Should a patient with severe hypertension be sent to the emergency room?

Management of a Patient with BP 190/100

A patient with a blood pressure of 190/100 who is asymptomatic and has no evidence of acute target organ damage should NOT be sent to the emergency room, but rather should be referred for prompt outpatient follow-up within 1-2 weeks. 1

Differentiating Hypertensive Categories

When evaluating a patient with BP 190/100, it's crucial to distinguish between:

1. Hypertensive Emergency: Severe BP elevation (typically >180/120 mmHg) WITH evidence of acute target organ damage 1
2. Hypertensive Urgency: Severe BP elevation (typically >180/110 mmHg) WITHOUT evidence of acute target organ damage 1
3. Uncontrolled Hypertension: BP elevation without symptoms or acute target organ damage 1

Assessment for Target Organ Damage

The key factor in decision-making is not just the BP number but the presence or absence of acute target organ damage. Evaluate for:

• Neurological symptoms: Altered mental status, severe headache, visual disturbances, seizures
• Cardiovascular symptoms: Chest pain, shortness of breath
• Renal involvement: Check for proteinuria, hematuria
• Retinal changes: Hemorrhages, exudates, papilledema

Management Algorithm

If NO acute target organ damage (most likely scenario with BP 190/100):

• Do NOT send to ER 2
• Arrange prompt outpatient follow-up within 1-2 weeks
• Consider initiating or adjusting oral antihypertensive therapy
• Advise on lifestyle modifications

If ANY signs of acute target organ damage:

• Send to ER immediately for hypertensive emergency management 2, 1
• IV antihypertensive therapy will likely be required
• Target BP reduction by approximately 15-25% within the first 24 hours, not immediate normalization 1

Evidence-Based Rationale

The American College of Emergency Medicine guidelines clearly state 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 in some patients" 2.

Studies have shown that up to one-third of patients with elevated blood pressure in the emergency department will normalize before arranged follow-up 2, highlighting that a single elevated reading doesn't necessarily require emergency intervention.

Important Caveats

• Avoid rapid BP reduction in asymptomatic patients as this can be harmful 2, 1
• If the patient has symptoms suggesting target organ damage (severe headache, chest pain, visual changes, neurological deficits), ER evaluation is warranted
• For specific conditions like aortic dissection, stroke, or preeclampsia, specific BP targets and timelines apply 1
• If the patient lacks reliable follow-up, consider same-day or next-day evaluation in an urgent care or primary care setting rather than the ER

Bottom Line

For an asymptomatic patient with BP 190/100 and no evidence of acute target organ damage, emergency room evaluation is not necessary and may lead to inappropriate rapid BP lowering. Instead, arrange prompt outpatient follow-up and management.