidence)
Decker WW, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult
Patients with Asymptomatic Hypertension in the ED. Annals of Emergency Medicine, 2006;47(3):
30

31. Isolated elevated BP: ACEP
n “If blood pressure measurements are persistently elevated
with a systolic blood pressure greater than 140 mm Hg or
diastolic blood pressure greater than 90 mm Hg, the patient
should be referred for follow-up of possible hypertension and
blood pressure management.” (Level B evidence)
n “Patients with a single elevated blood pressure reading may
require further screening for hypertension in the outpatient
setting.” (Level C evidence)
Decker WW, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult
Patients with Asymptomatic Hypertension in the ED. Annals of Emergency Medicine, 2006;47(3):
31

32. Hypertensive Urgency
n Does this exist?, is this a disease?
n Not an ICD-9 code for this
n Probably we’re talking about a clinical scenario:
n (1) a severely elevated blood pressure in patient with
n (2) a history of known hypertension (perhaps not always)
n (3) without end organ dysfunction (asymptomatic)
32

33. Hypertensive Urgency
n Treatment
n Treat any underlying end
organ dysfunction
n Apply same strategy as with
those with isolated elevated
blood pressure?
n Do nothing?
n Have patient take home anti-
hypertensive medications?
n Refer back to PCP?
n Evaluation
n History
n Can be tricky if its
hypertension +
complaints
n Physical exam
n Bruits?
n Murmurs?
n Retina?
n Studies?
n CBC, basic, UA
n EKG
n CXR
33

34. Hypertensive Urgency
n From JNC 7, appears to be expert opinion:
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7). National Heart, Lung, and Blood Institute,
“
“
“
“
• Some patients with hypertensive urgencies
may benefit from treatment with: oral, short-
acting agent such as captopril, labetalol, or
clonidine followed by several hours of
observation
• No evidence to suggest that failure to
aggressively lower BP in the ER is associated
with any increased short-term risk to the
patient who presents with sever hypertension
• Such a patient may benefit from: adjustment
in their antihypertensive therapy (particularly
the use of combination drugs, or reinstitution
of medication if noncompliance is a problem
• Patients should not leave the ER without a
confirmed followup visit within several days
• Term “urgency” has led to overly aggressive
management of many patients with severe,
uncomplicated hypertension
• Aggressive dosing with intravenous drugs
or even oral agents, to rapidly lower BP is
not without risk
• Oral loading doses of antihypertensive
agents can lead to cumulative effects
causing hypotension, sometimes following
discharge from the ER
• Patients who continue to be noncompliant
will often return to the ER within weeks
34

35. Maxim 3
Not all hypertensive
emergencies are the same
LESSON: Treatment is based on the
underlying cause
35

36. Teaching Point
n Hypertensive emergencies are probably better
categorized by the underlying pathophysiology of
the individual disease
n Think of the hypertension as a manifestation of that
disease
n Think of the treatment as being determined by that
individual disease process
n You may not think of the myriad of diseases that we deal
with everyday as being hypertensive emergencies
36

37. Pathophysiology
n Primary actors:
n Kidneys
n Adrenals
n Vascular bed
n Heart
Source Undetermined
37

38. Pathophysiology
n Receptors:
n Beta blockers
n Calcium channel blockers
n Angiotensin-Renin system
n Alpha blockers
n Diuretics
Source Undetermined
38

39. Pathophysiology
n Concept of
autoregulation
n Chronic hypertension
shifts curve and range
of BP’s under which
brain regulates its blood
flow
n Therefore in
hypertensives, need
higher BP’s to maintain
cerebral perfusion
n Underpins BP
management in stroke
Source Undetermined
39

40. (ED) Hypertensive Emergencies
n Cardiovascular system
n Acute aortic dissection
n Congestive heart failure/
pulmonary edema
n Neurologic system
n Ischemic stroke
n Hemorrhagic stroke
n Subarachnoid hemorrhage
n Hypertensive encephalopathy
n Acute renal failure
n Nephrotic and nephritic
syndromes
n Endocrine
n Thyroid storm
n Pheochromocytoma
n Drug related
n Sympathomimetic toxidrome
(cocaine/amphetamine
toxicity)
n MAOI toxicity
n Withdrawal (alcohol)
n Pregnancy related
n Preeclampsia/eclampsia
40

41. Hypertensive Encephalopathy
n Definition
n A reversible cerebral
disorder associated with a
high BP in the absence of
cerebral thrombosis or
hemorrhage
n Symptoms
n Headache, seizures,
visual disturbances,
nausea, vomiting,
confusion
n Diagnosis
n Made after excluding
other pathology
n Cause
n Theorized that a rapid
rise in BP overwhelms
the autoregulatory
mechanisms of the brain
and leads to blood-brain
barrier permeability and
brain edema
41

42. Let’s Play a Game: Target BP
n Disease
n Acute aortic dissection
n Acute congestive heart
failure/pulmonary edema
n Acute ischemic stroke, tPA
candidate
n Acute ischemic stroke, non-
tPA candidate
n Acute intracranial
hemorrhage
n Hypertensive encephalopathy
n Cocaine toxicity
n Delirium tremens
n Preeclampsia/eclampsia
n Target BP
n 10-15% reduction in mean
arterial pressure
n 20-25% reduction in mean
arterial pressure
n Under 185/110
n Systolic BPs as low as tolerable
(100-120 mmHg)
n Goal 160/90
n Goal 140/90
n Treat the cause, not the BP
n None of the above
n Unknown
42

43. n IV drug
options
The Seventh
Report of the
Joint National
Committee on
Prevention,
Detection,
Evaluation, and
Treatment of
High Blood
Pressure (JNC 7).
National Heart,
Lung, and Blood
Institute, 2003. 43

44. Let’s Play a Game: Drug of Choice
n Disease
n Acute aortic dissection
n Acute congestive heart
failure/pulmonary edema
n Acute ischemic stroke, tPA
candidate
n Acute ischemic stroke, non-
tPA candidate
n Acute intracranial
hemorrhage
n Hypertensive encephalopathy
n Cocaine toxicity
n Delirium tremens
n Preeclampsia/eclampsia
n Drug of choice
n Nitroglycerin
n Nitroprusside
n Labetolol
n Hydralazine
n Fenodolpam
n Esmolol
n Phentolamine
n Lasix
n Nicardipine
n None of the above
44

45. Outline
n Background
n Small group discussion
n Evidence based lecture
n Final thoughts and questions/comments
45

46. Objectives
n Know how to evaluate someone who is
hypertensive (which may mean doing nothing)
n Know how to distinguish between hypertensive
emergencies and non-emergencies—and how to
manage them
n Competently be able to appropriately disposition
patients over the range of hypertension problems—
from someone with an elevated blood pressure to
hypertensive emergencies
46

47. Final Thoughts
n Goals in evaluation
n Decide if someone has inaccurate measurement vs elevated blood pressure
vs hypertension
n Decide if someone has a hypertensive urgency vs. emergency
n Decide if someone has end organ dysfunction/damage
n Not all elevated blood pressures are the same
n Spectrum of disease
n Not all hypertension requires testing
n Not all hypertension requires lowering of blood pressure
n Treatment of hypertensive emergencies is determined by the underlying
pathophysiology of the disease process
n The disposition of patients with elevated blood pressures varies
n Education vs. prescribing anti-hypertensives vs. follow up with PCP
n Questions/comments? 47