Be ready to manage patients with very high blood pressure

What should you do when patients report a very high blood pressure (BP) reading on a home monitor or pharmacy? Don't automatically refer to the emergency department (ED) for a blood pressure above 180/120 mmHg.

Advise promptly rechecking BP, and ensure proper technique, sit quietly for 5 minutes, appropriate cuff size, feet on the floor, etc. And shift the focus away from blood pressure numbers to the patient. Ask about alarm symptoms suggesting hypertensive EMERGENCY such as chest pain, shortness of breath, or vision changes. Send these patients with confirmed, very high blood pressures to the ED immediately. A headache or nosebleed alone doesn't indicate an emergency. Many of us were taught that a blood pressure above 180/120 mmHg without alarm symptoms is a hypertensive URGENCY. But think of the term "severe asymptomatic hypertension" instead, it better describes the situation. In this case, suggest GRADUAL lowering toward goal with usual blood pressure medications over days to weeks. Explain that in most cases it took time to reach high BP values, so it's okay to gradually lower them. Discourage adding PRN (as needed) clonidine or nifedipine IR, rapid blood pressure drops can reduce blood flow and lead to a stroke, heart attack, etc.

Use some rules of thumb to guide next steps and follow-up. Ask patients about typical blood pressures, when they last took antihypertensive medications, and possible causes of spikes, such as high salt intake or NSAIDs. Nonadherence is the top reason for very high blood pressure. In general, suggest resuming antihypertensive medications and seeing the prescriber within a week. But watch for exceptions. Refer for follow-up in a day or two if patients report adherence to medications and diet, if BPs differ widely from their norm, or patients don't have a history of high BPs. The same goes for patients with a history of cardiovascular or kidney disease since very high BPs can worsen these conditions. Document your discussions if needed. Check in with patients to ensure follow-up occurred and to reinforce medications adherence. Also advise bringing in their home blood pressure monitor to verify accuracy and technique. For further information, see note on Management of severe hypertension in adults.

References

• Whelton, P.K., Carey, R.M., Aronow, and others. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary. Journal of the American College of Cardiology, 71(19), pp.2199–2269. Available at: https://www.onlinejacc.org/content/71/19/2199

  Kallioinen, N., Hill, A., Horswill, M.S., Ward, H.E. and Watson, M.O. (2017). Sources of inaccuracy in the measurement of adult patients’ resting blood pressure in clinical settings. Journal of Hypertension, [online] 35(3), pp.421–441. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5278896