A Junior Doctor's Guide to Managing Hypertension in the Emergency Department

As a junior doctor working in the emergency department, hypertension is one of the most common conditions you’ll encounter. While many patients present with chronic hypertension that is well-controlled, others will have acute or exacerbated high blood pressure that requires prompt management. Understanding the clinical approach—what questions to ask, what investigations to conduct, and what the management should be—is crucial in ensuring your patients get the best possible care.

History Taking – Key Questions to Ask

Your first task is to gather a thorough history. The more specific you are with your questions, the better you'll be at narrowing down the causes of the hypertension and formulating a management plan. Here are some key points to cover:

·     When did the symptoms start?

·     Is this a new episode of high blood pressure, or is the patient experiencing a hypertensive crisis on top of pre-existing hypertension?

·     Do they have a history of hypertension?

·     If they do, has their blood pressure been well controlled, or have they missed medications recently?

·     Have they experienced any symptoms of end-organ damage (e.g., chest pain, shortness of breath, headache, blurred vision)?

·     Are they experiencing any specific symptoms?

·     Chest pain: Could indicate a hypertensive emergency with complications like myocardial infarction or aortic dissection.

·     Headache or blurred vision: These symptoms are concerning for possible hypertensive encephalopathy or retinopathy.

·     Shortness of breath: Could be related to heart failure or pulmonary edema, both of which can be exacerbated by high blood pressure.

·     Confusion or altered mental status: Suggests hypertensive encephalopathy or stroke.

·     Are there any triggers for the increased blood pressure?

·     Stress, alcohol, caffeine, drugs (e.g., cocaine, amphetamines), or medication non-compliance are common culprits.

·     Family history of hypertension or cardiovascular disease?

·       A family history of hypertension or other cardiovascular conditions (stroke, MI) can increase the patient’s risk.

·     Medication history:

·     Are they on antihypertensive drugs? If so, what class (ACE inhibitors, calcium channel blockers, diuretics)? Have they been taking their prescribed medications?

·     Any recent changes to their medication regimen?

·     Past medical history:

·      Is there any history of renal disease, endocrine disorders (e.g., hyperthyroidism, pheochromocytoma, hyperaldosteronism), or other conditions that can cause secondary hypertension?

Physical Examination – What to Look for

A focused and systematic physical exam is essential in helping you understand the severity and potential causes of the hypertension. Here are the key areas to assess:

·       General appearance: Look for signs of acute distress or end-organ damage, such as chest pain or shortness of breath.

·       Vital signs: Besides blood pressure (check both arms if necessary), assess heart rate, respiratory rate, and oxygen saturation.

·       Cardiovascular examination: Listen for signs of heart failure (e.g., crackles, S3 gallop) or murmurs suggestive of aortic dissection.

·       Neurological exam: Check for signs of hypertensive encephalopathy or stroke—altered mental status, focal deficits, or papilledema.

·       Fundoscopy: This is essential for detecting signs of hypertensive retinopathy, which can indicate the severity of the hypertension.

·       Abdominal exam: Palpate for an abdominal mass or bruit that may suggest pheochromocytoma or renovascular hypertension.

Investigations – What to Order

Once you have a thorough history and physical exam, you’ll need to order relevant investigations to confirm the diagnosis, identify the underlying cause, and guide your treatment.

Blood pressure measurement:Always measure blood pressure in both arms to rule out any significant differences. For a hypertensive emergency, blood pressure is usually >180/120 mmHg.

·     Blood tests:

·     Basic metabolic panel: To assess renal function and electrolytes, as kidney injury is a potential complication of uncontrolled hypertension.

·     Complete blood count (CBC): To look for signs of anemia or infection.

·     Troponin levels: If there are concerns about myocardial infarction or ischemia.

·     B-type natriuretic peptide (BNP): Helpful in identifying heart failure.

·     Urinalysis:Urinalysis can show signs of end-organ damage (e.g., proteinuria, hematuria) in cases of secondary hypertension like glomerulonephritis.

·       Electrocardiogram (ECG):This will help assess for arrhythmias, left ventricular hypertrophy (a common finding in chronic hypertension), or signs of ischemia.

·     Chest X-ray:Can be useful in assessing for pulmonary edema (suggestive of hypertensive heart failure) or signs of aortic dissection.

·     Echocardiogram:This may be considered if there are concerns about left ventricular dysfunction or other structural cardiac issues.

·     Special investigations (if indicated):

·     CT or MRI of the brain: If there are signs or symptoms suggesting a stroke or hypertensive encephalopathy.

·     CT angiogram or MRI angiography of the chest/abdomen: If there is suspicion of aortic dissection or renovascular hypertension.

Management Plan – How to Treat Hypertension in the ED

The treatment approach depends on whether the hypertension is classified as an emergency or urgent:

·     Hypertensive Emergency

A hypertensive emergency is when blood pressure is severely elevated (>180/120 mmHg) with evidence of acute organ damage (e.g., stroke, myocardial infarction, aortic dissection, hypertensive encephalopathy). The key principles are:

·     Reduce blood pressure gradually (no more than 25% in the first hour).Rapid reduction in blood pressure can precipitate ischemia in vital organs, particularly the brain.

·     Use intravenous antihypertensive medications:

·     Nitroprusside: A fast-acting vasodilator used in the acute setting.

·     Labetalol: A beta-blocker with additional alpha-blocking activity that is useful for managing hypertensive emergencies.

·     Nicardipine: A calcium channel blocker used for gradual blood pressure reduction.

·     Treat the underlying cause:

·     Acute myocardial infarction: Administer antiplatelet therapy and manage as per acute coronary syndrome protocols.

·     Aortic dissection: Consider immediate surgical consultation.

·     Hypertensive encephalopathy: Manage with gradual blood pressure reduction and support for brain function.

·     Stroke: Antihypertensive therapy may be required to prevent hemorrhagic damage.

·       Monitor in a high-dependency unit:These patients require intensive monitoring with repeat blood pressure measurements and frequent reassessments.

Hypertensive Urgency

In a hypertensive urgency, the patient has high blood pressure (>180/110 mmHg) but no evidence of acute organ damage. The goal here is to lower blood pressure over hours to days:

·     Oral antihypertensive medications:

·     Clonidine: A centrally acting alpha-2 agonist.

·     Captopril: An ACE inhibitor that can provide quick relief.

·     Amlodipine: A long-acting calcium channel blocker for gradual control.

·     Discharge with follow-up:

·     Provide lifestyle advice on diet, exercise, and salt reduction.

·     Arrange urgent follow-up with the patient’s primary care physician to reassess blood pressure management.

Discharge and Follow-up Care

Before discharging a patient with hypertension from the ED, ensure:

·       The patient’s blood pressure is under control and stable.

·       They understand the importance of adherence to their antihypertensive regimen.

·       They know when to seek further medical help if their symptoms worsen (e.g., severe headache, chest pain, shortness of breath).

·       Provide clear instructions for follow-up care.