Hypertension is a common finding in patients presenting to the emergency department. The clinical context in which this is seen can represent a broad spectrum of disease: from asymptomatic individuals incidentally noted at triage to have elevated blood pressures to critically ill patients with hypertension-induced damage to critical organs. Determining the best management approach to such patients represents a significant challenge, as well as a frequent source of controversy, to emergency medicine and critical care clinicians.
A number of questions face the practitioner, including whether or not blood pressure reduction will be helpful or harmful, how quickly and to what level the blood pressure should be reduced, and what the appropriate agent is to use for a given situation. Additionally, the presence of preexisting conditions needs to be considered when making treatment decisions, as well as the patient's baseline blood pressure.
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. Always 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 needing 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 pressures are noted in more than 25% of all patients presenting to the emergency department.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 or the intensive care unit (ICU).
Essential to appropriate management is first obtaining an accurate measurement. Patients should be seated for at least 5 minutes prior to the measurement being taken, 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.1
Hypertension can be broadly divided into primary (“essential”) and secondary hypertension. Essential hypertension, for which no cause is found, accounts for more than 90% of the cases of hypertension.4 Many pathophysiologic causes have been hypothesized, but generally it is believed that the primary cause is through renal mechanisms amplified by sympathetic nervous system activity and vascular remodeling. Essential hypertension has a tendency to cluster in families, often in association with other genetically inherited syndromes.4
Secondary hypertension can occur through a variety of causes. Renovascular disease, such as that due to renal artery stenosis or fibromuscular dysplasia, should be suspected in any young patient with hypertension or any patient with rapidly progressive symptoms. Decreased pressures ...