Asymptomatic hypertension: Difference between revisions
| Line 44: | Line 44: | ||
==Management== | ==Management== | ||
;Routine ED medical intervention is NOT required (Level C)<ref name=ACEP2013 /> | |||
;In select patient populations, physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control (Level C)<ref name=ACEP2013 /> | |||
;Patients should be referred for outpatient follow up (Level C)<ref name=ACEP2013 /> | |||
===Outpatient Hypertension Medications=== | |||
*First line for people without comorbidities | *First line for people without comorbidities | ||
**[[Hydrochlorothiazide]] 12.5mg, max 25mg | **[[Hydrochlorothiazide]] 12.5mg, max 25mg | ||
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| [[DM]] || thiazide, CCB, ACEI, or ARB || thiazide or CCB | | [[DM]] || thiazide, CCB, ACEI, or ARB || thiazide or CCB | ||
|} | |} | ||
==Disposition== | ==Disposition== | ||
Revision as of 11:51, 4 December 2016
Background
- JNC 7 recommends 2 or more properly measured, seated blood pressure readings on each of 2 or more office visits to establish the diagnosis of hypertension[1]
JNC-7 Classification
| Class | Systolic | Diasolic | |
| Normal | <120 | and | <80 |
| Pre-hypertension | 120-130 | or | 80-89 |
| Stage 1 | 140-150 | or | 90-99 |
| Stage 2 | ≥160 | or | ≥100 |
- JNC-8 Changes: In patients ≥60 yr the threshold has increased from <140/90 to <150/90[2]
- Any age with diabetes mellitus and >140/90
Clinical Features
- None (asymptomatic by definition)
Differential Diagnosis
Hypertension
- Hypertensive emergency
- Stroke
- Sympathetic crashing acute pulmonary edema
- Ischemic stroke
- Intracranial hemorrhage
- Preeclampsia/Eclampsia
- Autonomic dysreflexia
- Scleroderma renal crisis
- Acute glomerulonephritis
- Type- I myocardial infarction
- Volume overload
- Urinary obstruction
- Drug use or overdose (e.g stimulants, especially alcohol, cocaine, or Synthroid)
- Renal Artery Stenosis
- Nephritic and nephrotic syndrome
- Polycystic kidney disease
- Tyramine reaction
- Cushing's syndrome
- Obstructive sleep apnea
- Pheochromocytoma
- Hyperaldosteronism
- Hyperthyroidism
- Anxiety
- Pain
- Oral contraceptive use
Evaluation
Asymptomatic hypertension
- Urine pregnancy in all women of child-bearing age (consider preeclampsia if positive)
- Routine screening for acute target organ injury (e.g. creatinine, UA, ECG) is NOT required (Level C)[3]
- In select patient populations, screening of creatinine may identify injury that affects disposition (Level C)[3]
Suggested algorithm:
- <120 diastolic
- No screening ED workup --> home with outpatient treatment
- >210 systolic or >120-130 diastolic
- Chem 7 (creatinine) --> home with outpatient treatment if no evidence of acute renal failure
- "No other diagnostic screening tests (e.g. UA, ECG) appear to be useful"[3]
- Chem 7 (creatinine) --> home with outpatient treatment if no evidence of acute renal failure
Management
- Routine ED medical intervention is NOT required (Level C)[3]
- In select patient populations, physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control (Level C)[3]
- Patients should be referred for outpatient follow up (Level C)[3]
Outpatient Hypertension Medications
- First line for people without comorbidities
- Hydrochlorothiazide 12.5mg, max 25mg
- Need labs before starting, does not work in people with CKD
- Hydrochlorothiazide 12.5mg, max 25mg
- First line for people with DM and/or proteinuria
- ACEi/ARB: Lisinopril either Qday or BID
- Need Chem 10 before and after starting to check for hyperkalemia and creatinine
- Start 10mg lisinopril QD
- ACEi/ARB: Lisinopril either Qday or BID
- Anyone with CAD, CHF
- Beta-Blocker (do not need labs)
- Amlodipine for anyone, except for people with LE edema (do not need labs)
- Start amlodipine 5mg QD
- Diltiazem for proteinuria in people unable to tolerate ACEi (do not need labs)
- Lasix for CHF and/or lower extremity edema secondary to proteinuria
JNC 8 Recommendations[2]
| Population | Non-black Patients | Black Patients |
|---|---|---|
| General population | thiazide, CCB, ACEI, or ARB | thiazide or CCB |
| CKD | ACEI or ARB | ACEI or ARB |
| DM | thiazide, CCB, ACEI, or ARB | thiazide or CCB |
Disposition
- See workup, if no evidence of acute renal failure, outpatient treatment
See Also
References
- ↑ Chobanian AV, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - The JNC 7 Report. JAMA. 2003; 289(19):2560-2572.
- ↑ 2.0 2.1 James PA, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311(5):507-520.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure. ACEP Clinical Policies Subcommittee on Asymptomatic Hypertension. Annals of Emergency Medicine. 2013; 62(1):59-63.