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“The treatment of the hypertension itself is a difficult and almost hopeless task in the present state of our knowledge and in fact, for ought we know the hypertension may be an important compensatory mechanism which should not be tampered with even if it were certain that we could control it.”

Paul D. White, M.D., 1931, excerpt from “Cardiac Disease

Hypertension is a common finding in patients presenting to the emergency department, and is seen in a broad range of conditions—from asymptomatic hypertension to acute intracranial hemorrhage. Determining the best management approach represents a significant challenge to emergency physicians and intensivists alike, and is a source of ongoing controversy. Essentially, three questions must be answered:

  1. Will acute blood pressure reduction be helpful or harmful?

  2. If blood pressure reduction is indicated, what is the target?

  3. Which therapeutic agent should be used?

The diagnostic and therapeutic approach should not be algorithmic, guided strictly by numbers. Instead, clinicians should base their clinical decisions on a number of principles, most importantly the presence or absence of end-organ damage. Treat the patient, not the number.


Hypertension is an increasingly important health care issue, with more than 50 million people in the United States having high blood pressure requiring treatment.1 The prevalence increases with age, with more than half of people between the ages of 60 and 69 affected, increasing to more than three quarters of people over the age of 70.1 Elevated blood pressure is noted in more than 25% of all patients presenting to the emergency department (ED).2,3 The ability to rapidly recognize and, when necessary, appropriately treat hypertension is therefore a critical skill for any practitioner in the emergency department (ED) or the intensive care unit (ICU).


Essential to appropriate management is first obtaining an accurate measurement. Ideally, patients should be seated with feet on the floor and arm supported at heart level. The auscultatory method should be used, and should be performed by a trained practitioner. The cuff bladder should encircle at least 80% of the arm, and at least two measurements should be performed with the average recorded. In reality, ED patients will often be screened utilizing automated BP cuffs against the backdrop of a chaotic waiting room or triage area, some of whom will still be strapped to an EMS gurney and in extremis. Take these measurements with a grain of salt, and when in doubt, check the pressure yourself.

Arterial catheters are frequently recommended in place of noninvasive monitoring for patients on antihypertensive infusions, but there is surprisingly little evidence to support this position. A recent large cohort study evaluating the use of arterial catheters in critically ill patients in general requiring mechanical ventilation found no benefit on ...

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