Severe Asymptomatic Hypertension: Evaluation and Treatment

 

Am Fam Physician. 2017 Apr 15;95(8):492-500.

Author disclosure: No relevant financial affiliations.

Hypertension affects one-third of Americans and is a significant modifiable risk factor for cardiovascular disease, stroke, renal disease, and death. Severe asymptomatic hypertension is defined as severely elevated blood pressure (180 mm Hg or more systolic, or 110 mm Hg or more diastolic) without symptoms of acute target organ injury. The short-term risks of acute target organ injury and major adverse cardiovascular events are low in this population, whereas hypertensive emergencies manifest as acute target organ injury requiring immediate hospitalization. Individuals with severe asymptomatic hypertension often have preexisting poorly controlled hypertension and usually can be managed in the outpatient setting. Immediate diagnostic testing rarely alters short-term management, and blood pressure control is best achieved with initiation or adjustment of antihypertensive therapy. Aggressive lowering of blood pressure should be avoided, and the use of parenteral medications is not indicated. Current recommendations are to gradually reduce blood pressure over several days to weeks. Patients with escalating blood pressure, manifestation of acute target organ injury, or lack of compliance with treatment should be considered for hospital admission.

Hypertension affects more than 30% of adults in the United States and is a significant modifiable risk factor for cardiovascular disease, stroke, renal disease, and death.1,2 Several high-quality studies have shown that treatment of hypertension reduces long-term hypertension-related adverse outcomes and all-cause mortality.35

WHAT IS NEW ON THIS TOPIC: SEVERE ASYMPTOMATIC HYPERTENSION

The U.S. Preventive Services Task Force recommends out-of-office blood pressure monitoring (using home and ambulatory blood pressure monitoring devices) as an important adjunct to in-office measurements for diagnosing hypertension.

A recent trial of an outpatient population referred to the emergency department for severe asymptomatic hypertension showed that only 5% of tests ordered had abnormal results, and 2% of patients had evidence of target organ injury. Less than 1% of patients had a major adverse cardiovascular event within six months.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Patients with severely elevated blood pressure should have a history and physical examination to distinguish between severe asymptomatic hypertension and hypertensive emergency.

C

6, 10, 13

A 30-minute rest period is recommended when the initial blood pressure reading is severely elevated. In more than 30% of patients, the blood pressure will lower to an acceptable level without intervention following the rest period.

C

15

An immediate diagnostic evaluation is not required in the initial management of severe asymptomatic hypertension.

C

8, 17, 18

Aggressive lowering of blood pressure can be harmful and should be avoided in patients with severe asymptomatic hypertension. Gradual reduction over several days to weeks is recommended.

C

10, 21


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Patients with severely elevated blood pressure should have a history and physical examination to distinguish between severe asymptomatic hypertension and hypertensive emergency.

C

6, 10, 13

A 30-minute rest period is recommended when the initial blood pressure reading is severely elevated. In more than 30% of patients, the blood pressure will lower to an acceptable level without intervention following the rest period.

C

15

An immediate diagnostic evaluation is not required in the initial management of severe asymptomatic hypertension.

C

8, 17, 18

Aggressive lowering of blood pressure can be harmful and should be avoided in patients with severe asymptomatic hypertension. Gradual reduction over several days to weeks is recommended.

C

10, 21


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Severe asymptomatic hypertension, or hypertensive urgency, is defined as severely elevated blood pressure (180 mm Hg or more systolic, or 110 mm Hg or more diastolic) without acute target organ injury.6 Patients may still have headache, lightheadedness, nausea, shortness of breath, palpitations, epistaxis, or anxiety, depending on the acuity and severity of blood pressure elevation.

Hypertensive emergency is defined as severe blood pressure elevation in

The Authors

ROBERT GAUER, MD, is an assistant professor of family medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md. He is also a hospitalist at Womack Army Medical Center, Fort Bragg, N.C.

Address correspondence to Robert Gauer, MD, Womack Army Medical Center, Bldg. 4-2817, Riley Rd., Fort Bragg, NC 28310 (e-mail: robertgauer@yahoo.com). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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