ASYMPTOMATIC ELEVATED BLOOD PRESSURE IN THE ED

As emergency department providers, we see elevated blood pressures on a daily basis. In some cases, this is reflective of an emergency medical condition which must be identified and stabilized.  But what if the patient with elevated blood pressure is:

  1. asymptomatic, and
  2. denies any related symptoms, and
  3. has a normal physical exam?

The American College of Emergency Physicians (ACEP) periodically publishes clinical policies that answer specific clinical questions. ACEP recently released a policy addressing Asymptomatic Elevated Blood Pressure in the ED.  Although these policies are not meant to establish a standard of care, you should feel very comfortable practicing in accordance with these recommendations. I encourage you to read the clinical policy yourself which outlines the evidence for the recommendations.  See the link to the policy at the bottom of this email.

The short version of this policy is:

You do not need to do any screening tests, nor provide any medical treatment, for patients with asymptomatic elevated blood pressure.

The policy addresses whether performing screening tests to detect target organ injury, which would indicate a hypertensive emergency, is useful or necessary.  This recommendation assumes that your history and physical exam are essentially normal (with respect to the hypertension).

Your chart documentation should include:

  • History:  absence of chest pain, shortness of breath, severe headache, or neurologic symptoms.
  • Physical exam:  normal cardiovascular, pulmonary, and neurologic exams.

For the purposes of the policy, the screening tests that you do not need to do are:

  • ECG.
  • CXR.
  • Blood or urine tests to detect clinically occult abnormalities (e.g., anemia, cardiac ischemia, CHF, renal insufficiency).

In a nutshell, the ACEP recommendation for the asymptomatic patient with elevated blood pressure is:

Routine screening is not required.  However, in select populations (poor follow up is their example), screening for an elevated creatinine may identify kidney injury that could affect disposition.

Similarly, the ACEP recommendation for the asymptomatic patient with markedly elevated blood pressure (considered by ACEP to be >180/110) is:

ED medical intervention is not required.  However, in select populations (again, poor follow up is the example given) emergency physicians may treat in the ED and/or initiate outpatient therapy.

All of these patients should be referred for follow up.

These are Level C recommendations from ACEP.  This means there are limited data but there is some level of consensus among experts regarding the recommendation.  Of course, you should use your best medical judgment in any clinical scenario.

I think this policy really gives us the freedom to practice the way we see fit.  There is a lack of evidence to support ordering any screening tests or acutely controlling asymptomatic elevated blood pressure.  This may be a deviation from your usual practice, or what other healthcare workers and patients may be accustomed to.  This information is for you to incorporate into your practice along with what you’ve learned in training and from your experience, colleagues, and continuing education.

Click for ACEP’s Asymptomatic Elevated Blood Pressure

I welcome your feedback on this topic. What do you do?  What do you think is best practice?

Marc Futernick, MD
ED Medical Director at California Hospital Medical Center, Los Angeles, CA
Member of VEP Board of Directors
marcfuternick@aol.com

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