Should a patient with persistent severe hypertension be sent to the Accident and Emergency (A&E) department?

Management of Asymptomatic Severe Hypertension (195/133 mmHg)

Do not send this patient to A&E if they are truly asymptomatic and have no evidence of acute target organ damage. 1, 2, 3

Critical First Step: Assess for Target Organ Damage

The key distinction is whether this represents a hypertensive emergency (with acute organ damage requiring ICU admission) versus hypertensive urgency (severe BP elevation without acute organ damage). 2, 3

Immediately assess for these specific signs of acute target organ damage: 2, 3

• Neurologic: Altered mental status, confusion, severe headache with focal deficits, visual changes suggesting hypertensive encephalopathy, signs of stroke/intracerebral hemorrhage
• Cardiac: Chest pain (acute MI, unstable angina), acute dyspnea (acute left ventricular failure/pulmonary edema)
• Vascular: Severe tearing chest/back pain (aortic dissection)
• Renal: Oliguria, acute renal failure
• Ophthalmologic: Funduscopic examination for papilledema, hemorrhages, exudates

If Patient is Truly Asymptomatic (Hypertensive Urgency)

Initiating treatment for asymptomatic hypertension in the ED is not necessary when patients have follow-up, and rapidly lowering blood pressure in asymptomatic patients is unnecessary and may be harmful. 1

Why Not Send to A&E:

• No evidence exists demonstrating improved patient outcomes or decreased mortality/morbidity with acute ED management of elevated BP alone 1
• Up to one-third of patients with diastolic BP >95 mmHg normalize spontaneously before arranged follow-up 1
• Rapid BP lowering can precipitate renal, cerebral, or coronary ischemia 2, 3
• Case reports document poor outcomes including hypotension, MI, stroke, and death from rapidly lowering BP in asymptomatic patients 1

Appropriate Management:

Arrange urgent outpatient follow-up within 24-48 hours with their primary physician for gradual BP reduction with oral antihypertensives. 1, 2, 3

• Reinstitute or intensify oral antihypertensive therapy (ACE inhibitors, ARBs, calcium channel blockers, or diuretics) 2, 3
• Address medication compliance issues, which are often the underlying cause 2
• Goal is gradual BP reduction over 24-48 hours, NOT immediate normalization 2, 4

If Any Signs of Target Organ Damage Present (Hypertensive Emergency)

Immediate A&E referral with ICU admission is mandatory. 2, 3

• Initiate parenteral (IV) antihypertensive therapy 2, 3, 5
• Reduce BP by no more than 25% within first hour, then to 160/100 mmHg over next 2-6 hours 2, 3
• First-line IV agent: Nicardipine 5 mg/hr, increasing by 2.5 mg/hr every 5-15 minutes (max 15 mg/hr) 3
• Alternative: Labetalol (avoid in reactive airways disease, COPD, heart block, bradycardia) 2, 3

Common Pitfalls to Avoid

• Do not use short-acting nifedipine due to risk of rapid, uncontrolled BP falls 2
• Do not use IV medications for hypertensive urgency - reserved only for true emergencies 2
• Do not normalize BP acutely - patients with chronic hypertension have altered autoregulation and acute normalization causes hypoperfusion 6
• Do not treat the number alone - treating urgency as emergency leads to unnecessary hospitalization and potential harm from overly aggressive treatment 3