The Concept of a “Hypertensive Urgency” is a Myth

One of my nurses called me recently worried about a patient’s blood pressure.  The patient had just recently arrived at the jail and had no complaints, but when his blood pressure was measured, it was 230/120.  The patient otherwise felt fine and had no complaints, but the nurse was concerned that the blood pressure was dangerously high and we needed to give the patient something to get this blood pressure down right away.  My nurse had been taught that such patients had a “Hypertensive Urgency” and needed to be given a medication that would immediately lower their blood pressure.

The problem is that this concept of a “hypertensive urgency” is a myth.  It is not in this patient’s best interest to acutely lower his blood pressure.  In order to explain why, I need to give a brief history this concept.

Medical doctors did indeed once believe that there was a hypertensive urgency.  I myself was taught this when I did my emergency medicine residency in Akron, Ohio in the 1980s.  At that time, it was taught that there were two types of critical hypertension that I would have to deal with in the emergency department.

First, there was the “Hypertensive Emergency,” which occurred when the patient had a very high blood pressure (say 260/140) plus some life-threatening emergency related to that high blood pressure.  An example would be a patient who is having a heart attack with acute congestive heart failure and very high blood pressure.  Another example would be a patient who is bleeding into their brain from a hemorrhagic stroke plus monstrously high blood pressure.  In both cases, lowering the blood pressure within minutes is a critical emergency and we emergency physicians were taught how to do this.

The other type of acute hypertensive problem we learned about at the time was this “Hypertensive Urgency.”  This was defined at the time as a diastolic blood pressure of over 110 in an otherwise asymptomatic patient.  It was taught then that this blood pressure was so high, that even though the patient felt well, they were at high risk of suddenly having something bad happen, like a stroke.  Because of the fear of this risk, the patient was given a medication to lower the blood pressure within minutes.  The two most common medications used to do this were clonodine (Catapress) and nifedipine (Procardia).  In my early years working in the emergency department, I used to treat patients in this way all of the time.  The first editions of national guidelines on the treatment of hypertension, like the Joint National Committee guidelines in The Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, contained a section devoted to this practice.

But then in the 1980s and the 1990s, research done on this practice showed a couple of disturbing things:

1.  Clonodine, nifedipine and the other drugs used to treat a “Hypertensive Urgency” did lower the blood pressure.  But when these patients were followed further, it was found that their blood pressures returned to the pretreatment levels almost as soon as they got home.  The treatment lasted, at most, several hours.

2. Some patients who had their blood pressures lowered in this way had strokes.  The reason for this is what is known as the “perfusion pressure” of the brain.  Simplistically stated, suddenly lowering the blood pressure in some patients lowers the delivery of blood to the brain to critical levels, which can cause an acute stroke.

3.  In fact, when large groups of patients with the so-called hypertensive urgency were evaluated, those treated with clonodine or nifedipine or other drugs do worse overall than those not treated.

The bottom line is that rapidly lowering the blood pressure of those with high blood pressure gives no benefit and may cause harm.  Because of this and other research, the concept of the hypertensive urgency has been dropped from the medical literature.

For example, the  seventh edition of the Joint National Committee guidelines in The Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC -7) (found here) does not recommend the administration of antihypertensive agents to acutely lower BP in the absence of “end-organ damage.”

Similarly,  the clinical policy published by the American College of Emergency Physicians (ACEP) (found here, second from the bottom) states:

  1. Rapidly lowering blood pressure in asymptomatic patients in the Emergency department is unnecessary and may be harmful in some patients.
  2. When Emergency Department treatment for asymptomatic hypertension is initiated, blood pressure management should attempt to gradually lower blood pressure and should not be expected to be normalized during the initial ED visit.

So what should be done with the patient my nurse called me about?  The first thing is to verify that the reading of 220/110 is accurate.   Sometimes BP machines can give inaccurate numbers.  I have seen inmates who could artificially elevate their blood pressures by surreptitiously flexing their biceps during the reading.  One way to quickly verify the blood pressure result is to take the blood pressure in both arms, one after the other, then wait 5-10 minutes and take a BP reading again in both arms, but this time manually.  This gives you four BP readings.  Let’s assume that these four readings consistently showed a blood pressure of around 220/110.

This particular patient already was taking three blood pressure medications prescribed by his outside physician, so he falls into the category of “poorly controlled hypertension.”  By far and away, the most common cause of poorly controlled hypertension is noncompliance– the patient has not been taking his blood pressure medications properly.  I know that this patient has been taking them for the couple of days he has been in the jail but I do not know if he was taking them on the outside.  Most likely, he was not. (I wrote about this previously in “The Compliance Trap,” found here ).  Since he has only been in jail only for a short time, I think the most reasonable course is to continue him on his current medication regimen and schedule him for a Hypertension Chronic Care follow-up in about a month.  He will have been on his current three drug regimen for a month then, and I will have a pretty good idea of how well it is working.  If I schedule him for routine blood pressure checks in the meantime, I would do this no more often than one week apart.

However, let’s assume that this patient with the blood pressure of 230/120 has no previous diagnosis of hypertension and is on no medications.  What should be done with him?  Well, even though he has not known about it, he has probably had hypertension for a long time.  There is no urgency to start him on any medications right now.  Emergency Medicine guidelines say that emergency physicians do not have to start blood pressure medications in the ED as long as they have arranged follow-up with a primary care physician.  In a correctional facility, this consists of scheduling this patient for the next medical clinic where his hypertension work up and therapy can begin.

I know that many of my colleagues prefer to start a hypertension medication such as a diuretic or a diuretic/ACE inhibitor combo right away via phone order rather than wait until clinic.  I think this is OK as long as the patient is still scheduled to be seen in the next clinic. However, there are a couple of problems with this approach.  One is that statistically, patients with an isolated BP reading of >160/100 (stage 2 hypertension by JNC-7 criteria) have a 90+% chance of having the diagnosis of hypertension eventually confirmed.  This is a pretty high percentage, but it is not 100%.  There are occasionally false positives for various reasons.  Second, you are beginning therapy for a chronic, perhaps life-long disease process, without having discussed this with the patient.  Nor have you discussed potential side effects and potential side effects of the medications you are beginning.  You have not discussed lifestyle changes that are at least as effective as medications.  You have not given the patient a chance to be an informed partner in the decision making process.

The whole point is that there is no rush, no urgency, in this situation.  The idea of a “Hypertensive Urgency” has turned out to be a myth.  In my mind, it is better to bring the patient to the next medical clinic, verify the diagnosis with repeat blood pressures, do the work up, and discuss the diagnosis and treatment options with the patient.

How do you handle big blood pressures at your facility?  Anybody out there still use nifedipine or clonodine?

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9 thoughts on “The Concept of a “Hypertensive Urgency” is a Myth

  1. Dr. Silva

    Actually the JNC-7 CLEARLY state that you must treat hypertensive urgencies: “Patients with markedly elevated BP but without acute target organ damage usually do not require hospitalization, but they should receive immediate combination oral antihypertensive therapy.” You’re right in saying it shouldn’t be treated aggressively though. As someone’s who’s worked at a maxiumum security jail, I understand the challenges of ensuring that patients follow up with their PCP afterwards. However, not to treat a hypertensive urgency is inappropriate as well.

    Reply
    1. Jeffrey Keller Post author

      Thanks for the comment, Dr. Silva. I start such patients on two agents, usually HCTZ and an ACE inhibitor. The question is whether to start those medications before I have seen them, like if I get a phone call from a nurse on a Saturday. It is analogous to an ER doc finding very high blood pressure in a patient presenting to the ER with some other problem, like an ankle sprain. Should the ER doc prescribe antihypertensives or refer the patient to his primary care provider? The ER literature says that it is OK to wait, as in this quote from Rosen’s textbook: Elevated BP without evidence of progressive end-organ involvement does not require urgent treatment in the ED. Historically, these patients, on the basis of arbitrarily defined BP elevations and the ill-conceived term “hypertensive urgency,” were inappropriately treated with antihypertensive agents in the ED with little regard for the chronicity of the condition, potential adverse effects of acutely lowering their BP, or transition to a stable, oral, outpatient regimen for long-term control. It is unnecessary to lower BP acutely in the ED for these patients, and this practice may actually cause increased risk of adverse effects. These patients are best managed with a long-term, ambulatory regimen, monitored and adjusted by their primary care provider.
      So I personally start the antihypertensives in clinic.

      Reply
  2. Nurse

    I am a nurse working in a jail and works in the screening or intake area, the patients are fresh arrest from the streets and most likely they are under the influence of either alcohol and drugs. I would say at least for most of them, how would you take into consideration those factors with regards to HTN and the urgency to treat them. I know that those contributing factors can often aggrevate the conditions and is there a big difference in treating them versus pt that are already incarcerated and been in jail for a longer period of time. We currently dont have a specific guidelines on the ranges on how we route the pts. And it would be great to have a guideline so we can route pt appropriately and effectively.

    Reply
  3. Mark Schaffield

    Thanks for your insights. I am probably your contemporary and have a long ER history. Have you noticed the dramatic rise in the use of Clonidine for HTN over the last few years? This was a 3rd or 4th line antihypertensive even when I was practicing Internal Medicine. Now, it seems, the young hypertensives are prescribed it as a first line drug. It is the only antihypertensive that I know of that will cause inmates to argue, file grievences, etc. when I change it. What do you think the attraction is? Thanks, Mark Schaffield MD

    Reply
    1. Jeffrey Keller MD Post author

      Hi Mark! I’m always happy to run into fellow ER docs. I have indeed run into a dramatic increase in the use of clonidine recently, but not as a hypertension drug. It is being prescribed as a psychiatric drug to treat “nightmares.” It is evidently quite sedating, so I have also seen it prescribed as a sleeping aid. In my jails, it has great value back in the dorms, because of its sedating effects. The magic word is “nightmares,” so I often get kites saying something like “I keep having nightmares. What can be done to help me?” The goal is to be prescribed clonidine. Back when clonidine was used for hypertension, it had to be prescribed 3 or 4 times a day, but I never see that. I just see the nighttime dosing.

      Reply
      1. mark schaffield

        Funny how medical practice is “location specific”. In my area there is a “heroin epidemic” (as the local news is fond of calling it). The hyperbole is probably justified. On any given day, we have a huge number of heroin addicts in the 3 county jails that I cover. These folks have the most interesting array of infections that I have ever seen. I feel like I’m living in the “Golden Age” of pain and fevers – from endocarditis to infections of the skin, psoas muscle, kidneys, epidural space, etc. The local community of doctors seems to deal with this population by prescribing heavy doses of gabapentin, Oxy, SSRI’s and anything that a 30 year old on SSI “needs”. The clonidine seems to be used as an adjunct for the treatment of withdrawal symptoms from narcotics and alcohol. We live in a chemical world, no? Mark Schaffield

        Reply
        1. Jeffrey Keller MD Post author

          Hi again Mark. Yes, I use clonidine for opiate withdrawal in my facilities. It works quite well–much better than “cold turkey” detoxification. But that is all that I personally prescribe clonidine for.

          Reply
  4. Janice Edmonds

    Please don’t call any RN that works with you “My Nurse”.
    It’s very degrading and insulting.

    Reply
  5. Donna

    I would have to say that a large amount of new inmates present with a higher than usual BP initially. For those with ___/110 or higher who are asymptomatic I place on medical watch and conduct BP checks daily untill the Doctor sees them. My Doctor,(had to say it), prefers to let them finish withdrawl, sleep, get good nutrition, and climatized prior to ordering medications.

    As far as clonidine is concerned I have an inmate now with BP controlled on Metoprolol but insisting that it is not and requesting clonidine. He has not prescribed clonidine for BP management in the 8 years we’ve worked together.

    Reply

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