Management of Elevated Blood Pressure in Acute Care: Statement From the American Heart Association

Elevated blood pressure (BP) is often seen in clinical settings, especially in acute care where the clinical significance can be difficult to determine. Although hypertensive emergencies occur in 0.2% of adult emergency department visits, mortality rates have decreased over the past 20 years. Asymptomatic elevated BP measurements are present in up to 72% of hospitalized patients. The American Heart Association published a scientific statement summarizing the evidence of risks and management of elevated BP in acute care settings.

Because previous terms such as hypertensive crisis and hypertensive urgency imply an urgency that is not present, the AHA recommends objective terms for labeling inpatient BP findings. Hypertensive emergency refers to a systolic BP of more than 180 mm Hg and a diastolic BP of more than 110 mm Hg with evidence of new or worsening target-organ damage. Asymptomatic markedly elevated BP applies to similar BP levels as hypertensive emergency without evidence of new or worsening target-organ damage. Because target-organ damage can be present at lower BP measurements, these levels are not thresholds but should increase suspicion.

BP can be affected by patient position, arm support and position relative to the heart, leg crossing, and incorrect cuff sizing (in one study, 36% of inpatient BP measurements were obtained with inappropriately sized cuffs). Although arterial lines can be affected by movement and calibration, they tend to be more accurate in intensive care environments.

Hypertensive Emergency

The BARKH acronym (brain, arteries, retina, kidney, heart) can be used to remember target organs that should be evaluated. After obtaining a history, including medications and adherence and available previous BP readings, physical examination should focus on pulses, heart and lung auscultation, and a funduscopic examination. Laboratory evaluation should include a basic metabolic panel, complete blood cell count, assessment of volume status, chest radiography, and 12-lead electrocardiography.

After confirming new or worsening target-organ damage, rapidly decreasing BP is recommended, with BP goals based on the specific injury. Patients with stroke, cerebral hemorrhage, and hypertensive retinal injury should be treated to produce an immediate drop in mean arterial pressure of 15%. Patients with hypertensive encephalopathy should be treated to decrease mean arterial pressure by 20% to 25%. For aortic dissection, systolic BP should be quickly decreased to less than 120 mm Hg. The systolic BP target for preeclampsia and related diseases is 160 mm Hg. For heart failure, mean arterial pressure should be reduced by 25%. Systolic BP should be decreased to less than 140 mm Hg in patients with pulmonary edema or acute coronary syndrome. For hypertensive kidney injury, mean arterial pressure should be decreased by 20% to 25% over several hours.