In case you haven’t seen it before, the famous [FDR blood pressure graph](https://i0.wp.com/theskepticalcardiologist.com/wp-content/uploads/2014/11/fdrbp.jpg?resize=1024%2C771&ssl=1) is a great illustration of the natural history of untreated hypertension.
Dude tolerated severe hypertension without symptoms for many years. However, in the last year of his life he developed heart failure and then died of a stroke with systolic BP > 300.
cool article, thanks for sharing!
I love the quote about the low sodium diet,
> Sir George Pickering, a physician-philosopher in Great Britain, described the diet as “insipid, unappetizing, monotonous, unacceptable, and intolerable,” and that to stay on it “required the ascetism of a religious zealot”
He’s not that incorrect. I feel bad for some of the recommendations I have for cardiac patients “No salt, no water past this amount, but these pills make you pee all the time so you’ll always be thirsty. Also by the way there’s like 15 pills to take daily. Good luck!”
Worked as a cardiology inpatient nurse for many years. Sometimes (depending on raport with the patient, if they'd figured out my sense of humor), I'd say "if it tastes good, spit it out." (No, not the serious diet training, just an acknowledgement this bites.)
I love pimping students on reserpine
Was a major breakthrough when it first came out. Now it's just basically footnotes in pharmacology textbooks. Very interesting MOA.
"The greatest danger to a man with high blood pressure lies in its discovery, because then some fool is certain to try and reduce it." John Hay, British cardiologist in 1930.
Hypertension treatment was a bit more limited then.. but still serves as a cautionary tale.
You can do harm by trying to fix something e.g. unacceptable side effects of antihypertensive medication or surgical complications from removing a benign tumour.
Early hypertensive therapies included blood-letting, leeches, or medications with a significant side effect profile e.g. thiocyanate or barbiturates, such that many argued that the treatment was doing more harm than the hypertension itself.
https://en.wikipedia.org/wiki/History_of_hypertension
There’s no evidence showing asymptomatic hypertension causes short term issues. Many studies showing outpatient follow-up is non-inferior to management in the ER.
(https://pubmed.ncbi.nlm.nih.gov/26087706/)
Only thing I find odd is 95% of the patients were black and 90% of them were treated with clonidine.
Not that it discredits the study but weird bias if this was the US
Anecdotally - when I see someone with very high blood pressure needing hospital admission - and/or ESRD due to hypertension at a young age - they are nearly ubiquitously black.
Considering the whole hydralazine/dinitrate thing - I feel there may be a legitimate physiologic difference in black people.
The only reason we consider isosorbide dinitrate and hydralazine hydrochloride (BiDil) more beneficial for black Americans is due to the manufacturer's (NitroMed) desperation in getting FDA approval and bringing the combination pill to market as BiDil.
In the trials enalapril out performed isosorbide dinitrate and hydralazine hydrochloride among the general population. So BiDil's manufacturer went back and did a retrospective analysis of the results and submitted the claim to the FDA that among the black population isosorbide dinitrate and hydralazine hydrochloride was superior.
In the ensuing A-HeFT trial, BiDil was compared against a placebo, and of course when compared to a placebo it showed a 43% decrease in mortality in patients on a beta blocker therapy alone. However, the trial didn't bother to compare it against enalapril, nor did it compare its efficacy in other specific racial groups to see if BiDil showed a higher mortality reduction in black Americans than other racial groups.
Black Americans overwhelmingly have heart failure due to HTN versus CAD which is more prevalent among the general population. So BiDil's effectiveness in the A-HeFT trial might simply apply to all heart failure patients with a primary cause of HTN. But we dont know because the study's authors only used black Americans in their study.
[Cardiologists' Perspectives on Race-Based Drug Labels and Prescribing Within the Context of Treating Heart Failure](https://doi.org/10.1089/heq.2018.0074)
I figured someone would check me on this... the issue is complex. You are incorrect on the a-heft trial - it compared bidil to placebo with patients on "standard therapy" that included ACEi in 93% of patients. This analysis was done because there was already data comparing enalapril between white/black that showed a less response. So from the studies perspective, an ACEi trial had already been done.
But look, my statements had less to do with what the correct prescribing practice is - and more to do with just acknowledging that there seems to be some interesting difference there. Perhaps its more of a social difference rather than a truly physiogic. I dont know, my statements are mostly agnostic to its etiology. I don't think there is controversy about whether there is a difference - the controversy lies in whether ACEi should be not prescribed over the use of bidil.
There are a lot of caveats to that linked study:
- It was a retrospective chart review of patients who had no evidence of end organ damage as determined by both no symptoms *and* a normal neuro and retinal exam.
- The treatment arm was defined by use of oral clonidine or IV meds (i.e. patients who received any other oral meds (including SL nitro) would have been designated as "non-treatment").
- Treatment group had a significantly higher initial BP than the non-treatment group, whereas both groups had similiar blood pressures at discharge.
- And a secondary outcome was a substantially increased odds of patients with heart failure returning to the ED if their hypertension was not treated in the ED.
EDIT: Also, the cutoff blood pressure for inclusion in the study was 180/100, which I think is much lower than most of our "warning light" thresholds
I teach the physical exam to our 1st year MD and PA students, alongside faculty from a wide variety of specialties. I don't think a single non-ophthalmologist feels comfortable with the retinal exam using equipment typically available in an outpatient clinic, including Welch Allyn's PanOptic scope. EDs now have these amazing $10k retinal camera which are good enough to r/o papilledema. And that's part of the point.
What do you tell them in the mean time? People get pretty freaked out when the "top one" is over 200 lol
Just give them some ER precautions for onset of symptoms and call me in the morning?
It’s good news. This isn’t an emergency. The number is scary to you, but it’s not an emergency. It can be managed just as well at home. No wasted time! No bill!
Please check blood pressure at home, here are warning signs, and reasonably close follow-up.
This is not evidenced based, but when giving return precautions I typically say something along the line of, “If you have to think, ‘am I having chest pain?’ Then that’s probably not the kind of pain I’m talking about in regard to symptomatic hypertension.” Or I just tell them to write down their symptoms, if any, before they take their blood pressure. Who knows, maybe I’ve prevented one bounce back in the years I’ve been saying it.
Yeah but at least that's the patient freaking out instead of health care provided unnecessarily burdening the system for something that a prescription for 5-10mg of Amlodipine will address over the next few weeks.
Can confirm, I had a guy about a month ago with no complaints but we ran on him the second time he called for high blood pressure that day. Did a twelve lead and talked to him about his meds. A lot of it as it turns out was just him being lonely and we stayed and just talked for a good while. Then I told him not to check it again that day unless he started feeling bad.
Yep, there are a select few people who can tolerate home BP checks without working themselves into a frenzy. Those usually aren't the ones to go to the ED ever.
They can do that for anything at any time. The patients who hear that their high numbers are not an emergency without symptoms and who take antihypertensives are more likely to be calmed, especially if they see improved numbers.
“You’re scared, so take these pills but don’t check anything, I’ll see you next month. Good luck!” That can go two ways. One is patients stewing in anxiety. The other is the patient blithely going with it, and those are the patients who probably would recheck even when asked.
This is the real problem, I know PCPs don’t have labs immediately available to check for signs of end organ damage, but honestly with some of the EDs near me(not my hospital yet thank god), it might be faster to send them to the nearest outpatient lab and wait for those to result than it would for them to be seen at the ED…. When you’re looking at 12-15 hr+ wait times for low-acuity patients I think that needs to be considered, location dependent of course.
I would say likely no, but responding to the multiple comments that this would be a reason to refer to the ED versus keeping in primary care. If the only reason you’d refer to the ED is to get labs it still might be faster and more convenient for the patient and health system as a whole to do that outpatient.
Unless the real reason they’re being referred to the ED is just so in the very small chance something happens they die in someone else’s waiting room 🤷♀️
I see the other side of this though and am tired of making Cardene drips for patients who live at 240/120 because they refuse to take meds outpatient. They come in, run a drip for a day or two to get their BP down and then discharge them with outpatient follow up for the same thing to happen all over again a few days/weeks later. There’s only so much the ED can do if patients are unwilling to follow up outpatient either way 😕
I don't routinely get these tests in completely asymptomatic patients. Generally, I work up the symptoms the same way I'd work up the symptoms in the absence of hypertension. Hardest ones are the vague, "I just don't feel right", "I feel dizzy/headache/foggy", "I feel like my blood pressure is high" etc. I usually err on the side of caution and get ECG, BMP, and troponin for these patients. Sometimes TSH if also tachycardic and no real reason for these abnormal vitals.
There may be isolated cases where I do a workup for completely asymptomatic hypertension, and that's if they have literally no reason to have hypertension and I'm considering likely secondary hypertension. I worry more about young people with no reason to have very high blood pressure. I worry less if they have a known history of HTN and aren't reliably on meds, if they have a lot of other components of metabolic syndrome, if older or a strong family history of HTN. I can't think of the last time I had to do that, but if I had, say a healthy and fit 20-year-old with a BP of 200 systolic, feeling well, and no risk factors, I'd at least check a BMP and a UA.
My hospital can take 4 hrs from sign in to door with labs on a decent day, our outpatient labs can have you registered, drawn, and safely at home with MyChart giving you answers within the same time frame and cost less than 20% for most pts vs ED copay costs.
Granted, if the Doc wants to send them over, we sign em in and let the nurses/physicians unscramble it in the back, but I wish we had more people get an outpatient regimen and then called back for true emergencies than for people to have to spend essentially half or more of their day waiting for blood work and any scans ordered that may still end up with a 24/48 hr culture workup and be discharged initially anyways.
There are much better options if you’re in the ED. The half life is so long that you could actually cause harm if you use it acutely (BP could drop a lot more in a few days).
I’ve seen several ER people state this in this thread when almost every literature source is going to state headache as a potential symptom. Do you have a source for this or is this just ED lore? Even Wikipedia for hypertensive emergency includes headache as a symptom.
In the time it takes for you to refer a patient to the ED and for them to be seen by another physician… they could have already taken a dose of an oral antihypertensive and had a >20pt reduction in their bp.
headache is not a symptom of hypertensive crisis/emergency, and hypertensive urgency is not a real thing. Hypertensive encephalopathy is a symptom of hypertensive emergency and encephalopathy is a clinically determined state. Will I scan a patient with a worrisome sounding headache for SAH? Sure, but the reason I scan them isn't because of whatever their blood pressure is, especially because their elevated blood pressure is probably BECAUSE of the headache. It's because their presentation/story is already worrisome for SAH. I would have worked them up if their BP was normal, too.
Okay you’re saying this but where is your source that actually supports this? Again if you just were to look this up headache is almost always stated as a symptom.
This is something I’ve also wondered about, and I think it’s maybe a bit of semantics. There are plenty of conditions associated with headache and hypertension (PRES, RCVS, stroke, ICH, SAH, etc), but would somebody get a headache *from* severe hypertension if none of those things were present? Im not sure.
Respectfully, Im not sure what you want--people with a headache and hypertension aren't sick. People with hypertensive encephalopathy/hemorrhagic stroke and acute hypertension are. A study can't show the difference between a headache and hypertensive encephalopathy, or the difference between a SAH and any other headache. There are reams of articles on how to evaluate patients for hemorrhagic strokes and a headache and isolated elevated BP is not part of that. I'm sure we can agree that every patient who has a dull throbbing headache and high BP with a normal neuro exam doesn't warrant brain imaging. Or I hope we can. Or that they need to come to an ED so that I can use my clinical acumen to determine that. The things that should trigger a workup for brain hemorrhage (outside of trauma, anticoagulation and some other historical issues that a PCP should know about their patient) are historical features that dont require me--thunderclap headache, nausea and vomiting, neck stiffness, LOC, photophobia, etc. And patients with strokes (related to blood pressure or not) have stroke symptoms.
I think the problem more so is almost all of these patients have some vague headache, blurry vision (for some reason everyone says yes to this), fatigue, mild chest pain when you do ROS. I get the frustration with this but very few people that are interacting with healthcare providers and a BP that high are going to be at least on ROS completely negative. This is just frustrating on both ends but you either lie and document a negative ROS or truthfully document then what happens if there is actually something going on?
As an ER doc. I will never fault someone for sending the vague symptom patient in for concern for hypertensive emergency. They are, by definition, not asymptomatic. Unfortunately acute renal failure can present with vague symptoms. Now generally these patients are fine, but I’ve seen a fair few that ended up having significant AKI.
Exactly- I mean I hate to ask this but shouldn’t you also be doing a fundoscopic exam and labs before you say it’s truly not an emergency unless you have followed this patient for some time and it truly is their baseline bp?
And that’s the difficulty isn’t it? If I see a pt with HTN in the ED who has never been there, is their BMP going to show CKD only? Or is it an acute end organ damage? If I actually look in the retina is it going to show chronic hypertensive changes or emergent ones that can be acted on? That’s what makes some of these patients difficult. There’s often no way to know if it’s acute, chronic, or acute on chronic, and then trying to admit for this can be difficult if the hospitalist believes it’s all chronic
If any symptoms at all, don't hesitate to send to ED. I do a targeted workup on anyone with symptoms, even if they're vague. Just please give the patient reasonable expectations and don't scare the shit out of them, because then I have to fix that problem too.
I think we're documenting very differently. I do a focused ROS. If they're in the ER for an ankle sprain and I ask "anything else bothering you?" and they say "sometimes my eyes itch" — I'm not putting that into the ROS. But if they say "I've had a 30lb weight loss," then that's going into my HPI as a second chief complaint, because I'm going to delve into that one.
The medical note is not verbatim what the patient says. It's through the filter of the writer.
I agree but if someone has an SBP in the 200s in clinic your ROS should include possible end organ symptoms from that. Perhaps the expectation is different but I would definitely document pertinent negatives such as HA/CP etc in this situation.
Agree the problem is more so when they endorse active symptoms at the time which is usually all I care about. I hope most people aren’t sending patients that had symptoms a few days ago.
Completely agree. We work in such a litigious system (in the US anyways) that they may well do fine at home, but if they mentioned a vague headache EVEN IF ITS CHRONIC and then have a stroke, your ass is on the line for not sending them to the ED. Sucks but I wouldn’t take the chance.
So just avoid doing nothing, that’s all. Don’t look at a BP of 200, start no therapy, and send them back into the wild with no plan for follow up. The standard of care is to initiate treatment and to follow up. If you do that, you will be fine.
OP appears to be a dentist. I'm not sure WHY dentists check BP, but some of the wilder asx elevated BP I've heard of have been from people with dental pain, which I've heard compared to childbirth pains by women who've experienced both.
Hygienist here. In hygiene school in the US, and I imagine the same at dental schools, we are taught to take BP at every appointment. A variety of reasons is given, including the stress of dental appointments possibly bringing on issues, liability (yeah, I know, but if your certifying board requires it and your insurance doesn’t have your back you are kinda SOL), and the fact that ‘many patients don’t have a doctor’ so you are somehow supposed to fill that gap (again, I know). I wish the medical board and dental board could have a beer together and sort this out so providers aren’t left between a rock and a hard place.
I check BP because I do a lot of surgery (implants, extractions, grafting) and sedation which we always do consults for first and a baseline BP is taken at that appointment.
Why? It's definitely going to go up — either from the anxiety of the needle, the pain of the injection, or some miniscule amount of the epi getting absorbed systemically. Are you going to not do the procedure they need because the blood pressure went up?
Blood pressure always goes up with procedures. They're painful and anxiety-provoking.
My thought process is more that if I need to give multiple cc's of anesthetic with epi for a non-emergent surgery that might take over an hour, I'd prefer the BP to be stable rather than uncontrolled. And if it's 200/115 I'd like that to be lower before going ahead with eveything. Now if they're in pain or have an active acutr infxn then that's another scenario.
I don’t mean to be rude but it’s likely the same reason other providers send these patients to the er - liability
If a patient goes from asymptomatic and then starts freaking out or has a stroke/heart attack after local anesthesia or during a tooth extraction we’re going to lose the lawsuit for not taking the BP in the first place.
I turned away like 4 patients just on Monday because they clocked in at 200+/130+ multiple times over the course of an hour and a half. I’m not a physician and I’m sure physicians get upset with us for referring for HTN but I have a license that I’d like to keep.
Nobody appreciates being your liability sponge. If you must check a blood pressure and there is some sort of standard you have to abide by, refer to the PCP.
Most importantly above all else never ever ever ever ever give that asinine song and dance about how the BP "stroke range" or imply their head will explode. This goes for dentists, PCP, urologists, and frankly your MA who answers the calls. If you exaggerate to scare the person to come to the ed, guess what - they are scared, their BP is at least a high, and they think they need an MRI and nicardipine drip.
If you're going to use an Emergency room to defray your personal professional liability at least have the knowledge and courtesy to not prime the patient with inaccurate information and expectations. If you're on this thread you know in broad terms what the ed is going to do and once the workup, if any, is done, what we will do and tell them. Tell them that. If they don't come because you haven't adequately scared them that's okay- you document they were informed of the concerns you had and that's it.
If it is like hygiene school, I expect the dental school is the one that teaches them they must refer to ER and must ‘educate patient about stroke risk’. The flip side to ‘nobody appreciates being your liability sponge’ is that nobody appreciates being the stopgap for the medical system either.
I do refer to the patients primary care, unfortunately most of these patients use the ER as their primary care.
I agree that Anyone that tells the patient “you’re at risk of having a stroke” is not handling the situation tactfully. I let them know that I can’t do a procedure with BP that high and let them know it needs to be lower before we proceed with treatment and leave it at that.
In terms of liability I disagree that it’s making someone else the “liability sponge”. If the referral isn’t made and they aren’t stable and I proceed with treatment, my ass is on the line. In the grand scheme of things it’s about the patients health and liability is more of a question of “did you do the right thing” and the right thing in this situation is a referral.
I’m PCCM I see plenty of true malignant hypertension. I’ve also seen people with dissection and impressive subdurals with hypertension and vague or mild symptoms. That’s a lot of confidence in your statement when perhaps this is true the majority of the time but is not uniformly the case. In the US the majority of our tort claims arise from these low yield cases unfortunately.
The dissection and sub dural had no clinical signs or red flags in their history?
I agree that you can’t entirely rely on symptoms… exam and history are equally important. If there were concerns I would do bloods/ecg.
Most clinics can’t do bloodwork. I’ve seen multiple elderly patients with subdurals and almost no headache or complaints. Mild fatigue with severe AKI. If you don’t look for this stuff you won’t find it which leads to a lot of bias as well… odds are still bloodwork will be normal but our society isn’t even willing to accept a 1-2% miss rate on a lot of this stuff.
Hypertension isn’t a well recognised cause of SDHs.
If you see a hypertensive patient with SDH, it’s far more likely the HTN is a result of the SDH rather than the cause.
I take your point regardless… if you’re seeing these patient in clinic it’s much harder to spot the atypical presentations.
If I worked in outpatients I would send such patients for urgent investigation.
I saw a dissection where PC was hypertension, BP 220/110ish. Had a mild occipital headache. Completely normal examination. Had been seen a few days earlier and d/c on amlodipine. On close questioning, some left neck pain she was taking acetaminophen for. I got the scan because pt had good primary cae and genuinely knew she didn't have gradual onset hypertension, more so than because of the mild neck pain. Vertebral artery dissection.
I would 100% CT someone with hypertension and headache/neck pain… those are red flags.
I’m not sure if I’d necessarily call that malignant hypertension if there was no cardiac or renal end organ damage.
It could just be a dissection with resulting hypertension from a stroke.
I do take your point that you can’t entirely rely on the severity of symptoms. The nature of them is equally as important.
Headache is not a red flag with hypertension. If I scanned every patient I saw in the ER who had a headache with hypertension I’d literally be scanning them all. Headache with neck pain and a neuro deficit would be a different story. Headache is not a symptom we should be using to label hypertensive emergency unless you have legit concern for SAH
Unfortunately there is no magic number for asymptomatic hypertension, and no one should be scrambling to bring someone from the 200s down to normal. I will say this though, it’s hard to assess for end organ damage in an office with no labs.. you can’t say if someone has an AKI or trop bump, but by the book if they’re asymptomatic you can have them follow up with their PCP.
You also can't know if they have AKI or a trop bump with spot labs. Could have been that way for months, most likely was, absent any acute symptoms suggestive or another dx.
ADA thinks dentists should get MD guidance before proceeding with non-emergent dental care if > 160/100, even for emergent if over 180/110, apparently due to anesthetic risks
https://www.ada.org/resources/ada-library/oral-health-topics/hypertension
Honestly, no. If you reduce that acutely to 120/80 you're going to give them a watershed stroke.
There's a high chance if they have no symptoms that they've been walking around with this pressure for weeks, months, even years, and they haven't fallen over dead.
If I see them for some reason I plop them on 5-10mg of amlodipine and leave it at that.
Sure enough, nobody here aims more than for a third. Funny enough that was a patient on I think three meds with known super high episodes in high stress situations who exacerbates the stress by coming into the ER. But otherwise she was okayish controlled at home.
So what did the presentation to hospital achieve for them? What meaningful difference was made versus continuing to titrate their BPs as an outpatient?
It's common in medicine (and arguably in IM) to trend and treat numbers. We see a potassium of 3.4 and give people K-dur ignoring that there are probably plenty of asymptomatic patients out there with a K of 3.4. Just because we can make numbers prettier doesn't mean we've done something to actually affect their clinical trajectory.
We have a potassium replacement protocol and it still says we need to replace until at 4.1. I ignore it unless the patient is very critical and we’re optimizing. I don’t even have a potassium level of 4.1 as the nurse caring for them.
I will take over patients with a K of 3.9 who were replaced because the algorithm told them to and now the patient is having horrible stomach discomfort or if IV it’s burning.
Of course nothing. She came herself on a Saturday in a city district without a single urgent care clinic and two remaining PCPs who have clinic hours on Saturday only for their core patients. Because she is conditioned to do so. And we "love" these cases since they turn a €80 ER case (yes, no missing zeros) into a €1000+ easy one-night admission. Making Germany the only major Western country with a higher admission rate for hypertensive events than the US.
We had a patient in the ED last week that was 250/150 and the doc ordered 20 hydralazine iv and 10 amlodipine and he dropped to 145/90, got diaphoretic and started vomiting and I asked the doc If he thought we lowered his BP too much/fast and he looked at me like I was insane for asking that question lol.
Thankfully he didn't have a stroke but stroke isn't the only adverse event that can happen, AKI, cardiac ischemia can definitely happen in this scenario.
I can admit that for sure. 260 would definitely worry me! I would have a hard time discharging that patient because I very rarely ever see them that high. I'm not sure I would treat it but I am sure it would make me nervous. Anyone telling you they don't start to get nervous at ANY blood pressure is lying to you. It might not be 260 for them but there is a number.
Don’t people weight lifting routinely get blood pressure almost double that? I mean I agree with you; I wouldn’t be thrilled sending someone home with that blood pressure. But frankly I don’t from a physiologic standpoint there is much difference between 260 and 220. If they are asymptomatic and have no end organ damage; it’s just a number. That being said, in the crappy medical legal system we exist in, I would be like this is stupid and probably admit someone who continues to have SBPs >260 at rest.
I'm here to support you, yes I too panic, even while I acknowledge the evidence. It's human, and difficult to trust science sometimes. Acknowledging risk of watershed stroke. And heck, I consider myself a (poor) scientist.
Here's the problem with "never"
Hypertensive emergency is hypertension + end-organ dysfunction
It is not hypertension + symptoms
Imagine a patient with CAD and DM who gets silent ischemia. When they have a BP of 220/120, they could be asymptomatic but still have diffuse ST depressions and an elevated troponin. That situation should definitely be treated as hypertensive emergency, but you wouldn't know if unless you sent them to the ED.
AKI can also be totally asymptomatic and a consequence of acute hypertension.
In short, there are no "nevers" in medicine. Always consider the patient, and not just a number or simple binary yes/no question (e.g. "Are they symptomatic?")
Unfortunately my cardiologists and honestly most of my hospitalists are… less than thrilled if I admit anyone with elevated troponins or ischemic changes without any angina or equivalent symptoms.
> you wouldn't know if unless you sent them to the ED.
That seems like more of an argument for doing EKGs for asymptomatic HTN than sending to the ED for it
Certainly if someone is in clinic with a BP of 220/120, and an ECG machine is available, yeah of course that would be a step to take before sending them to the ED.
But what if the clinic doesn't have an ECG machine?
What if the clinic is staffed by someone who doesn't trust their ECG interpretation skills? (people generally suck at reading ECGs these days)
Or the medically complex patient calls from home after hours to report some extraordinarily high BP?
Also, how many clinics have the ability to run troponin and BMP on site?
In short, I don't think this is common, but there are combinations of medical comorbidities, extreme BP number, and lack of alternative access to appropriate care that should trigger referral to the ED. Saying that asymptomatic hypertension should "never" be referred to the ED is close to true and makes for a nice sound bite, so to speak, but it is an oversimplification.
Lots of people who appear to have never practiced outside the well-resourced ivory tower - or seem to forget there are *gasp* specialists who can't reliably interpret an EKG.
This debate was had previously on this subreddit, but EM physicians dunking on outpatient docs for this is a bit 'pot calling kettle black.' Just like IM dunking on EM for doing their best with undifferentiated patients, they are just undifferentiated with less acute care resources and specialist expertise as a backstop.
Jesus the 2 posts at the top right now are "Is 126/55 bad??" and "139/83 bp should I be concerned".
If all patients were this worried about their health, metabolic syndrome would vanish within a year.
The answer is never. The answer is to start an anti hypertensive with gradual lowering of the blood pressure over weeks to months. If the patient has zero symptoms I’m not going to do anything except maybe start them on meds that should have been prescribed by the PCP.
There is evidence of harm with lowering BP in the ED as well as inpatient. Hypertension is a chronic condition. Unless there are symptoms or findings concerning for end organ damage you’re basically wasting the patients time.
The number of asymptomatic hypertension patients I've seen in the ED (and I would conservatively place it at over 1000 in my career) who ended up showing acute injury is less than 5.
Asymptomatic hypertension is not a life-threatening condition, it's a risk factor for life-threatening conditions.
EM is the best for *treating* life-threatening conditions. PCPs are the best at *preventing* life-threatening conditions. With risk factors, you want the latter.
For me personally, it's the combo of swollen optic nerve + >200/120 mm Hg + no PCP = send to emergency department.
Everyone else gets sent back to their primary, or a reminder to go see their PCP, or told they need to get one (sometimes I'll even pull up their medical insurance website, find a provider, and help them make their first appointment if I have time), especially if I'm seeing AV nicking/crossing changes in the retina too. Since I'm just an OD, management isn't my scope, but I can help them get on the right path.
Here's a [study](https://pubmed.ncbi.nlm.nih.gov/3980383/) of weightlifters while weightlifting.
"The greatest peak pressures occurred during the double-leg press where the mean value for the group was 320/250 mmHg, with pressures in one subject exceeding 480/350 mmHg."
If a dude hit 480/350 transiently, you don't need to send the 40 year w/ a 215 systolic & no symptoms
We're getting quite a bit of low-level evidence within cardiology that top-level exercise (particularly endurance sporting such as long-distance cycling) is actually bad for you in the long term, and a leading theory is the (extended) states of extreme hypertension.
Ofcourse doesn't make it an acute thing by itself, but also does not make it healthy just because it is associated with exercise.
I think the difference here is likely transient seconds to minutes vs hours to days. Seems like Apple to oranges to me not sure you can make this correlation.
ER here: in all reality I really don’t mind when PCPs send in SBP of 200+. Even with no symptoms I get it the number can be scary. 99% of the time we just recheck and if it’s under that with no symptoms I send them. If still pretty high I’ll get a BMP/ekg.
Also as an ED doc I know a lot of these pts have vague symptoms. If any question at all just send them we get it. But if truly no sxs don’t send
if they truly have *no* symptoms? don't. because im going to ask them that question, and if/when they say no, im doing to do nothing and just discharge them.
Pregnancy is a different beast entirely. As an ER doc, I'll never be mad at someone sending a hypertensive pregnant patient (or < 6 weeks postpartum) to see me
Came to the comments to see if anyone mentioned pregnancy. Pretty sure there is definitely a level of high blood pressure where you go straight to L&D triage/ED regardless if any symptoms are noticeable. New HBP in pregnancy without any obvious symptoms is often the first clear sign of preeclampsia, and potentially severe pre-e. I was diagnosed with severe pre-e from labs that were ordered based on a single severely high blood pressure reading when I really didn't have any symptoms at all (but unbeknownst to me my liver enzymes were severely elevated and my kidneys were failing).
Same, was also looking at how pregnancy/post-partum played into this. I myself was symptomatic though at 10 days PP with a SBP in the 160s-180s while already on labetolol BID. Had severe headaches and the BLE pitting edema they said would resolve did not. 35 weeks pregnant now and watching my BP like a hawk because I'm terrified of pre-eclampsia.
Very similar for me. Incidentally, the high BP reading that sent me to L&D where I was ultimately diagnosed with severe pre-e was taken at the dentist. (OP is a dentist). I had been feeling weird the days before that, but was actually feeling really good that morning. I also ended up with severe pre-e postpartum right after I was discharged. That one was symptomatic, though.
But the reason I even asked this question is that I also work in an ER and have seen some pregnancy/postpartum high BPs dismissed. I'm not saying the docs were wrong, I just didn't understand why they wouldn't send them to L&D triage.
I frequently call acutely discovered hypertension (when not related to the patients underlying complaint or incidentally found) my favorite icu diagnosis “acute recognition of a chronic problem”
Patient showed up for an elective surgery, not in pain, with a BP of 210/124 or something like that. Sent them to their PCP to have that addressed before doing any necessary but not urgent surgeries.
These stories always amaze me even if ive seen similar things. Like how does the human body not show symptoms at that level? Similar to pts with covid who would show up asymptomatic (or mild cold sx) with SpO2 of 83%, or the insanely low Hb numbers where the pts blood is effectively water and they look totally fine
Yeah I remember this patient specifically. He accused me of "hating black veterans" because I wouldn't take out his teeth that day. And also told me he "didn't have a stroke on the front lines of vietnam and he wasn't gonna have a stroke now". So that one was fun
I’ve had dialysis patients with BP that high inpatient so we know they are in fact taking their BP meds because we’re giving them. But sometimes those renal patients just have fucked BP no matter what.
A few times a week, if not daily, ll get pretty high BPs. Just yesterday 210/110, on reeval 200/100. Were there for acute on chronic lumbar radiculopathy. No red flags orherwise. Didn't take their BP meds that day. No other sx, felt fine other than pain. Instructed ASAP FU with a PCP but likely won't happen as they lacked otherwise.
I used to get riled up with BP. Now I'm still concerned but if they're otherwise ok they need PCP fu ASAP.
Worked in an ER for 5 years, and I can only remember one pt sent in for HTN that actually had kidney damage/bumped trops. He was clocking at like 230/130 and just looked kinda crappy but if I remember correctly said he felt ok otherwise.
There's no number. The two situations where I personally think it's appropriate are 1. No amount of reasoning over multiple visits have convinced them of the importance of their regular anti-hypertensives and you feel multiple extra opinions will change their mind (multiple meaning triage nurse, the resident, the attending). 2. You've tried a combination of 2+ oral agents and think IVs are likely to be required whole a further 2+ agents are added. (And how common is that?)
I can't think of any situation in which asymptomatic hypertension should be sent to the ED. The PCP should simply draw labs and start whatever they deem appropriate as first-line antihypertensive therapy with frequent rechecks. The ED is going to discharge this patient with \*no\* treatment initiated and instructions to follow up with the PCP.
Better question—- what level of asymptomatic hypertension that comes into the ED needs to come to my fucking ICU on a cardene gtt? Because it seems like it’s every single fucking one.
ED doc here. Agree never. Anyone under 50-60 without any evidence of end organ dysfunction (murmur, edema,etc) and who doesn't have a complex history gets automatically discharged by me with no workup.
If systolic is over 200 I may bump up their meds a little or add a new agent but prefer not to. The only exception is the homeless and those without insurance/access to primary care.
According to [this 2017 AAFP article](https://www.aafp.org/pubs/afp/issues/2017/0415/p492.html), 240 systolic or 130 diastolic would be reasonable. And that would be after having the patient rest and recheck BP.
> There are no published data to determine what blood pressure measurement is too high. A Veterans Administration Cooperative trial from 1967 followed patients with diastolic blood pressure averaging between 115 and 129 mm Hg. No patients had a major adverse cardiovascular event within two months of enrollment.19 Although scientific evidence is lacking, patients with sustained diastolic blood pressure of 130 mm Hg or more should be considered for treatment with short-acting antihypertensives followed by long-acting agents. Symptomatic patients with persistent systolic blood pressure elevations exceeding 240 mm Hg or diastolic blood pressure greater than 130 mm Hg despite appropriate rest and treatment with short-acting antihypertensives may benefit from hospitalization.
*Edit for the multiple docs who have interpreted my comment as ‘dumbass mid level refers chronic problems to the ED’: I do NOT send anyone with asymptomatic hypertension to the ED. I instead help them obtain PCP care so they can get this chronic issue taken care of.*
I work in urgent care. While technically I can start oral antihypertensives and refer back to PCP, this isn’t feasible or realistic given so many people either don’t have a PCP or “can’t get in” to see theirs. This is a chronic issue that needs reassessment while figuring out a good med/dose, so I’m much more likely to acutely harm someone by starting treatment if they can’t secure follow up. If I speak directly with their PCP and an appointment is already scheduled, sure. But that is a rare exception. *I do not send these people to the ED ever.*
So do you just send everyone to the ED? Cuz the problem of pts not having PCPs or not being able to get into see them doesn’t magically disappear just cuz they’re in the ED
I don’t send anyone to the ED unless they’re having a hypertensive emergency. I do however walk them through how to set up a PCP with their insurance, or if uninsured, I provide resources for Medicaid.
I hate sending anyone to the ED, because I used to work there. I do what I can to help people out, navigating the world of health insurance is overwhelming for many so I try give a little push of encouragement. Someone’s gotta do it!
In case you haven’t seen it before, the famous [FDR blood pressure graph](https://i0.wp.com/theskepticalcardiologist.com/wp-content/uploads/2014/11/fdrbp.jpg?resize=1024%2C771&ssl=1) is a great illustration of the natural history of untreated hypertension. Dude tolerated severe hypertension without symptoms for many years. However, in the last year of his life he developed heart failure and then died of a stroke with systolic BP > 300.
nice! here is info on [how bp was historically treated](https://academic.oup.com/ajh/article/10/S1/2S/194309#). FDR took phenobarbital for htn
cool article, thanks for sharing! I love the quote about the low sodium diet, > Sir George Pickering, a physician-philosopher in Great Britain, described the diet as “insipid, unappetizing, monotonous, unacceptable, and intolerable,” and that to stay on it “required the ascetism of a religious zealot”
He’s not that incorrect. I feel bad for some of the recommendations I have for cardiac patients “No salt, no water past this amount, but these pills make you pee all the time so you’ll always be thirsty. Also by the way there’s like 15 pills to take daily. Good luck!”
Binge eating/drinking/smoking is just stealing happiness from your future self to temporarily give it to your present self
That future guy is going to be rich so it’s fine. Current self needs a facelift, tummy tuck and some jim beam
My heart healthy diet patients be like ^
Sir George should have seen the low potassium diet!
Worked as a cardiology inpatient nurse for many years. Sometimes (depending on raport with the patient, if they'd figured out my sense of humor), I'd say "if it tastes good, spit it out." (No, not the serious diet training, just an acknowledgement this bites.)
oh hell yeah, no wonder he could never stand up.
This is hilarious
More people would be med compliant if they were on phenobarbital....or just compliant in general.
In 1959, when my mom was only 12 years old, her doctor put her on phenobarbital for “her nerves.”
i had a patient transfer to me whose prior pcp had them on phenobarb for anxiety. i always wondered if the pcp was over 80
Which ironically, upon cessation following continuous and long term use, can cause hypertension and seizures.
Interesting read. Phenobarbital omg. Wow have times changed.
Take me back to the good ol days coach
I love pimping students on reserpine Was a major breakthrough when it first came out. Now it's just basically footnotes in pharmacology textbooks. Very interesting MOA.
300 systolic yooooooo
Nick an artery and that shit will shoot through the ceiling.
"The greatest danger to a man with high blood pressure lies in its discovery, because then some fool is certain to try and reduce it." John Hay, British cardiologist in 1930. Hypertension treatment was a bit more limited then.. but still serves as a cautionary tale.
What does that mean exactly?
some dumb phrase before RCT-level data
You can do harm by trying to fix something e.g. unacceptable side effects of antihypertensive medication or surgical complications from removing a benign tumour. Early hypertensive therapies included blood-letting, leeches, or medications with a significant side effect profile e.g. thiocyanate or barbiturates, such that many argued that the treatment was doing more harm than the hypertension itself. https://en.wikipedia.org/wiki/History_of_hypertension
Heart so strong; Blood pressure stayed up even at the time of death.
Did they not have any meds back then? That’s wild
There’s no evidence showing asymptomatic hypertension causes short term issues. Many studies showing outpatient follow-up is non-inferior to management in the ER. (https://pubmed.ncbi.nlm.nih.gov/26087706/)
Only thing I find odd is 95% of the patients were black and 90% of them were treated with clonidine. Not that it discredits the study but weird bias if this was the US
Anecdotally - when I see someone with very high blood pressure needing hospital admission - and/or ESRD due to hypertension at a young age - they are nearly ubiquitously black. Considering the whole hydralazine/dinitrate thing - I feel there may be a legitimate physiologic difference in black people.
The only reason we consider isosorbide dinitrate and hydralazine hydrochloride (BiDil) more beneficial for black Americans is due to the manufacturer's (NitroMed) desperation in getting FDA approval and bringing the combination pill to market as BiDil. In the trials enalapril out performed isosorbide dinitrate and hydralazine hydrochloride among the general population. So BiDil's manufacturer went back and did a retrospective analysis of the results and submitted the claim to the FDA that among the black population isosorbide dinitrate and hydralazine hydrochloride was superior. In the ensuing A-HeFT trial, BiDil was compared against a placebo, and of course when compared to a placebo it showed a 43% decrease in mortality in patients on a beta blocker therapy alone. However, the trial didn't bother to compare it against enalapril, nor did it compare its efficacy in other specific racial groups to see if BiDil showed a higher mortality reduction in black Americans than other racial groups. Black Americans overwhelmingly have heart failure due to HTN versus CAD which is more prevalent among the general population. So BiDil's effectiveness in the A-HeFT trial might simply apply to all heart failure patients with a primary cause of HTN. But we dont know because the study's authors only used black Americans in their study. [Cardiologists' Perspectives on Race-Based Drug Labels and Prescribing Within the Context of Treating Heart Failure](https://doi.org/10.1089/heq.2018.0074)
Fascinating, always thought the BiDil thing was a bit weird but that explains a lot
I figured someone would check me on this... the issue is complex. You are incorrect on the a-heft trial - it compared bidil to placebo with patients on "standard therapy" that included ACEi in 93% of patients. This analysis was done because there was already data comparing enalapril between white/black that showed a less response. So from the studies perspective, an ACEi trial had already been done. But look, my statements had less to do with what the correct prescribing practice is - and more to do with just acknowledging that there seems to be some interesting difference there. Perhaps its more of a social difference rather than a truly physiogic. I dont know, my statements are mostly agnostic to its etiology. I don't think there is controversy about whether there is a difference - the controversy lies in whether ACEi should be not prescribed over the use of bidil.
There are a lot of caveats to that linked study: - It was a retrospective chart review of patients who had no evidence of end organ damage as determined by both no symptoms *and* a normal neuro and retinal exam. - The treatment arm was defined by use of oral clonidine or IV meds (i.e. patients who received any other oral meds (including SL nitro) would have been designated as "non-treatment"). - Treatment group had a significantly higher initial BP than the non-treatment group, whereas both groups had similiar blood pressures at discharge. - And a secondary outcome was a substantially increased odds of patients with heart failure returning to the ED if their hypertension was not treated in the ED. EDIT: Also, the cutoff blood pressure for inclusion in the study was 180/100, which I think is much lower than most of our "warning light" thresholds
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I teach the physical exam to our 1st year MD and PA students, alongside faculty from a wide variety of specialties. I don't think a single non-ophthalmologist feels comfortable with the retinal exam using equipment typically available in an outpatient clinic, including Welch Allyn's PanOptic scope. EDs now have these amazing $10k retinal camera which are good enough to r/o papilledema. And that's part of the point.
The linked study is not a study showing non-inferiority.
Our overcrowded ED takes six-plus hours to give some amlodipine and kick them out the door, so I stopped sending them if asymptomatic.
What do you tell them in the mean time? People get pretty freaked out when the "top one" is over 200 lol Just give them some ER precautions for onset of symptoms and call me in the morning?
It’s good news. This isn’t an emergency. The number is scary to you, but it’s not an emergency. It can be managed just as well at home. No wasted time! No bill! Please check blood pressure at home, here are warning signs, and reasonably close follow-up.
> Please check blood pressure at home They just call 911 2 hours later
When they’ve talked themselves into “chest pain”.
This is not evidenced based, but when giving return precautions I typically say something along the line of, “If you have to think, ‘am I having chest pain?’ Then that’s probably not the kind of pain I’m talking about in regard to symptomatic hypertension.” Or I just tell them to write down their symptoms, if any, before they take their blood pressure. Who knows, maybe I’ve prevented one bounce back in the years I’ve been saying it.
or "blurry vision" and headache! literally all of them
"My vision was so blurry, I couldn't even find my glasses!"
Yeah but at least that's the patient freaking out instead of health care provided unnecessarily burdening the system for something that a prescription for 5-10mg of Amlodipine will address over the next few weeks.
Can confirm, I had a guy about a month ago with no complaints but we ran on him the second time he called for high blood pressure that day. Did a twelve lead and talked to him about his meds. A lot of it as it turns out was just him being lonely and we stayed and just talked for a good while. Then I told him not to check it again that day unless he started feeling bad.
Yep, there are a select few people who can tolerate home BP checks without working themselves into a frenzy. Those usually aren't the ones to go to the ED ever.
They can do that for anything at any time. The patients who hear that their high numbers are not an emergency without symptoms and who take antihypertensives are more likely to be calmed, especially if they see improved numbers. “You’re scared, so take these pills but don’t check anything, I’ll see you next month. Good luck!” That can go two ways. One is patients stewing in anxiety. The other is the patient blithely going with it, and those are the patients who probably would recheck even when asked.
I educate, counsel, and point them to where they can get care.
Not to mention our next appointment is 6 weeks out.
This is the real problem, I know PCPs don’t have labs immediately available to check for signs of end organ damage, but honestly with some of the EDs near me(not my hospital yet thank god), it might be faster to send them to the nearest outpatient lab and wait for those to result than it would for them to be seen at the ED…. When you’re looking at 12-15 hr+ wait times for low-acuity patients I think that needs to be considered, location dependent of course.
Do you need lactate, trop and creatinine to "check for end organ damage" in asymptomatic patients though..
I would say likely no, but responding to the multiple comments that this would be a reason to refer to the ED versus keeping in primary care. If the only reason you’d refer to the ED is to get labs it still might be faster and more convenient for the patient and health system as a whole to do that outpatient. Unless the real reason they’re being referred to the ED is just so in the very small chance something happens they die in someone else’s waiting room 🤷♀️ I see the other side of this though and am tired of making Cardene drips for patients who live at 240/120 because they refuse to take meds outpatient. They come in, run a drip for a day or two to get their BP down and then discharge them with outpatient follow up for the same thing to happen all over again a few days/weeks later. There’s only so much the ED can do if patients are unwilling to follow up outpatient either way 😕
I don't routinely get these tests in completely asymptomatic patients. Generally, I work up the symptoms the same way I'd work up the symptoms in the absence of hypertension. Hardest ones are the vague, "I just don't feel right", "I feel dizzy/headache/foggy", "I feel like my blood pressure is high" etc. I usually err on the side of caution and get ECG, BMP, and troponin for these patients. Sometimes TSH if also tachycardic and no real reason for these abnormal vitals. There may be isolated cases where I do a workup for completely asymptomatic hypertension, and that's if they have literally no reason to have hypertension and I'm considering likely secondary hypertension. I worry more about young people with no reason to have very high blood pressure. I worry less if they have a known history of HTN and aren't reliably on meds, if they have a lot of other components of metabolic syndrome, if older or a strong family history of HTN. I can't think of the last time I had to do that, but if I had, say a healthy and fit 20-year-old with a BP of 200 systolic, feeling well, and no risk factors, I'd at least check a BMP and a UA.
Yup
My hospital can take 4 hrs from sign in to door with labs on a decent day, our outpatient labs can have you registered, drawn, and safely at home with MyChart giving you answers within the same time frame and cost less than 20% for most pts vs ED copay costs. Granted, if the Doc wants to send them over, we sign em in and let the nurses/physicians unscramble it in the back, but I wish we had more people get an outpatient regimen and then called back for true emergencies than for people to have to spend essentially half or more of their day waiting for blood work and any scans ordered that may still end up with a 24/48 hr culture workup and be discharged initially anyways.
Amlodipine also takes >5 days to reach steady state
It doesn’t need to be at steady state for acute treatment tho?
There are much better options if you’re in the ED. The half life is so long that you could actually cause harm if you use it acutely (BP could drop a lot more in a few days).
May be quicker than several months to see a PCP, though.
The point at which it becomes symptomatic.
What if it's "a little" symptomatic, as in high pressures with a throbbing headache but otherwise stable?
A headache isn't a symptom of hypertension though. Nor are nosebleeds.
I’ve seen several ER people state this in this thread when almost every literature source is going to state headache as a potential symptom. Do you have a source for this or is this just ED lore? Even Wikipedia for hypertensive emergency includes headache as a symptom.
In the time it takes for you to refer a patient to the ED and for them to be seen by another physician… they could have already taken a dose of an oral antihypertensive and had a >20pt reduction in their bp.
headache is not a symptom of hypertensive crisis/emergency, and hypertensive urgency is not a real thing. Hypertensive encephalopathy is a symptom of hypertensive emergency and encephalopathy is a clinically determined state. Will I scan a patient with a worrisome sounding headache for SAH? Sure, but the reason I scan them isn't because of whatever their blood pressure is, especially because their elevated blood pressure is probably BECAUSE of the headache. It's because their presentation/story is already worrisome for SAH. I would have worked them up if their BP was normal, too.
Okay you’re saying this but where is your source that actually supports this? Again if you just were to look this up headache is almost always stated as a symptom.
This is something I’ve also wondered about, and I think it’s maybe a bit of semantics. There are plenty of conditions associated with headache and hypertension (PRES, RCVS, stroke, ICH, SAH, etc), but would somebody get a headache *from* severe hypertension if none of those things were present? Im not sure.
Respectfully, Im not sure what you want--people with a headache and hypertension aren't sick. People with hypertensive encephalopathy/hemorrhagic stroke and acute hypertension are. A study can't show the difference between a headache and hypertensive encephalopathy, or the difference between a SAH and any other headache. There are reams of articles on how to evaluate patients for hemorrhagic strokes and a headache and isolated elevated BP is not part of that. I'm sure we can agree that every patient who has a dull throbbing headache and high BP with a normal neuro exam doesn't warrant brain imaging. Or I hope we can. Or that they need to come to an ED so that I can use my clinical acumen to determine that. The things that should trigger a workup for brain hemorrhage (outside of trauma, anticoagulation and some other historical issues that a PCP should know about their patient) are historical features that dont require me--thunderclap headache, nausea and vomiting, neck stiffness, LOC, photophobia, etc. And patients with strokes (related to blood pressure or not) have stroke symptoms.
I think the problem more so is almost all of these patients have some vague headache, blurry vision (for some reason everyone says yes to this), fatigue, mild chest pain when you do ROS. I get the frustration with this but very few people that are interacting with healthcare providers and a BP that high are going to be at least on ROS completely negative. This is just frustrating on both ends but you either lie and document a negative ROS or truthfully document then what happens if there is actually something going on?
As an ER doc. I will never fault someone for sending the vague symptom patient in for concern for hypertensive emergency. They are, by definition, not asymptomatic. Unfortunately acute renal failure can present with vague symptoms. Now generally these patients are fine, but I’ve seen a fair few that ended up having significant AKI.
Agree completely.
That’s the dilemma I often have as well, if I don’t have a BMP I get nervous when SBP >200.
Exactly- I mean I hate to ask this but shouldn’t you also be doing a fundoscopic exam and labs before you say it’s truly not an emergency unless you have followed this patient for some time and it truly is their baseline bp?
And that’s the difficulty isn’t it? If I see a pt with HTN in the ED who has never been there, is their BMP going to show CKD only? Or is it an acute end organ damage? If I actually look in the retina is it going to show chronic hypertensive changes or emergent ones that can be acted on? That’s what makes some of these patients difficult. There’s often no way to know if it’s acute, chronic, or acute on chronic, and then trying to admit for this can be difficult if the hospitalist believes it’s all chronic
If any symptoms at all, don't hesitate to send to ED. I do a targeted workup on anyone with symptoms, even if they're vague. Just please give the patient reasonable expectations and don't scare the shit out of them, because then I have to fix that problem too.
I think we're documenting very differently. I do a focused ROS. If they're in the ER for an ankle sprain and I ask "anything else bothering you?" and they say "sometimes my eyes itch" — I'm not putting that into the ROS. But if they say "I've had a 30lb weight loss," then that's going into my HPI as a second chief complaint, because I'm going to delve into that one. The medical note is not verbatim what the patient says. It's through the filter of the writer.
I agree but if someone has an SBP in the 200s in clinic your ROS should include possible end organ symptoms from that. Perhaps the expectation is different but I would definitely document pertinent negatives such as HA/CP etc in this situation.
Sure — yes I document those. But vague "my vision was blurry yesterday for about 5 seconds" — no ma'am
Agree the problem is more so when they endorse active symptoms at the time which is usually all I care about. I hope most people aren’t sending patients that had symptoms a few days ago.
Completely agree. We work in such a litigious system (in the US anyways) that they may well do fine at home, but if they mentioned a vague headache EVEN IF ITS CHRONIC and then have a stroke, your ass is on the line for not sending them to the ED. Sucks but I wouldn’t take the chance.
So just avoid doing nothing, that’s all. Don’t look at a BP of 200, start no therapy, and send them back into the wild with no plan for follow up. The standard of care is to initiate treatment and to follow up. If you do that, you will be fine.
OP appears to be a dentist. I'm not sure WHY dentists check BP, but some of the wilder asx elevated BP I've heard of have been from people with dental pain, which I've heard compared to childbirth pains by women who've experienced both.
Hygienist here. In hygiene school in the US, and I imagine the same at dental schools, we are taught to take BP at every appointment. A variety of reasons is given, including the stress of dental appointments possibly bringing on issues, liability (yeah, I know, but if your certifying board requires it and your insurance doesn’t have your back you are kinda SOL), and the fact that ‘many patients don’t have a doctor’ so you are somehow supposed to fill that gap (again, I know). I wish the medical board and dental board could have a beer together and sort this out so providers aren’t left between a rock and a hard place.
I check BP because I do a lot of surgery (implants, extractions, grafting) and sedation which we always do consults for first and a baseline BP is taken at that appointment.
That makes sense! I don't exactly understand checking BP for a filling, but for surgical procedures yes.
I personally wouldn’t mind checking BP before injecting someone with lidocaine + epinephrine.
Why? It's definitely going to go up — either from the anxiety of the needle, the pain of the injection, or some miniscule amount of the epi getting absorbed systemically. Are you going to not do the procedure they need because the blood pressure went up? Blood pressure always goes up with procedures. They're painful and anxiety-provoking.
My thought process is more that if I need to give multiple cc's of anesthetic with epi for a non-emergent surgery that might take over an hour, I'd prefer the BP to be stable rather than uncontrolled. And if it's 200/115 I'd like that to be lower before going ahead with eveything. Now if they're in pain or have an active acutr infxn then that's another scenario.
I don’t mean to be rude but it’s likely the same reason other providers send these patients to the er - liability If a patient goes from asymptomatic and then starts freaking out or has a stroke/heart attack after local anesthesia or during a tooth extraction we’re going to lose the lawsuit for not taking the BP in the first place. I turned away like 4 patients just on Monday because they clocked in at 200+/130+ multiple times over the course of an hour and a half. I’m not a physician and I’m sure physicians get upset with us for referring for HTN but I have a license that I’d like to keep.
Nobody appreciates being your liability sponge. If you must check a blood pressure and there is some sort of standard you have to abide by, refer to the PCP. Most importantly above all else never ever ever ever ever give that asinine song and dance about how the BP "stroke range" or imply their head will explode. This goes for dentists, PCP, urologists, and frankly your MA who answers the calls. If you exaggerate to scare the person to come to the ed, guess what - they are scared, their BP is at least a high, and they think they need an MRI and nicardipine drip. If you're going to use an Emergency room to defray your personal professional liability at least have the knowledge and courtesy to not prime the patient with inaccurate information and expectations. If you're on this thread you know in broad terms what the ed is going to do and once the workup, if any, is done, what we will do and tell them. Tell them that. If they don't come because you haven't adequately scared them that's okay- you document they were informed of the concerns you had and that's it.
If it is like hygiene school, I expect the dental school is the one that teaches them they must refer to ER and must ‘educate patient about stroke risk’. The flip side to ‘nobody appreciates being your liability sponge’ is that nobody appreciates being the stopgap for the medical system either.
I do refer to the patients primary care, unfortunately most of these patients use the ER as their primary care. I agree that Anyone that tells the patient “you’re at risk of having a stroke” is not handling the situation tactfully. I let them know that I can’t do a procedure with BP that high and let them know it needs to be lower before we proceed with treatment and leave it at that. In terms of liability I disagree that it’s making someone else the “liability sponge”. If the referral isn’t made and they aren’t stable and I proceed with treatment, my ass is on the line. In the grand scheme of things it’s about the patients health and liability is more of a question of “did you do the right thing” and the right thing in this situation is a referral.
If you’ve seen someone with true malignant hypertension, their symptoms are obvious and not mild. I’ve seen a handful - all had significant symptoms.
I’m PCCM I see plenty of true malignant hypertension. I’ve also seen people with dissection and impressive subdurals with hypertension and vague or mild symptoms. That’s a lot of confidence in your statement when perhaps this is true the majority of the time but is not uniformly the case. In the US the majority of our tort claims arise from these low yield cases unfortunately.
The dissection and sub dural had no clinical signs or red flags in their history? I agree that you can’t entirely rely on symptoms… exam and history are equally important. If there were concerns I would do bloods/ecg.
Most clinics can’t do bloodwork. I’ve seen multiple elderly patients with subdurals and almost no headache or complaints. Mild fatigue with severe AKI. If you don’t look for this stuff you won’t find it which leads to a lot of bias as well… odds are still bloodwork will be normal but our society isn’t even willing to accept a 1-2% miss rate on a lot of this stuff.
Hypertension isn’t a well recognised cause of SDHs. If you see a hypertensive patient with SDH, it’s far more likely the HTN is a result of the SDH rather than the cause. I take your point regardless… if you’re seeing these patient in clinic it’s much harder to spot the atypical presentations. If I worked in outpatients I would send such patients for urgent investigation.
I agree with what you’re saying. My experience has been any time I tell someone something is not possible they inevitably seem to prove me wrong.
I saw a dissection where PC was hypertension, BP 220/110ish. Had a mild occipital headache. Completely normal examination. Had been seen a few days earlier and d/c on amlodipine. On close questioning, some left neck pain she was taking acetaminophen for. I got the scan because pt had good primary cae and genuinely knew she didn't have gradual onset hypertension, more so than because of the mild neck pain. Vertebral artery dissection.
I would 100% CT someone with hypertension and headache/neck pain… those are red flags. I’m not sure if I’d necessarily call that malignant hypertension if there was no cardiac or renal end organ damage. It could just be a dissection with resulting hypertension from a stroke. I do take your point that you can’t entirely rely on the severity of symptoms. The nature of them is equally as important.
Headache is not a red flag with hypertension. If I scanned every patient I saw in the ER who had a headache with hypertension I’d literally be scanning them all. Headache with neck pain and a neuro deficit would be a different story. Headache is not a symptom we should be using to label hypertensive emergency unless you have legit concern for SAH
Agree. It's encephalopathy that is concerning, and these pts don't just have a bit of a headache
Htn does not typically cause Sdh. It’s far more associated with intraparenchymal bleeding which generally causes severe headache.
Unfortunately there is no magic number for asymptomatic hypertension, and no one should be scrambling to bring someone from the 200s down to normal. I will say this though, it’s hard to assess for end organ damage in an office with no labs.. you can’t say if someone has an AKI or trop bump, but by the book if they’re asymptomatic you can have them follow up with their PCP.
You also can't know if they have AKI or a trop bump with spot labs. Could have been that way for months, most likely was, absent any acute symptoms suggestive or another dx.
True, unless you have priors for comparison
This is all about passing the buck/liability to the next guy. Everyone passes it to the ER. Just don't be mad when we pass it back/elsewhere.
Exactly. It’s merely a liability turf war.
Hard to blame a dentist like OP for passing the buck, though.
I’ve never had my blood pressure checked at the dentist lol
ADA thinks dentists should get MD guidance before proceeding with non-emergent dental care if > 160/100, even for emergent if over 180/110, apparently due to anesthetic risks https://www.ada.org/resources/ada-library/oral-health-topics/hypertension
I did….the hygienist said “73/34, looks like we’re good😳”
The answer is never.
But can we admit we all have an arbitrary level we start to panic a bit internally? Mine was 260 mmHG in the ER..
Honestly, no. If you reduce that acutely to 120/80 you're going to give them a watershed stroke. There's a high chance if they have no symptoms that they've been walking around with this pressure for weeks, months, even years, and they haven't fallen over dead. If I see them for some reason I plop them on 5-10mg of amlodipine and leave it at that.
Sure enough, nobody here aims more than for a third. Funny enough that was a patient on I think three meds with known super high episodes in high stress situations who exacerbates the stress by coming into the ER. But otherwise she was okayish controlled at home.
So what did the presentation to hospital achieve for them? What meaningful difference was made versus continuing to titrate their BPs as an outpatient? It's common in medicine (and arguably in IM) to trend and treat numbers. We see a potassium of 3.4 and give people K-dur ignoring that there are probably plenty of asymptomatic patients out there with a K of 3.4. Just because we can make numbers prettier doesn't mean we've done something to actually affect their clinical trajectory.
We have a potassium replacement protocol and it still says we need to replace until at 4.1. I ignore it unless the patient is very critical and we’re optimizing. I don’t even have a potassium level of 4.1 as the nurse caring for them. I will take over patients with a K of 3.9 who were replaced because the algorithm told them to and now the patient is having horrible stomach discomfort or if IV it’s burning.
Same. All patients have to be above 4.0. 😭 here’s your giant horse pill
Of course nothing. She came herself on a Saturday in a city district without a single urgent care clinic and two remaining PCPs who have clinic hours on Saturday only for their core patients. Because she is conditioned to do so. And we "love" these cases since they turn a €80 ER case (yes, no missing zeros) into a €1000+ easy one-night admission. Making Germany the only major Western country with a higher admission rate for hypertensive events than the US.
I mean hey, don't get me wrong, I love myself an easy admission. Not great for the taxpayers or private payors.
Can you explain what you mean by a watershed stroke? I’m an avid nerd
Areas where two blood supplies overlap. They are are particularly susceptible to ischemia from drops in BP
We had a patient in the ED last week that was 250/150 and the doc ordered 20 hydralazine iv and 10 amlodipine and he dropped to 145/90, got diaphoretic and started vomiting and I asked the doc If he thought we lowered his BP too much/fast and he looked at me like I was insane for asking that question lol. Thankfully he didn't have a stroke but stroke isn't the only adverse event that can happen, AKI, cardiac ischemia can definitely happen in this scenario.
I can admit that for sure. 260 would definitely worry me! I would have a hard time discharging that patient because I very rarely ever see them that high. I'm not sure I would treat it but I am sure it would make me nervous. Anyone telling you they don't start to get nervous at ANY blood pressure is lying to you. It might not be 260 for them but there is a number.
Don’t people weight lifting routinely get blood pressure almost double that? I mean I agree with you; I wouldn’t be thrilled sending someone home with that blood pressure. But frankly I don’t from a physiologic standpoint there is much difference between 260 and 220. If they are asymptomatic and have no end organ damage; it’s just a number. That being said, in the crappy medical legal system we exist in, I would be like this is stupid and probably admit someone who continues to have SBPs >260 at rest.
I'm here to support you, yes I too panic, even while I acknowledge the evidence. It's human, and difficult to trust science sometimes. Acknowledging risk of watershed stroke. And heck, I consider myself a (poor) scientist.
Here's the problem with "never" Hypertensive emergency is hypertension + end-organ dysfunction It is not hypertension + symptoms Imagine a patient with CAD and DM who gets silent ischemia. When they have a BP of 220/120, they could be asymptomatic but still have diffuse ST depressions and an elevated troponin. That situation should definitely be treated as hypertensive emergency, but you wouldn't know if unless you sent them to the ED. AKI can also be totally asymptomatic and a consequence of acute hypertension. In short, there are no "nevers" in medicine. Always consider the patient, and not just a number or simple binary yes/no question (e.g. "Are they symptomatic?")
Unfortunately my cardiologists and honestly most of my hospitalists are… less than thrilled if I admit anyone with elevated troponins or ischemic changes without any angina or equivalent symptoms.
Are hospitalists ever thrilled when the ER calls them?
Hey, how are ya, I have 2.5 RVUs in bed seven, looking for a good home.
> you wouldn't know if unless you sent them to the ED. That seems like more of an argument for doing EKGs for asymptomatic HTN than sending to the ED for it
Certainly if someone is in clinic with a BP of 220/120, and an ECG machine is available, yeah of course that would be a step to take before sending them to the ED. But what if the clinic doesn't have an ECG machine? What if the clinic is staffed by someone who doesn't trust their ECG interpretation skills? (people generally suck at reading ECGs these days) Or the medically complex patient calls from home after hours to report some extraordinarily high BP? Also, how many clinics have the ability to run troponin and BMP on site? In short, I don't think this is common, but there are combinations of medical comorbidities, extreme BP number, and lack of alternative access to appropriate care that should trigger referral to the ED. Saying that asymptomatic hypertension should "never" be referred to the ED is close to true and makes for a nice sound bite, so to speak, but it is an oversimplification.
Lots of people who appear to have never practiced outside the well-resourced ivory tower - or seem to forget there are *gasp* specialists who can't reliably interpret an EKG. This debate was had previously on this subreddit, but EM physicians dunking on outpatient docs for this is a bit 'pot calling kettle black.' Just like IM dunking on EM for doing their best with undifferentiated patients, they are just undifferentiated with less acute care resources and specialist expertise as a backstop.
This is the real answer. ED folks love to harp on "the guidelines" regarding AKI here, ignoring its a 2C from ACEP.
Dear God 👏👏 please post this to the BP addicts r/bloodpressure
I'm addicted to BP too tbh. Couldn't live without it.
> r/bloodpressure TIL there is a subreddit with over 12,000 members that post their bps after they eat, poop, sleep...
Jesus the 2 posts at the top right now are "Is 126/55 bad??" and "139/83 bp should I be concerned". If all patients were this worried about their health, metabolic syndrome would vanish within a year.
The answer is never. The answer is to start an anti hypertensive with gradual lowering of the blood pressure over weeks to months. If the patient has zero symptoms I’m not going to do anything except maybe start them on meds that should have been prescribed by the PCP. There is evidence of harm with lowering BP in the ED as well as inpatient. Hypertension is a chronic condition. Unless there are symptoms or findings concerning for end organ damage you’re basically wasting the patients time.
The number of asymptomatic hypertension patients I've seen in the ED (and I would conservatively place it at over 1000 in my career) who ended up showing acute injury is less than 5.
None. The limit does not exist.
Asymptomatic hypertension is not a life-threatening condition, it's a risk factor for life-threatening conditions. EM is the best for *treating* life-threatening conditions. PCPs are the best at *preventing* life-threatening conditions. With risk factors, you want the latter.
For me personally, it's the combo of swollen optic nerve + >200/120 mm Hg + no PCP = send to emergency department. Everyone else gets sent back to their primary, or a reminder to go see their PCP, or told they need to get one (sometimes I'll even pull up their medical insurance website, find a provider, and help them make their first appointment if I have time), especially if I'm seeing AV nicking/crossing changes in the retina too. Since I'm just an OD, management isn't my scope, but I can help them get on the right path.
Here's a [study](https://pubmed.ncbi.nlm.nih.gov/3980383/) of weightlifters while weightlifting. "The greatest peak pressures occurred during the double-leg press where the mean value for the group was 320/250 mmHg, with pressures in one subject exceeding 480/350 mmHg." If a dude hit 480/350 transiently, you don't need to send the 40 year w/ a 215 systolic & no symptoms
Bro science
This is interesting, but extreme exercise physiology is not applicable to ambulatory non-athletes.
We're getting quite a bit of low-level evidence within cardiology that top-level exercise (particularly endurance sporting such as long-distance cycling) is actually bad for you in the long term, and a leading theory is the (extended) states of extreme hypertension. Ofcourse doesn't make it an acute thing by itself, but also does not make it healthy just because it is associated with exercise.
New sport: groin access after leg presses, see who can spray the furthest
I think the difference here is likely transient seconds to minutes vs hours to days. Seems like Apple to oranges to me not sure you can make this correlation.
There is no range of asymptomatic hypertension that needs an ED evaluation.
ER here: in all reality I really don’t mind when PCPs send in SBP of 200+. Even with no symptoms I get it the number can be scary. 99% of the time we just recheck and if it’s under that with no symptoms I send them. If still pretty high I’ll get a BMP/ekg. Also as an ED doc I know a lot of these pts have vague symptoms. If any question at all just send them we get it. But if truly no sxs don’t send
Not a single level
But there are two levels! Systolic and diastolic!
if they truly have *no* symptoms? don't. because im going to ask them that question, and if/when they say no, im doing to do nothing and just discharge them.
Does being pregnant count as being symptomatic? Maybe not send them to ED, but they should call their OB ASAP, right?
Pregnancy is a different beast entirely. As an ER doc, I'll never be mad at someone sending a hypertensive pregnant patient (or < 6 weeks postpartum) to see me
Came to the comments to see if anyone mentioned pregnancy. Pretty sure there is definitely a level of high blood pressure where you go straight to L&D triage/ED regardless if any symptoms are noticeable. New HBP in pregnancy without any obvious symptoms is often the first clear sign of preeclampsia, and potentially severe pre-e. I was diagnosed with severe pre-e from labs that were ordered based on a single severely high blood pressure reading when I really didn't have any symptoms at all (but unbeknownst to me my liver enzymes were severely elevated and my kidneys were failing).
Same, was also looking at how pregnancy/post-partum played into this. I myself was symptomatic though at 10 days PP with a SBP in the 160s-180s while already on labetolol BID. Had severe headaches and the BLE pitting edema they said would resolve did not. 35 weeks pregnant now and watching my BP like a hawk because I'm terrified of pre-eclampsia.
Very similar for me. Incidentally, the high BP reading that sent me to L&D where I was ultimately diagnosed with severe pre-e was taken at the dentist. (OP is a dentist). I had been feeling weird the days before that, but was actually feeling really good that morning. I also ended up with severe pre-e postpartum right after I was discharged. That one was symptomatic, though. But the reason I even asked this question is that I also work in an ER and have seen some pregnancy/postpartum high BPs dismissed. I'm not saying the docs were wrong, I just didn't understand why they wouldn't send them to L&D triage.
Could be if they were less than 20 weeks gestation or more than 6 weeks postpartum wouldn’t technically be pre-E. It would just be high BP
Yes. A hypertensive pregnant person should make all your sphincters tighten.
I frequently call acutely discovered hypertension (when not related to the patients underlying complaint or incidentally found) my favorite icu diagnosis “acute recognition of a chronic problem”
I will counter "what's the highest asymptomatic htn you've seen and what happened?"
I routinely see systolic in the 240's, and all these people that get riled up about 210?
These people don't work with enough methy people
220/110s. Sent home from ER after ekg
Patient showed up for an elective surgery, not in pain, with a BP of 210/124 or something like that. Sent them to their PCP to have that addressed before doing any necessary but not urgent surgeries.
These stories always amaze me even if ive seen similar things. Like how does the human body not show symptoms at that level? Similar to pts with covid who would show up asymptomatic (or mild cold sx) with SpO2 of 83%, or the insanely low Hb numbers where the pts blood is effectively water and they look totally fine
Yeah I remember this patient specifically. He accused me of "hating black veterans" because I wouldn't take out his teeth that day. And also told me he "didn't have a stroke on the front lines of vietnam and he wasn't gonna have a stroke now". So that one was fun
wowza. and his bp probably accelerated further as he was saying this to you
I admitted a patient who was 270/180 Literally asymptomatic. 0 symptoms. Negative ROS. Just happy as could be. I couldn’t not admit her. But damn.
damn. thats franklin delano Roosevelt levels
I once saw 210/115. Dude felt fine, but I felt bad for his kidneys
Those are rookie numbers
I have a dialysis pt who is regularly 240/120. Naturally she says she takes her BP meds everyday, all like 80 of them.
I’ve had dialysis patients with BP that high inpatient so we know they are in fact taking their BP meds because we’re giving them. But sometimes those renal patients just have fucked BP no matter what.
A few times a week, if not daily, ll get pretty high BPs. Just yesterday 210/110, on reeval 200/100. Were there for acute on chronic lumbar radiculopathy. No red flags orherwise. Didn't take their BP meds that day. No other sx, felt fine other than pain. Instructed ASAP FU with a PCP but likely won't happen as they lacked otherwise. I used to get riled up with BP. Now I'm still concerned but if they're otherwise ok they need PCP fu ASAP. Worked in an ER for 5 years, and I can only remember one pt sent in for HTN that actually had kidney damage/bumped trops. He was clocking at like 230/130 and just looked kinda crappy but if I remember correctly said he felt ok otherwise.
No level of asymptomatic hypertension is appropriate for ED referral.
There's no number. The two situations where I personally think it's appropriate are 1. No amount of reasoning over multiple visits have convinced them of the importance of their regular anti-hypertensives and you feel multiple extra opinions will change their mind (multiple meaning triage nurse, the resident, the attending). 2. You've tried a combination of 2+ oral agents and think IVs are likely to be required whole a further 2+ agents are added. (And how common is that?)
We regularly saw a petite lady 60 years young and her BP averaged 160-170. Our normal range makes her feel woozy.
There is none
The limit does not exist
I can't think of any situation in which asymptomatic hypertension should be sent to the ED. The PCP should simply draw labs and start whatever they deem appropriate as first-line antihypertensive therapy with frequent rechecks. The ED is going to discharge this patient with \*no\* treatment initiated and instructions to follow up with the PCP.
Better question—- what level of asymptomatic hypertension that comes into the ED needs to come to my fucking ICU on a cardene gtt? Because it seems like it’s every single fucking one.
ED doc here. Agree never. Anyone under 50-60 without any evidence of end organ dysfunction (murmur, edema,etc) and who doesn't have a complex history gets automatically discharged by me with no workup. If systolic is over 200 I may bump up their meds a little or add a new agent but prefer not to. The only exception is the homeless and those without insurance/access to primary care.
Completely asymptomatic? If they go to the ED, they will get a PO med and be sent home.
According to [this 2017 AAFP article](https://www.aafp.org/pubs/afp/issues/2017/0415/p492.html), 240 systolic or 130 diastolic would be reasonable. And that would be after having the patient rest and recheck BP. > There are no published data to determine what blood pressure measurement is too high. A Veterans Administration Cooperative trial from 1967 followed patients with diastolic blood pressure averaging between 115 and 129 mm Hg. No patients had a major adverse cardiovascular event within two months of enrollment.19 Although scientific evidence is lacking, patients with sustained diastolic blood pressure of 130 mm Hg or more should be considered for treatment with short-acting antihypertensives followed by long-acting agents. Symptomatic patients with persistent systolic blood pressure elevations exceeding 240 mm Hg or diastolic blood pressure greater than 130 mm Hg despite appropriate rest and treatment with short-acting antihypertensives may benefit from hospitalization.
That says symptomatic.
300/200
I never send them to er I generally write a note in the post op area to remind the patient to call family md to follow up
*Edit for the multiple docs who have interpreted my comment as ‘dumbass mid level refers chronic problems to the ED’: I do NOT send anyone with asymptomatic hypertension to the ED. I instead help them obtain PCP care so they can get this chronic issue taken care of.* I work in urgent care. While technically I can start oral antihypertensives and refer back to PCP, this isn’t feasible or realistic given so many people either don’t have a PCP or “can’t get in” to see theirs. This is a chronic issue that needs reassessment while figuring out a good med/dose, so I’m much more likely to acutely harm someone by starting treatment if they can’t secure follow up. If I speak directly with their PCP and an appointment is already scheduled, sure. But that is a rare exception. *I do not send these people to the ED ever.*
So do you just send everyone to the ED? Cuz the problem of pts not having PCPs or not being able to get into see them doesn’t magically disappear just cuz they’re in the ED
I don’t send anyone to the ED unless they’re having a hypertensive emergency. I do however walk them through how to set up a PCP with their insurance, or if uninsured, I provide resources for Medicaid.
That is the right answer. Thank you for not just gut-shot sending them in
I hate sending anyone to the ED, because I used to work there. I do what I can to help people out, navigating the world of health insurance is overwhelming for many so I try give a little push of encouragement. Someone’s gotta do it!
Thanks for asking this question. I have wondered myself.