Is an electrocardiogram (ECG) indicated in a patient presenting with severe hypertension (blood pressure 170/140mmHg), headache, and vomiting, who has been given amlodipine (Amlodipine) 10mg and telmisartan (Telmisartan) 40mg?

ECG is Indicated in This Patient

Yes, a 12-lead ECG should be obtained immediately in this patient presenting with severe hypertension (BP 170/140 mmHg), persistent headache, and vomiting. 1, 2

Rationale for ECG in This Clinical Scenario

Guideline-Based Requirement

• A 12-lead ECG is part of the routine assessment for ALL hypertensive patients, regardless of symptom severity or blood pressure control status. 1, 2
• The European Society of Cardiology/European Society of Hypertension explicitly states that ECG should be obtained as a baseline evaluation in every hypertensive patient. 1

Critical Diagnostic Information Provided by ECG

Detection of Left Ventricular Hypertrophy (LVH):

• ECG can identify LVH using Sokolow-Lyon index (SV1 + RV5 >3.5 mV), modified Sokolow-Lyon index (largest S-wave + largest R-wave >3.5 mV), RaVL >1.1 mV, or Cornell voltage QRS duration product (>244 mV*ms). 1
• LVH detected by ECG is an independent predictor of cardiovascular events and mortality, particularly valuable in patients over 55 years of age. 1
• If LVH is detected, this mandates echocardiography for more detailed cardiac assessment and justifies more aggressive blood pressure targets. 2

Screening for Acute Complications:

• ECG detects patterns of ventricular overload or "strain" indicating severe cardiovascular risk. 1
• Identifies ischemia, which is critical given the severe hypertension and symptoms (headache, vomiting could represent hypertensive emergency). 1
• Detects conduction abnormalities and arrhythmias, including atrial fibrillation—a frequent complication requiring anticoagulation. 1
• Evaluates for left atrial dilatation, which increases risk of atrial fibrillation and cardiovascular death. 1

Risk Stratification:

• An abnormal ECG elevates cardiovascular risk classification, changing treatment intensity and monitoring frequency. 2
• Detection of LVH or other abnormalities influences medication selection, favoring agents that promote LVH regression. 2

Clinical Context: Why This Patient Specifically Needs ECG

Severe Hypertension with Symptoms

• BP of 170/140 mmHg represents severe hypertension (stage 2). 1
• The combination of severe BP elevation with headache and vomiting raises concern for hypertensive emergency (hypertensive encephalopathy, malignant hypertension). 1
• While GCS is 15/15 with no focal neurological deficits, symptoms warrant evaluation for acute target organ damage. 1

Baseline Assessment Before Treatment

• The patient has been given amlodipine 10mg and telmisartan 40mg—a reasonable combination for severe hypertension. 3, 4, 5, 6
• ECG must be obtained BEFORE or immediately after initiating treatment to serve as baseline for future comparison. 2
• This baseline is essential for monitoring treatment response and detecting treatment-related complications. 2

Common Pitfalls to Avoid

Do not delay ECG pending symptom resolution:

• ECG should be obtained immediately, not after blood pressure normalizes. 1
• Acute changes (ischemia, arrhythmias) may only be present during hypertensive crisis. 1

Do not rely on absence of focal neurological deficits:

• Normal neurological exam (GCS 15/15, no FND) does not exclude cardiac complications or hypertensive emergency. 1
• Cardiac damage (LVH, ischemia) may be asymptomatic or present only with non-specific symptoms like headache. 1

Do not assume young age negates need for ECG:

• If this patient is young, ECG is even more critical as it may reveal secondary causes of hypertension or early target organ damage. 7

Additional Investigations to Consider

If ECG shows abnormalities:

• Echocardiography becomes mandatory for detailed assessment of cardiac structure, function, and LV mass. 2, 7
• 24-hour Holter monitoring if arrhythmias or ischemic episodes are suspected. 1

Laboratory workup should include:

• Hemoglobin, platelets, creatinine, sodium, potassium, LDH, haptoglobin (to evaluate for thrombotic microangiopathy in malignant hypertension). 1
• Urinalysis for protein and microscopic examination (renal target organ damage). 1
• Fundoscopy to evaluate for retinal hemorrhages, cotton wool spots, or papilledema (malignant hypertension). 1

Imaging considerations:

• If symptoms persist or worsen despite BP control, consider CT/MRI brain to exclude cerebral hemorrhage or posterior reversible encephalopathy syndrome (PRES). 1