Clinical Guideline Knowledge Check:
Severe Hypertension in the Emergency Department
Two current (2017/2018) Hypertension Guidelines conflict in their definition and management of chronic hypertension.
Do they also conflict in their recommendations for acute severe hypertension?
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Today’s Guideline Knowledge Check question comes from the desk of Med-Challenger Emergency Medicine Editor-in-Chief, Andrea Eberly, MD, FAAEM.
Try this review question and find out if you’re following the most current guideline.
A 76 year old, healthy female presents to the emergency department after taking her own blood pressure for the first time at a relative’s home after a large family birthday celebration. Her blood pressure was 180 / 110 mm Hg. Due to the fact that her husband had recently had a stroke, this unexpected blood pressure finding triggers a visit to the emergency department.
Upon presentation, she is anxious but otherwise asymptomatic. Her vitals at triage are: blood pressure 185/115 mm Hg, pulse 66 bpm, respirations 14 and unlabored, pulse oximeter 97% on room air.
She is visiting from Sweden, does not normally see doctors, denies taking any medication, has never smoked, occasionally drinks a glass of wine, and has no past medical history. She does not know her cholesterol level.
The exam shows a physically fit person with no signs of end organ damage; an ECG is normal.
A urine dipstick shows trace protein; her electrolytes, CBC, and liver function tests are normal. Her cholesterol is 150; HDL 45; LDL 105.
What do the 2017 American Heart Association and 2018 European Society of Cardiology guidelines (both endorsed by USA medical societies) recommend with regards to blood pressure management for this particular patient?
The 2017 American Heart Association guidelines recommend intravenous antihypertensive treatment and admission, whereas the 2018 European Society of Cardiology guidelines recommend oral antihypertensive therapy and discharge.
Both hypertension guidelines recommend against intravenous antihypertensive therapy or admission.
Both hypertension guidelines recommend admission and gradually lowering the blood pressure with IV antihypertensive medication over 6-24 hours to a goal blood pressure of <140/90 mm Hg.
The 2017 American Heart Association guidelines recommend emergency department intravenous antihypertensive treatment to a goal blood pressure of less than 140/90 mm Hg over 1-3 hours followed by discharge on oral medication and a 24-hour follow up with a primary care physician. The 2018 European Society of Cardiology guidelines recommend the same except suggesting a goal pressure of less than 150 / 90 mm Hg for discharge.
Answer Explanation & References:
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About the Author:
Andrea Eberly, MD, FAAEM graduated from the David Geffen Medical School of Los Angeles (UCLA) and completed her residency in Emergency Medicine at the University Medical Center, Tucson, Arizona. After working as an attending physician in Tucson, she followed a recruiting call to the island of Guam, where she served in various roles, including as the director of the emergency department, the EMS Medical Director of Guam, and the Director of the 911 Call System. She has maintained her emergency medicine board certification through three cycles of American Board of Emergency Medicine Board Exams (last in 2014), all three with the help of Med-Challenger.