Asymptomatic markedly elevated blood pressure

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Asymptomatic markedly elevated blood pressure
Other names: Hypertensive urgency; severe asymptomatic hypertension; severe uncontrolled hypertension; severe uncomplicated hypertension;[1] asymptomatic uncontrolled hypertension[2]
SpecialtyFamily medicine
SymptomsNone, headache, nosebleed, leg swelling[3]
CausesStopping blood pressure medication, stimulants, high thyroid, pain, anxiety[4]
Differential diagnosisHypertensive emergency[3]
TreatmentTreat anxiety, blood pressure medication by mouth with close outpatient follow up[5][6]
FrequencyRelatively common[7]

Asymptomatic markedly elevated blood pressure, previously known as hypertensive urgency, is very high blood pressure, generally above 180 mmHg systolic or 110 mmHg diastolic, with no signs of organ damage.[3][4][8] The diagnosis may apply despite a person having a headache, nosebleed, or leg swelling.[3] It contrasts with hypertensive emergency where high blood pressure is accompanied by organ damage such as hypertensive encephalopathy, myocardial infarction, dissecting aortic aneurysm, kidney failure, or heart failure.[3]

Most cases occur in people with known high blood pressure; often when they are not taking medication for the condition.[6] Other causes may include the use of stimulants, high thyroid, pain, and anxiety.[4] Other conditions that may appear similar include calcified arteries and improper measuring technique.[4] Diagnosis may be based on symptoms and examination; with no further testing required.[9] It requires ruling out a hypertensive emergency.[10]

Treating anxiety, such as with benzodiazepines, may lower blood pressure.[5] If this is not sufficient blood pressure medication by mouth with close outpatient follow or simply close follow up is recommended.[6][8] Blood pressure should be reduced gradually, not rapidly.[6][2] Other recommended measures include a low salt diet, no alcohol, stopping smoking, and weight loss.[4] Without treatment, it is associated with a long-term risk of cardiovascular disease and death.[4]

Asymptomatic markedly elevated blood pressure is relatively common, occurring in nearly 5% of family doctor visits and 3% of emergency department visits.[7] It is present in about 10% of people admitted to hospital for other reasons.[8] Some view the term "hypertensive urgency" as inappropriate and suggest it be abandoned.[11] It generally does not need management in an emergency department or hospital.[2]

Definition

Asymptomatic markedly elevated blood pressure without evidence of new or worsening target-organ damage is defined as severely high blood pressure (>180/110 mmHg) with no evidence of end organ damage.[8][12] This is in contrast to asymptomatic elevated blood pressure which is greater than 130/80 mmHg.[8]

As of 2022, the European Society of Cardiology does not see the term hypertensive urgency as useful as it does not significantly differ from other types of asymptomatic high blood pressure.[11]The term "malignant hypertension", also known as accelerated hypertension, was included under this category with grade III/IV hypertensive retinopathy.[13][14][1] In 2018, the European Society of Cardiology and the European Society of Hypertension put "malignant hypertension" under the category of "hypertensive emergency", which emphasizes poor outcomes if the condition is not treated urgently.[12][15]

Risk factors

Risk factors for severe hypertension include older age, female sex, obesity, coronary artery disease, somatoform disorder, being prescribed multiple antihypertensive medications, and non-adherence to medication.[3]

Diagnosis

If a person has no signs of end organ damage, no further testing may be required.[9] Diagnosis requires ruling out a hypertensive emergency.[10]

Treatment

In asymptomatic markedly elevated blood pressure, blood pressure should be lowered gradually to ≤160/≤100 mmHg,[16] this can often be done as an outpatient.[3] There is limited evidence regarding the most appropriate rate of blood pressure reduction.[16]

Medications that may be used include calcium-channel blockers (such as amlodipine 5 mg once per day), alpha-1 blockers, or mineralocorticoid receptor antagonists.[11] Beta blockers and loop diuretics are generally not recommended initially.[11]

Intravenous medications in the emergency department are not recommended.[8] Nor is nifedipine under the tongue as it can cause rapid decrease of blood pressure which can precipitate ischemic events.[17] Aggressive dosing with intravenous medications or oral agents which lowers blood pressure too rapidly carries risk;[18] with no evidence that it improves outcomes as of 2023.[19]

Epidemiology

An analysis of 1,290,804 adults who presented to emergency departments in United States from 2005 through 2007 found a systolic blood pressure ≥180 mmHg in 14%.[20] Based on another study in a US public teaching hospital about 60% of hypertensive crises are due to asymptomatic markedly elevated blood pressure.[21]

References

  1. ↑ 1.0 1.1 Jolly, Hannah; Freel, E Marie; Isles, Chris (19 May 2023). "Management of hypertensive emergencies and urgencies: narrative review". Postgraduate Medical Journal. 99 (1169): 119–126. doi:10.1136/postgradmedj-2021-140899.
  2. ↑ 2.0 2.1 2.2 "Hypertensive emergency". EMCrit Project. Archived from the original on 8 July 2023. Retrieved 21 May 2024.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Pak KJ, Hu T, Fee C, Wang R, Smith M, Bazzano LA (2014). "Acute hypertension: a systematic review and appraisal of guidelines". The Ochsner Journal. 14 (4): 655–663. PMC 4295743. PMID 25598731.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Alley, WD; Copelin II, EL (January 2023). "Hypertensive Urgency". StatPearls. PMID 30020723.
  5. ↑ 5.0 5.1 "Hypertensive Emergencies - Cardiovascular Disorders". Merck Manuals Professional Edition. Archived from the original on 30 January 2023. Retrieved 20 June 2023.
  6. ↑ 6.0 6.1 6.2 6.3 Moe, Samantha (20 March 2017). "#183 What is Urgent About Hypertensive Urgency?". CFPCLearn. Archived from the original on 28 March 2023. Retrieved 16 June 2023.
  7. ↑ 7.0 7.1 Patel, Krishna K.; Young, Laura; Howell, Erik H.; Hu, Bo; Rutecki, Gregory; Thomas, George; Rothberg, Michael B. (1 July 2016). "Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting". JAMA Internal Medicine. 176 (7): 981. doi:10.1001/jamainternmed.2016.1509.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Bress, AP; Anderson, TS; Flack, JM; Ghazi, L; Hall, ME; Laffer, CL; Still, CH; Taler, SJ; Zachrison, KS; Chang, TI; American Heart Association Council on Hypertension; Council on Cardiovascular and Stroke Nursing; and Council on Clinical, Cardiology (August 2024). "The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association". Hypertension (Dallas, Tex. : 1979). 81 (8): e94–e106. doi:10.1161/HYP.0000000000000238. PMID 38804130.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ↑ 9.0 9.1 Briggs, Blake (September 2022). "Clinical Controversies: Hypertensive 'Urgency' is a Wastebasket Diagnosis". Emergency Medicine News. 44 (9): 14. doi:10.1097/01.EEM.0000874688.69911.bc. ISSN 1054-0725. Archived from the original on 13 September 2022. Retrieved 20 June 2023.
  10. ↑ 10.0 10.1 van den Born B (January 2019). "ESC Council on hypertension position document on the management of hypertensive emergencies". European Heart Journal - Cardiovascular Pharmacotherapy. 5 (1): 37–46. doi:10.1093/ehjcvp/pvy032. PMID 30165588.
  11. ↑ 11.0 11.1 11.2 11.3 Rossi, GP; Rossitto, G; Maifredini, C; Barchitta, A; Bettella, A; Cerruti, L; Latella, R; Ruzza, L; Sabini, B; Vigolo, S; Seccia, TM (January 2022). "Modern Management of Hypertensive Emergencies". High blood pressure & cardiovascular prevention : the official journal of the Italian Society of Hypertension. 29 (1): 33–40. doi:10.1007/s40292-021-00487-1. PMID 34813055.
  12. ↑ 12.0 12.1 Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. (October 2018). "2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension". Journal of Hypertension. 36 (10): 1953–2041. doi:10.1097/HJH.0000000000001940. PMID 30234752.
  13. ↑ Kitiyakara C, Guzman NJ (January 1998). "Malignant hypertension and hypertensive emergencies". Journal of the American Society of Nephrology. 9 (1): 133–142. doi:10.1681/ASN.V91133. PMID 9440098.
  14. ↑ Henderson AD, Biousse V, Newman NJ, Lamirel C, Wright DW, Bruce BB (December 2012). "Grade III or Grade IV Hypertensive Retinopathy with Severely Elevated Blood Pressure". The Western Journal of Emergency Medicine. 13 (6): 529–534. doi:10.5811/westjem.2011.10.6755. PMC 3555579. PMID 23359839.
  15. ↑ Shantsila A, Lip GY (June 2017). "Malignant Hypertension Revisited-Does This Still Exist?". American Journal of Hypertension. 30 (6): 543–549. doi:10.1093/ajh/hpx008. PMID 28200072.
  16. ↑ 16.0 16.1 Varon J, Elliott WJ (17 November 2021). Bakris GL, White WB, Forman JP (eds.). "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults". www.uptodate.com. Archived from the original on 2020-06-27. Retrieved 2017-12-02.
  17. ↑ Makó K, Ureche C, Mures T, Jeremiás Z (9 June 2018). "An Updated Review of Hypertensive Emergencies and Urgencies". Journal of Cardiovascular Emergencies. 4 (2): 73–83. doi:10.2478/jce-2018-0013.
  18. ↑ Yang JY, Chiu S, Krouss M (May 2018). "Overtreatment of Asymptomatic Hypertension-Urgency Is Not an Emergency: A Teachable Moment". JAMA Internal Medicine. 178 (5): 704–705. doi:10.1001/jamainternmed.2018.0126. PMID 29482197.
  19. ↑ Fuchs, Flávio Danni; Gus, Miguel; Gonçalves, Sandro Cadaval; Fuchs, Sandra Costa (7 February 2023). "Is it Time to Retire the Diagnosis "Hypertensive Emergency"?". Journal of the American Heart Association. 12 (3). doi:10.1161/JAHA.122.028494.
  20. ↑ Shorr AF, Zilberberg MD, Sun X, Johannes RS, Gupta V, Tabak YP (March 2012). "Severe acute hypertension among inpatients admitted from the emergency department". Journal of Hospital Medicine. 7 (3): 203–210. doi:10.1002/jhm.969. PMID 22038891.
  21. ↑ Preston RA, Baltodano NM, Cienki J, Materson BJ (April 1999). "Clinical presentation and management of patients with uncontrolled, severe hypertension: results from a public teaching hospital". Journal of Human Hypertension. 13 (4): 249–255. doi:10.1038/sj.jhh.1000796. PMID 10333343.
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