Hypertension is among the most common medical conditions for which emergency patients seek care. The ACEP clinical policies provide guidance on the appropriate work-up and treatment of these patients. Given the occasional lack of clarity on whether a patient’s presentation is on the spectrum of more acute/serious, EPs may feel more comfortable in discharging patients with poor follow-up if they are able to safely prescribe antihypertensive treatment. Prior to prescribing treatment, EPs should refer to the JNC 8 guidelines to appropriately start antihypertensive treatment in select patient groups in the ED. The guidelines of JNC 8 are therefore worth referring to in order to appropriately start treatment in select patient groups from the ED.
Case Scenarios Continued
Case 1
[The 65-year-old black man who presented with headache and dizziness, and had an initial BP of 240/130 mm Hg.]
After treating the patient with prochlorperazine and diphenhydramine, his headache resolved. His BP improved but remained elevated at 190/120 mm Hg. On further questioning, the patient reported a history of similar headaches and wondered whether it was related to his BP. The head CT scan was negative for any acute hemorrhage, infarct, or mass; the ECG only showed evidence of left ventricular hypertrophy; and the BMP showed normal renal function.
After a long discussion with the patient, you agreed to start him on amlodipine 5 mg/d and referred him for follow-up with a local PCP.
Case 2
[The 90-year-old white woman with a history of CHF and an initial BP of 220/140 mm Hg at presentation.]
The BMP evaluation showed a baseline creatinine level of 1.3 mg/dL. Given this patient’s history of CHF, amlodipine would not be the ideal next agent to prescribe. After discussion with her PCP, you elected to start her on losartan at 25 mg/d, and instructed her to follow-up with her PCP within 1 week.
Case 3
[The 32-year-old white woman who presented at the advice of a pharmacist and had an initial BP of 240/100 mm Hg.]While reviewing the patient’s work-up and history, you noted her plans to become pregnant, and recalled a recent review on BP management, noting the contraindications associated with ARB or ACE-I in pregnancy. Based on the patient’s uninsured status and poor follow-up, you considered prescribing amlodipine. Prior to issuing the prescription, you performed a repeat BP check and noted that the patient’s BP had decreased to 130/85 mm Hg. Given the marked improvement in the patient’s BP during her ED course, you were not convinced that she truly had hypertension.
Instead of prescribing an antihypertensive agent, which may not ultimately benefit this patient, you advised her to seek follow-up care at an outpatient clinic to have her BP rechecked. The patient agreed, and you referred her to a local free clinic.
