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Asymptomatic Elevated Blood Pressure

Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure (February 2013)

Scope of Application

This guideline is intended for physicians working in emergency departments.

Inclusion Criteria

This guideline is intended for patients aged 18 years or older who present to the ED with asymptomatic elevated blood pressure without signs and symptoms of acute target organ injury.

Exclusion Criteria

This guideline is not intended to address the care of patients who present to the ED with signs or symptoms of acute hypertensive emergencies (ie, patients with clinical findings that suggest acute target organ injury such as acute stroke, cardiac ischemia, pulmonary edema, encephalopathy, and congestive heart failure), pregnant patients, those with end-stage renal insufficiency, emergent conditions that are likely to cause elevated blood pressure not directly related to acute target organ injury (eg, trauma, other pain syndromes), and acute presentations of serious medical conditions associated with hypertension such as stroke, myocardial infarction, and congestive heart failure.

Critical Questions

  • In ED patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce rates of adverse outcomes?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    (1) In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required. (2) In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission).
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    (1) In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required. (2) In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission).
  • In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    (1) In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required. (2) In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control. [Consensus recommendation] (3) Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation]
    Level A Recommendations
    None specified.
    Level B Recommendations
    None specified.
    Level C Recommendations
    (1) In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required. (2) In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control. [Consensus recommendation] (3) Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation]

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Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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