To the Editor As emergency medicine physicians and hypertension (HTN) researchers, we read with great interest the work by Patel et al1 on severely elevated blood pressure (BP) in the office setting. It was reassuring to see their data support the approach endorsed by the American College of Emergency Physicians2 that focuses on end organ damage as the critical branch point for decision making, while challenging, as we have previously, the wisdom of acute BP reduction for the sake of treating numbers.3 That only 387 patients (0.7%) were sent to the emergency department (ED) is encouraging; it seems that health care providers in their system understood that asymptomatic HTN is largely an outpatient condition. This is in contrast to our recent work4 in the Nationwide Emergency Department Survey that found that ED visits for HTN are rising rapidly. Given the lack of detectable differences between groups in cardiac outcomes at all study end points, it seems that referral to the ED absent end-organ damage for patients with markedly elevated BP may increase resource usage without yielding significant gains in hard end points. Notwithstanding, differences in BP control at 1 month were noted, suggesting that EDs may have a role to play in the continuum of care for patients with HTN, perhaps through identification of precipitating causes, patient education and counseling, and/or titration of antihypertensive therapy. Among 310 patients who were discharged from the ED, new antihypertensive medication was added for 26.5% and dose was increased for 7.4%. Whether this improved BP control in the short term is unclear, but it is consistent with data on the safety and efficacy of initiation of antihypertensive therapy from the ED for patients with uncontrolled HTN who were enrolled in clinical trials.5 Perhaps most importantly, as so eloquently demonstrated by this study, “hypertensive urgency” is probably not a useful categorization. The paucity of adverse cardiac events shortly after an ED visit or hospitalization suggests that, despite traditional teaching, these patients may not have impending end-organ damage but rather are at high risk for adverse consequences if such poor control persists over time. Continued use of the term hypertensive urgency will only lead to confusion among health care providers and patients and contribute to overuse of health care resources without clear patient benefit. When it comes to asymptomatic HTN, perhaps the best teaching is based on a twist of an old adage—don't just do something, stand there.
McNaughton CD, Brody A, Levy PD. Appropriate Management of Asymptomatic Hypertension. JAMA Intern Med. 2016;176(11):1723–1724. doi:10.1001/jamainternmed.2016.5925
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