Does a patient with severe hypertension require immediate ER attention?

Management of a Patient with BP 180/90: ER Referral Decision

A patient with a blood pressure of 180/90 without symptoms or signs of target organ damage does not require immediate ER referral, but should be referred for prompt outpatient follow-up within 1-2 weeks.

Assessment of Hypertensive Status

When evaluating a patient with BP 180/90, the key determination is whether this represents a hypertensive emergency, urgency, or uncontrolled hypertension:

1. Hypertensive Emergency:

   • Definition: Severe BP elevation (typically >180/120 mmHg) WITH evidence of acute target organ damage 1
   • Signs to look for: Retinal hemorrhages/exudates, altered mental status, chest pain, pulmonary edema, neurological deficits, acute kidney injury
   • Requires immediate hospitalization and IV therapy

2. Hypertensive Urgency:

   • Definition: Severe BP elevation (typically >180/110 mmHg) WITHOUT evidence of acute target organ damage 1, 2
   • May have non-specific symptoms like headache, malaise
   • Can be managed in outpatient setting

3. Uncontrolled Hypertension:

   • BP elevation without symptoms or acute target organ damage
   • Managed through outpatient follow-up

Decision Algorithm for BP 180/90

Step 1: Evaluate for symptoms and signs of target organ damage

• Check for: headache, visual disturbances, chest pain, shortness of breath, neurological symptoms
• Perform: fundoscopic exam (look for retinal hemorrhages, exudates, papilledema)
• Consider: basic lab work (creatinine, urinalysis), ECG if available

Step 2: Determine appropriate management based on findings

For BP 180/90 specifically:

• This BP level is below the typical threshold for hypertensive emergency/urgency (180/110-120)
• The diastolic pressure of 90 mmHg is significantly lower than the 110-120 mmHg threshold for urgency/emergency

Step 3: Management recommendation

• Without symptoms or target organ damage: Outpatient follow-up within 1-2 weeks 1
• With symptoms but no target organ damage: Consider same-day or next-day follow-up
• With signs of target organ damage: Immediate ER referral

Evidence-Based Rationale

The European Society of Cardiology position document clearly states that hypertensive emergencies require both very high BP values AND acute hypertension-mediated organ damage 1. The diastolic pressure of 90 mmHg in this patient is well below the threshold of concern.

The American College of Emergency Medicine guidelines specifically recommend that "initiating treatment for asymptomatic hypertension in the ED is not necessary when patients have follow-up" and that "rapidly lowering blood pressure in asymptomatic patients in the ED is unnecessary and may be harmful" 1.

Common Pitfalls to Avoid

1. Overreaction to a single elevated reading: Up to one-third of patients with elevated BP in the ED will normalize before arranged follow-up 1

2. Rapid BP reduction in asymptomatic patients: This can be harmful and is specifically advised against in guidelines 1, 2

3. Failure to distinguish between emergency and urgency: The absence or presence of acute target organ damage is the critical differentiator, not just the BP number

4. Ignoring follow-up capability: Ensure the patient has access to follow-up care within an appropriate timeframe

Conclusion for BP 180/90

A BP of 180/90 without symptoms or signs of target organ damage represents uncontrolled hypertension rather than a hypertensive emergency or urgency. The appropriate management is to arrange prompt outpatient follow-up rather than ER referral. The diastolic pressure of 90 mmHg is particularly reassuring in this case, as it falls well below the concerning threshold of 110-120 mmHg.