Cardiology/clinical policyClinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Asymptomatic Hypertension in the Emergency Department
Introduction
Hypertension is ubiquitous. It affects approximately 50 million individuals in the United States and 1 billion individuals worldwide.1 Hypertension accounts for 35 million office visits in the United States, making it the most common primary diagnosis, yet 30% of those with this condition are unaware of their condition.2, 3
The health risks caused by prolonged untreated hypertension are serious. As noted in the recent report by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7 Report) for individuals aged 40 to 70 years, each increment of 20 mm Hg in systolic blood pressure or 10 mm Hg in diastolic blood pressure doubles the risk of cardiovascular disease events independent of other factors.1, 4 JNC 7 defined an important new category in the spectrum of blood pressure assessment, termed “prehypertension,” which includes individuals with a systolic blood pressure of 120 to 139 mm Hg or a diastolic blood pressure of 80 to 89 mm Hg. These patients are at twice the risk of developing hypertension as those with values below this range, highlighting the need for careful screening in the primary care setting.5
The issue of patients presenting to the emergency department (ED) with an incidental finding of asymptomatic hypertension is a dilemma faced by every practicing emergency physician countless times each day. Further, many patients evaluated in the ED do not regularly consult health care providers, and many have substantial socioeconomic barriers to receiving care in a primary care setting. Based on these concerns, this clinical policy was developed to provide an analysis of the literature about asymptomatic hypertension in the ED.
Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. The American College of Emergency Physicians (ACEP) clearly recognizes the importance of the individual physician’s judgment. Rather, this guideline defines for the physician those strategies for which medical literature exists to provide support for answers to the crucial questions addressed in this policy.
Section snippets
Definitions
The definitions of hypertension used in this report are those developed by JNC 7 (see Table),1 and include normal, prehypertension, stage I hypertension, and stage 2 hypertension. Acute hypertensive emergencies are not addressed by this policy.
Methodology
This clinical policy was created after careful review and critical analysis of the peer-reviewed literature. A MEDLINE search of English-language articles published between January 1992 and January 2005 was performed using combinations of the key words “hypertension” and “emergency department.” Terms were then exploded as appropriate. Abstracts and articles were reviewed by subcommittee members, and pertinent articles were selected. These articles were evaluated, and those addressing the
1. Are ED blood pressure readings accurate and reliable for screening asymptomatic patients for hypertension?
The association of hypertension with poor long-term health outcomes is well established.1 However, the issue of how to approach the incidental finding of asymptomatic hypertension in the ED remains a quandary. On 1 hand, the patient and the emergency physician are brought together to address that patient’s emergency complaint, not long-term health maintenance issues, which are generally believed by both the patient and provider to be beyond the scope of an ED visit. On the other hand, failing
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Cited by (0)
Approved by the ACEP Board of Directors, September 23, 2005