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Education

Hypertension

mLpenguin

• 1 min read
Hypertension
Photo by Robert Anasch / Unsplash

Start With Definitions

  • Normal: <120 / <80 mmHg
  • Elevated: 120-129 / <80 mmHg
  • Stage 1 HTN: 130-139 / 80–89 mmHg
  • Stage 2 HTN: ≥140 / ≥90 mmHg

But in the ED, the key terms are:

  • Hypertensive Urgency: Severe BP elevation (≥180/≥120) without acute target-organ damage.
  • Hypertensive Emergency: Severe BP elevation with evidence of acute target-organ damage (e.g., encephalopathy, stroke, MI, aortic dissection, AKI, pulmonary edema).

The ER Perspective

Your job is not to “normalize” BP in every patient, but to decide:

  • Is there target-organ damage?
  • Does this require acute treatment or safe outpatient follow-up?

Remember: A single elevated BP in the ER rarely equals a true hypertensive emergency. Pain, anxiety, and acute illness can transiently raise pressures.

History and Exam

When you encounter elevated BP, think end-organ damage. Ask about:

  • Neurologic: Headache, vision changes, confusion, focal deficits, seizure.
  • Cardiac: Chest pain, dyspnea, palpitations.
  • Renal: Oliguria, hematuria, edema.
  • Vascular: Back pain (think dissection).

Exam should include:

  • Fundoscopic exam (papilledema = concerning).
  • Neuro exam.
  • Cardiac and lung exam (signs of failure).
  • Check for unequal pulses/BPs (dissection).

Workup

  • Basic labs: BMP (renal function), UA (protein, blood), troponin if chest pain.
  • ECG: Look for LVH, ischemia.
  • Imaging: CT head if neuro symptoms, CXR if pulmonary edema or dissection suspected.

Management

Hypertensive Emergency

  • Admit to ICU.
  • Lower MAP by no more than 25% in the first hour, then to 160/100 over 2-6 hours.
  • IV agents: Nicardipine, labetalol, nitroglycerin, nitroprusside (depending on context).
  • Tailor drug choice to condition (e.g., nitroprusside for dissection, nitroglycerin for ACS/PE).

Hypertensive Urgency

  • No acute IV therapy needed.
  • Oral agents (e.g., captopril, clonidine, labetalol) sometimes used.
  • More important: Ensure follow-up within days.

Asymptomatic Hypertension

  • No emergent treatment needed.
  • Reinforce lifestyle changes, consider restarting/adjusting outpatient meds.
  • Document safe discharge and arrange primary care follow-up.