When Ambulatory Patients Have a Blood Pressure ≥180/110 mm Hg, What Next?
Gregory W. Rutecki, MD
Rutecki GW. When ambulatory patients have a blood pressure ≥180/110 mm Hg, what next? Consultant. 2016;56(12):1127.
It’s late Friday afternoon, and you are seeing your last patient of the week. This man has run out of his antihypertensive medications, and he has repeated blood pressure (BP) measurements in your office exceeding 180/110 mm Hg. The patient has no cardiac, pulmonary, or neurologic complaints.
When you examine him, there are no signs of hypertensive target organ injury (eg, heart, brain, eyegrounds). You consider sending him to the nearest emergency department (ED). But is there a danger in restarting his medications, sending him home, and seeing him first thing next week?
This month’s Top Paper (of which I am excited to be a coauthor) may change your thinking.1
A systolic BP of 180 mm Hg or greater or a diastolic BP of 110 or greater is defined as severe hypertension. If that BP is accompanied by target organ injury—that is, central nervous system (stroke, alterations in consciousness), cardiac (angina or heart failure), or other abnormalities (grade 3 or 4 hypertensive retinopathy)—it should be characterized as a hypertensive emergency. Patients with a hypertensive emergency should be admitted immediately for aggressive BP lowering. If there are no target organ problems accompanying the elevated BP, it is called a hypertensive urgency. If urgent patients are followed, how do they fare in disparate circumstances (that is, either going home or receiving more aggressive care in the ED or hospital)? This Top Paper answers this question.
A retrospective cohort study identified 58,535 individuals who met the definition of having a hypertensive urgency, of whom 1278 were appropriate for follow-up and study. The 852 individuals who were sent home after receiving the diagnosis of hypertensive urgency were compared with the 426 who were transferred to the ED and/or admitted to the hospital. The outcome measure used to compare the 2 groups was the occurrence of major adverse cardiovascular events (MACE), which included acute coronary syndromes, strokes or transient ischemic attacks, uncontrolled hypertension (≥140/90 mm Hg), and hospital admissions over 6 months.
At 7 days, no differences were observed between the 2 groups using MACE criteria, and the same could be said at 8 to 30 days and again at 6 months. However, patients who had been sent home were more likely to have uncontrolled hypertension at 1 month, but not 6 months later. At 8 and 30 days later, patients who had been sent home were less likely to end up in the hospital. Remember, not ending up in the hospital did not increase a patient’s risk of MACE events.
So, on Friday afternoon (or at any other time), sending a patient with a hypertensive urgency to the ED or admitting the patient to the hospital does not improve outcomes! It may be that the habit of assuming that all BPs elevated to a certain point are dangerous should be revisited, and that a change in practice should result. Also, never forget to look for signs of target organ injury that require admission and aggressive lowering of BP.
Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the Consultant editorial board.
- Patel KK, Young L, Howell EH, Hu B, Rutecki G, Thomas G, Rothberg M. Characteristics and outcomes of patients presenting with hypertensive urgency in the office setting. JAMA Intern Med. 2016;176(7):981-988.