Severe Hypertension – Emergency or time to chill?

It’s one of those days when everything seems hard. Take Shuman – 55 years old, he came in with a sore foot but at the end of the consultation asked if you could quickly check his blood pressure. It hasn’t been checked in years. Ok, let’s get that QOF box ticked. 

180/100…

“It’s a bit high, just relax and let’s try that again.”

Turns out someone telling someone to relax always has the opposite effect. 

190/110…

192/120…

As he gets more worried his blood pressure gets more elevated. Should we be worried? 

This is a very common scenario in general practice – a patient presents with new severe hypertension, but what is the most appropriate way to manage this? Should a person go straight to hospital? Should we start immediate anti-hypertensives? Or do we have more time than we think? 

This is a surprisingly difficult question to answer as there is a lack of a strong evidence base to guide clinicians. Indeed national and international guidelines have different definitions of severe hypertension and different recommendations on how to manage it.  This is compounded by the fact that despite this clearly being a problem predominantly identified in the community, these recommendations are almost exclusively aimed at specialist hospital care. 

How then should we manage Shuman? 

Pulling together recommendations from NICE 2023 Hypertension in Adults, ESC 2024 guidance and a recent clinical review in the BMJ the first question is whether the patient is in significant danger due to the elevated blood pressure. 

Severe hypertension is defined as a clinic blood pressure of ≥180mmHg systolic and/or ≥120 mmHg diastolic. While we naturally focus on the numbers glaring back at us from the BP machine these are less important than any associated symptoms and signs.

NICE advises indications for same-day hospital assessment in the presence of a BP ≥180/120 are:

• Retinal haemorrhage or papilloedema, OR
• Life threatening symptoms which suggest a hypertensive emergency, such as new-onset confusion, chest pain, signs of heart failure or acute renal impairment.
  • The BMJ adds dyspnoea, visual disturbances, neurological symptoms and headache to that list, although it notes that an isolated headache does not indicate a hypertensive emergency.
• Suspected phaeochromocytoma, e.g. labile/postural hypotension, headache, palpitations, pallor, abdo pain or diaphoresis

The absence of symptoms is reassuring, with a study finding their lack ruled out an emergency with a negative predictive value of 99%. 

For most, immediate hospital admission will not be required. But should we start anti-hypertensives immediately in the community? 

To answer this question we need to know whether the patient has any end-organ damage: excluding eye signs on fundoscopy, cardiac changes on ECG and renal injury with urine dip, urine ACR and serum creatinine/eGFR. At the same time it is worth assessing for other risk factors such as dyslipidaemia and hyperglycaemia. 

The reality is in general practice this cannot be done in an hour or two. At best we are likely to get the results within 24 hours, often much longer. Does this mean patients will need to be referred to hospital anyway to have end-organ damage rapidly assessed? 

What data exists here is reassuring. The BMJ reference a retrospective study of almost 60k thousand patients in outpatient clinics, where 4.6% had a BP >180/110. Almost ¾ had known hypertension and 6/10 were already on two or more BP medications. Outcomes did not improve with ED or hospital assessment. 

NICE recommendations echo this: “carry out investigations as soon as possible…”, although it implies this should be days not weeks. 

• If there is evidence of end-organ damage we should initiate antihypertensive treatment straight away. The aim is for a modest reduction – a target of 160/100mmHg over 6-24h. More rapid reduction can lead to ischaemic organ damage. 
• If there is no evidence then we have time – NICE suggests repeat clinic readings or home/ambulatory BP measurements and follow up with 1 week.

But perhaps none of this worry is actually necessary – and what we all need to do is chill…

A 2017 RCT published in the Journal of Hypertension showed that patients with severe hypertension in the emergency department had equal falls in blood pressure if given oral telmisartan or simply rested for 2 hours. Almost 70% had a reduction in BP of 10-35%, a mean drop in SBP of 32mmHg.

Mindfulness with slow breathing has been shown to be effective by 3 hours, and diazepam may result in a larger drop than captopril, which isn’t to say we should start all our hypertensive patients on benzos but does show the rapid effects of anxiousness and stress on our cardiovascular system, and how relaxing can reduce them.

Our greatest tools in assessing severe hypertension may well be reassurance and time.

If you’re worrying about how you might interpret your hypertensive patient’s ECG, or if you want to learn more about cardiovascular disease then join us on Friday 4^th April from 9:30 – 13:00 for our updated Hot Topics in Primary Care Cardiology & ECG course. Designed to upskill GPs and other primary care clinicians on ECG analysis and common cardiovascular conditions this is exactly the course for you.