At what blood pressure reading should a patient attend Accident and Emergency (A+E)?

When to Attend A&E for Elevated Blood Pressure

A patient should attend Accident and Emergency immediately if their blood pressure is ≥180/120 mmHg AND they have any symptoms or signs suggesting acute organ damage, such as severe headache, visual disturbances, chest pain, shortness of breath, neurological symptoms, or altered consciousness. 1

Blood Pressure Thresholds for Emergency Assessment

• BP ≥180/120 mmHg requires immediate assessment for hypertensive emergency if accompanied by any evidence of acute target organ damage 2, 1
• The absolute BP number alone does not determine emergency status—the presence of acute organ damage is the critical factor distinguishing a true emergency from an urgency 1, 3
• For screening BP readings of ≥180/110 mmHg, assessment for hypertensive emergency is recommended, with prompt confirmation within a week if no emergency features are present 2

Signs and Symptoms Requiring Immediate A&E Attendance

Neurological manifestations that warrant immediate emergency attendance include:

• Severe headache with altered mental status 1
• Visual disturbances or vision loss 1
• Confusion, drowsiness, or loss of consciousness 1
• Seizures 1
• Focal neurological deficits suggesting stroke 1

Cardiovascular manifestations requiring immediate A&E attendance include:

• Chest pain suggesting acute coronary syndrome 1
• Severe shortness of breath or acute pulmonary edema 1
• Symptoms of aortic dissection (tearing chest/back pain) 1

Other critical features include:

• Acute kidney injury symptoms 1
• Severe nosebleeds that won't stop 1
• Multiple episodes of vomiting with severe headache 1

When A&E Attendance is NOT Required

Asymptomatic severely elevated BP (hypertensive urgency) can be managed without emergency attendance:

• BP ≥180/120 mmHg WITHOUT any symptoms or signs of organ damage does not require immediate A&E attendance 2, 4, 3
• These patients should have BP lowered gradually over 24-48 hours with oral medications and outpatient follow-up within 2-4 weeks 2, 3
• Eight of eleven guidelines reviewed recommended outpatient treatment for hypertensive urgencies rather than emergency department management 2

Critical Pitfalls to Avoid

Do not dismiss moderately elevated readings in previously normotensive patients:

• The rate of BP rise may be more important than the absolute value 1
• Patients without chronic hypertension may develop organ damage at lower BP thresholds (e.g., eclampsia can cause emergencies at systolic BP >170 mmHg) 5

Do not assume all high BP readings require emergency treatment:

• Up to one-third of patients with diastolic BP >95 mmHg normalize before follow-up 1
• Many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated 1

Verify the BP reading properly:

• Repeat measurements should be taken in both arms before making decisions 2
• Ensure proper measurement technique to avoid false readings 2

Practical Algorithm for Patients

1. If BP ≥180/120 mmHg with ANY symptoms (headache, visual changes, chest pain, breathlessness, confusion, neurological symptoms) → Attend A&E immediately 1

2. If BP ≥180/120 mmHg but completely asymptomatic → Contact GP urgently for assessment within 24-48 hours, do not attend A&E 2, 3

3. If BP 160-179/100-109 mmHg → Arrange GP confirmation within 1 month 2

4. If uncertain about symptoms → Err on the side of caution and attend A&E for assessment, as subtle organ damage may not be immediately apparent 1