Is it reasonable to advise a patient with hypertension (high blood pressure) who missed 2 days of antihypertensive medication and has a clinic blood pressure of severe hypertension to resume medication and seek emergency care if symptoms persist or blood pressure does not decrease?

Management of Asymptomatic Severe Hypertension

Your approach of advising the patient to go home and take her blood pressure medications, with instructions to seek emergency care if her blood pressure does not decrease, was reasonable and appropriate for an asymptomatic patient with severe hypertension. 1

Assessment of Hypertensive Patients

When evaluating patients with severely elevated blood pressure, the key distinction is between:

• Hypertensive emergency: Severe BP elevation with acute target organ damage
• Hypertensive urgency: Severe BP elevation without acute target organ damage

Your patient presented with:

• BP of 179/121 mmHg
• No symptoms
• History of missing antihypertensive medication for 2 days
• Reports of lower home BP readings

Key Decision Points

1. Absence of symptoms: The American College of Emergency Medicine guidelines explicitly state that asymptomatic hypertension does not require emergency department evaluation when follow-up is available 2, 1

2. No evidence of target organ damage: Without symptoms suggesting organ damage (headache, visual disturbances, chest pain, neurological symptoms), immediate emergency intervention was not indicated 2

3. Known cause of elevation: The patient's non-adherence to medication for 2 days provides a clear explanation for the BP elevation 1

Evidence-Based Management

The 2006 American College of Emergency Medicine guidelines (which remain current practice) specifically recommend:

• "Initiating treatment for asymptomatic hypertension in the ED is not necessary when patients have follow-up" (Level B recommendation) 2
• "Rapidly lowering blood pressure in asymptomatic patients in the ED is unnecessary and may be harmful" (Level B recommendation) 2

Research has shown that up to one-third of patients with elevated diastolic blood pressures greater than 95 mmHg on initial ED visit normalize before arranged follow-up 2, 1.

Appropriate Steps You Took

1. ✓ Advised resumption of regular antihypertensive medication
2. ✓ Provided clear instructions for when to seek emergency care
3. ✓ Avoided unnecessary emergency department referral for asymptomatic hypertension

Important Considerations

• White coat effect: The higher clinic reading compared to reported home readings is consistent with white coat hypertension, which is common 3

• Gradual reduction: Guidelines recommend gradual blood pressure reduction in asymptomatic patients over 24-48 hours rather than rapid reduction, which can be harmful 1, 4

• Follow-up importance: Ensuring the patient has appropriate follow-up is critical 1

When Emergency Evaluation IS Needed

Emergency evaluation would be indicated if the patient had:

• Symptoms suggesting target organ damage (severe headache, visual changes, chest pain, shortness of breath, neurological symptoms)
• Blood pressure ≥180/110 mmHg WITH evidence of acute organ damage 2, 1

Common Pitfalls to Avoid

• Overreacting to numbers alone: The absolute BP number is less important than the presence of symptoms or target organ damage 4
• Rapid BP reduction: This can lead to organ hypoperfusion in chronically hypertensive patients 4
• Ignoring follow-up: Ensuring the patient has a plan for ongoing BP management is essential

In conclusion, your management approach was consistent with current guidelines for asymptomatic severe hypertension. Resuming antihypertensive medication with clear instructions for when to seek emergency care is the appropriate standard of care for this clinical scenario.