From the Guidelines
Patients with hypertension should be admitted to the Emergency Department when they present with hypertensive emergencies, which include blood pressure readings typically exceeding 180/120 mmHg with evidence of acute target organ damage, as stated in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The indications for admission to the ED include:
- Hypertensive encephalopathy
- Acute stroke
- Acute myocardial infarction
- Acute heart failure with pulmonary edema
- Aortic dissection
- Eclampsia/severe preeclampsia
- Acute kidney injury These conditions are considered hypertensive emergencies and require immediate attention to prevent further target organ damage.
Patients with severe asymptomatic hypertension (hypertensive urgency) without organ damage may be managed in the ED with oral medications and close follow-up rather than admission, as they do not have a hypertensive emergency and can usually be treated with oral BP-lowering agents and usually discharged after a brief period of observation 1. Initial management of hypertensive emergencies typically involves IV medications such as labetalol, nicardipine, or clevidipine, with the goal of reducing mean arterial pressure by no more than 25% within the first hour, then to 160/100-110 mmHg within the next 2-6 hours, and then to normal over the next 24-48 hours 1. Rapid blood pressure reduction is necessary in aortic dissection (target SBP <120 mmHg within 20 minutes) but should be avoided in acute stroke unless extremely elevated, as stated in the 2019 ESC council on hypertension position document on the management of hypertensive emergencies 1. The technique for measuring blood pressure is also important, and the auscultatory method using a mercury sphygmomanometer is the traditional method of measurement against which other methods are compared, although automated oscillometric devices may also be used if they meet the Association for the Advancement of Medical Instrumentation standards 1.
From the Research
Indications for Admission to ED with Hypertension
The decision to admit a patient with hypertension to the Emergency Department (ED) depends on several factors, including the presence of symptoms, the severity of the hypertension, and the presence of end-organ damage. The following are some indications for admission:
- Presence of symptoms such as chest pain, headache, or shortness of breath 2
- Systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 120 mmHg without signs and symptoms of end-organ damage or dysfunction 3
- Presence of end-organ damage, such as acute left-ventricular heart failure, acute coronary syndrome, or acute aortic dissection 2, 4
- History of hypertension, diabetes, ischemic heart disease, or cerebrovascular accident, which are risk factors for end-organ damage 3
- Presence of hypertension-mediated organ damage (HMOD), such as acute ischemic stroke 5
Management of Hypertension in the ED
The management of hypertension in the ED depends on the severity of the condition and the presence of symptoms. The following are some general guidelines:
- For patients with asymptomatic severe hypertension, routine investigations should be performed to detect end-organ damage, and the patient should be monitored closely for any signs of deterioration 3
- For patients with hypertensive urgency, the blood pressure should be reduced over a period of 24 to 48 hours, and the patient can be managed on an outpatient basis if follow-up is available 2
- For patients with hypertensive emergency, the blood pressure should be reduced rapidly, and the patient should be admitted to the hospital for close monitoring and management 2, 4
- Intravenous antihypertensive drugs should be used in patients with HMOD, and oral antihypertensive drugs can be used for gradual reduction of blood pressure 5
Prognosis of Patients with Hypertension in the ED
The prognosis of patients with hypertension in the ED depends on the severity of the condition and the presence of end-organ damage. The following are some general findings:
- Patients with very severe acute hypertension have poor long-term clinical prognoses, with high mortality rates at 3 months, 1 year, and 3 years 5
- Patients with HMOD have a significantly higher mortality rate than those without HMOD 5
- The risk of serious outcomes within 7 days of initial presentation to the ED is low in patients with a chief complaint of hypertension or high blood pressure and no serious associated complaint 6