BP 252/130…start IV Fluids…this won’t blow up the patient…

 

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The diagnosis of hypertensive emergency is made based upon the findings of hypertension in the setting of end-organ damage (usually heart, brain, or kidneys). What you really care about is the rate of increase rather than the actual BP number (there is no defining threshold).

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Think before pulling the trigger: HTN Emergency

Key Points in High BP management:

  1. Don’t get worried with numbers, treat only if the patient is symptomatic. Asymptomatic HTN goes home with good follow up/discharge instructions.
  2. High BP + end organ damage is HTN emergency, again don’t look at specific numbers to call it HTN emergency.
  3. Reduce MAP by 20-25% in the first hour with titratable IV meds (Exception dissection, eclampsia where you need to get down as quickly as possible)
  4. Most of them are fluid depleted and need IV fluids, which also prevents the sudden drop in pressures after commencing IV therapy.
  5. NTG drip is not the answer to everything!

Treat the patient not the monitor

If your patient doesn’t have any of the conditions below, then their 200/110mmHg pressure won’t kill them but there is a good chance you will by trying to lower their blood pressure acutely in the ED… treat the patient not the monitor



 

Elevated Asymptomatic Hypertension: To Treat or Not to Treat?

Patients with markedly elevated blood pressure (SBP ≥ 160 mmHg, DBP ≥ 100 mmHg) require neither screening diagnostic studies nor acute treatment in the emergency department, as long as they are asymptomatic. Initiation of therapy may be considered in special patient populations, such as those with poor follow up.

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Please stop with the STAT ORAL ANTIHYPERTENSIVES…you are harming patients

A Hypertensive emergency is any elevation in blood pressure in the presence of end-organ dysfunction. Aggressively treating severe asymptomatic hypertension (very high blood pressure without clear end organ damage) is not indicated, not supported by the literature and DANGEROUS. First, do no harm.

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Latest guidelines for the management of Hypertension – JNC VIII

Recommendation 1

In the general population aged ≥60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation – Grade A)

Corollary Recommendation

In the general population aged ≥60 years, if pharmacologic treatment for high BP results in lower achieved SBP (eg, <140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted. (Expert Opinion – Grade E)

Recommendation 2

In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg. (For ages 30-59 years, Strong Recommendation – Grade A; For ages 18-29 years, Expert Opinion – Grade E)

Recommendation 3

In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg. (Expert Opinion – Grade E)

Recommendation 4

In the population aged ≥18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E)

Recommendation 5

In the population aged ≥18 years with diabetes, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E)

Recommendation 6

In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation – Grade B)

Recommendation 7

In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. (For general black population: Moderate Recommendation – Grade B; for black patients with diabetes: Weak Recommendation – Grade C)

Recommendation 8

In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status. (Moderate Recommendation – Grade B)

Recommendation 9

The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed. (Expert Opinion – Grade E)

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