The Critical Care Advice Column: AMA

[zzyzx]

Great stuff, Brandon! Threads like these make me keep coming back to this site!

I especially like your post on pulmonary HTN.

Okay, now I have to think of something to ask...

 

[zzyzx]

Brandon, a guy comes into your hospital with a chief complaint of a lac to his finger. In triage his BP is 240/120. He states that he has not been taking his BP meds in months. He has not other medical history and has no other immediate complaints.

Your MD, your nurses, and the medic who brought him to the hospital all think he should get SL nitro and IV hydralazine to quickly lower his BP.

How do you convince them that treating asymptomatic hypertension is a usually a bad idea.

 

[Carlos Danger]

Brandon, a guy comes into your hospital with a chief complaint of a lac to his finger. In triage his BP is 240/120. He states that he has not been taking his BP meds in months. He has not other medical history and has no other immediate complaints.

Your MD, your nurses, and the medic who brought him to the hospital all think he should get SL nitro and IV hydralazine to quickly lower his BP.

How do you convince them that treating asymptomatic hypertension is a usually a bad idea.

Why would treating severe hypertension be a bad idea?

I definitely wouldn't use nitro, and may or may not use hydralazine, and I may consult the hospitalists and let them deal with it and not personally give anything. But there is no way that a BP or 240/120 doesn't need to be addressed. I'm not aware of any standard that would recommend that.

Looking forward to hearing Brandon's input.

 

[zzyzx]

LOL. I'll let Brandon answer that for you.

 

[E tank]

I'd think risk stratification would be a priority before starting aggressive therapy on a patient that presents with a pressure like this. Just because he says he has "no other medical history" in no way means he isn't at risk for end organ damage from a pressure like that. There are plenty of cardiac/end organ risk stratification tools to use to determine a course of action, but if truly as advertised an aggressive approach might not be called for. Does not mean that a po dose of beta blocker (or something) with a prescription and a follow up appointment is the wrong thing to do, it just means more information is needed.

 

[VFlutter]

LOL. I'll let Brandon answer that for you.

Not sure what is funny about that. It comes down to Hypertensive Urgency vs Emergency. Just because the patient is asymptotic does not mean that there is no underlying end organ dysfunction. If the patient truly has Hypertensive Urgency then aggressive blood pressure management is not needed and may potentially be detrimental (i.e Ischemic events). That being said the patient still needs blood pressure management. Giving them a single dose of IV antihypertensives until they are started on PO is not going to cause an issue as long as you are not acutely by dropping the pressure over 25%.

 

[Carlos Danger]

LOL. I'll let Brandon answer that for you.

What is so funny to you about severe hypertension? If you don't think a BP of 240/120 needs to be addressed, then you have some reading to do.

The literature is clear that there is no benefit to routine lowering of hypertension in the acute setting. And also that if BP is lowered, it should be done over the course of hours or even days, and probably with enteral agents rather than with a slug of nitro. However, those recommendations are all based on the JNC 7 definition of "markedly elevated BP", which is only 160/100, and also assume that follow-up is available, the patient is compliant, and no end-organ damage is evident.

But if someone walks in with a BP of 240/120, you have a case of severely elevated BP that is probably incompatible with normal organ function, and therefore needs to be investigated for end-organ damage and have management initiated. This likely requires admission, especially when the patient has already admitted to non-compliance with his prescribed regimen.

So your original question is the wrong one because it contradicts itself. "Quickly lowering his BP" is the wrong approach. But that is not the same thing as saying that "treating asymptomatic BP is a usually a bad idea".

 

[Brandon O]

Brandon, a guy comes into your hospital with a chief complaint of a lac to his finger. In triage his BP is 240/120. He states that he has not been taking his BP meds in months. He has not other medical history and has no other immediate complaints.

Your MD, your nurses, and the medic who brought him to the hospital all think he should get SL nitro and IV hydralazine to quickly lower his BP.

How do you convince them that treating asymptomatic hypertension is a usually a bad idea.

An interesting question, but as we see, one with many other questions embedded.

Many of us have tried to consign to the ash heap of history the idea of "hypertensive urgency." This is essentially the "scary high blood pressure that doesn't seem to be causing any problems." Although many humans (EMS and nursing humans among them) seem genetically disposed to be alarmed by high numbers, the operative part of that sentence is probably the part about no problems. As famed cardiologist Dr. Will Smith wrote, "Don't start nothing, won't be nothing."

Obviously, hypertension as a chronic condition is bad for you, causing nastiness like cardiac and renal disease. But a condition it probably took the patient years to develop need not necessarily be corrected in an hour, and in fact this may cause signs and symptoms of hypoperfusion, as their system has regulated itself to maintain flow at much higher pressures.

True hypertensive emergency is another matter. This is the "scary high blood pressure that is causing problems," i.e. end organ dysfunction. This should be corrected briskly, usually to about a generic goal of a 25% reduction in MAP, unless you care to make up a different arbitrary goal, or unless disease-specific targets are present (made-up or not; see previous discussion on intracranial hemorrhage). There is also a middle ground of hypertension with no real organ injury but predisposing factors that seem to make it unusually risk, such as a known aortic aneurysm.

So the easy answer is to fix hypertensive emergencies and ignore hypertensive urgencies. (Well, refer them to outpatient management.) That's well and good for an ivory tower discussion. But if you claim you'd be happy ignoring a blood pressure of 180 or 200, all we'll have to do is keep running it up like an auctioneer and eventually you'll crack. 240? 280? 300? At some point your basic animal instincts will brush aside your evidence-based parts and concede to lowering the blood pressure.

What most of us will shoot for, partially based on expert consensus (unsupported, natch) is a SBP <180 and perhaps a DBP <110. Some go a bit more aggressive and say <160/100. Since this is purely based on fear, you can really pick your threshold. In the ICU I say <180 unless there are special circumstances. Like treating fever with antipyretics, I frankly care very little, but the nurses will keep calling.

To summarize, there is not much evidence that treating asymptomatic hypertension does any good. However, we all do it if it's high enough, and probably will until there is a study proving that X blood pressure is safe to ignore.

 

[zzyzx]

The problem I see when I work in the ER is that both physicians and nurses freak out over a BP like 240/120 but asymptomatic. They don't consider that the patient who tells them he's been noncompliant with his meds for months has likely been walking around with that BP for months as well. Perhaps part of the problem is that it's called hypertensive URGENCY. So, the patient gets slammed with nitro and IV anti-hypertensives.

The other problem I see is that little thought is given to what happens to the patient after he/she is discharged home. How long is the half life of an IV anti-hypertensive, and what happens when the medication wears off. Will their BP bounce back to an even higher level? If they actually do fill their Rx right away, which is unlikely, what effect will the new medication have considering that they have already been given BP meds in the ER.

 

[Carlos Danger]

The other problem I see is that little thought is given to what happens to the patient after he/she is discharged home. How long is the half life of an IV anti-hypertensive, and what happens when the medication wears off. Will their BP bounce back to an even higher level? If they actually do fill their Rx right away, which is unlikely, what effect will the new medication have considering that they have already been given BP meds in the ER.

This is why these patients need to be admitted, at least for 23 hour obs. Get the BP down a fair bit over a handful of hours with PO meds, and discharge them with scripts and a follow up appt. If they choose not to follow through, that's 100% on them. I can say I did everything in my power to help them get their BP under control.

I know what the research says, but what % of the patients looked at in those studies had a BP this high? Probably few. Not nearly enough to have confidence that it is safe to discharge someone with a BP this high. Maybe it is safe, but I sure can't point to a study or a guideline that says it is.

It's one thing to say "the research doesn't support admitting them", and it's another to be the independent practitioner who signed the order discharging someone with a BP of 240/120.

 

[Brandon O]

This is why these patients need to be admitted, at least for 23 hour obs. Get the BP down a fair bit over a handful of hours with PO meds, and discharge them with scripts and a follow up appt. If they choose not to follow through, that's 100% on them. I can say I did everything in my power to help them get their BP under control.

I know what the research says, but what % of the patients looked at in those studies had a BP this high? Probably few. Not nearly enough to have confidence that it is safe to discharge someone with a BP this high. Maybe it is safe, but I sure can't point to a study or a guideline that says it is.

It's one thing to say "the research doesn't support admitting them", and it's another to be the independent practitioner who signed the order discharging someone with a BP of 240/120.

Right.

zzyzx does, of course, have a point. Quite possibly many of these patients would be 100% fine if they'd simply stayed out of our paws and, say, took their meds and followed up with their PCP. But even adopting this outlook, again: at some point you'll break. If you're the one responsible, some number is too high and you won't let them walk out that door.

This is the sort of thing where it can be helpful to have an institutional policy. Or at least some professional guidelines. That way it's not quite so arbitrary with everyone applying their own different, equally unsupported levels of risk/fear tolerance.

 

[E tank]

How often do patients present like this that do not have comorbidities that require a more active management of their pressure? There are those that do, but by and large, these people are deconditioned and ill and require more than a follow up appointment and a script.

The suggestion that hydralazine and nitro as some kind of one-two punch on even an emergency is a bit of a canard. No one does that, and if they do they have more problems than treating when they shouldn't.

 

[VFlutter]

The problem I see when I work in the ER is that both physicians and nurses freak out over a BP like 240/120 but asymptomatic. They don't consider that the patient who tells them he's been noncompliant with his meds for months has likely been walking around with that BP for months as well.

I still think that saying the patient is "asymptomatic" is totally irrelevant without labs. The patient may feel fine but if they are walking around with a pressure of 240/120 for months they are going to have end organ dysfunction that warrants intervention, preferably before it is irrevocable.

 

[Carlos Danger]

How often do patients present like this that do not have comorbidities that require a more active management of their pressure? There are those that do, but by and large, these people are deconditioned and ill and require more than a follow up appointment and a script.

I still think that saying the patient is "asymptomatic" is totally irrelevant without labs. The patient may feel fine but if they are walking around with a pressure of 240/120 for months they are going to have end organ dysfunction that warrants intervention, preferably before it is irrevocable.

Exactly. It's the difference between doing cookbook medicine and clinical medicine.

 

[Brandon O]

I still think that saying the patient is "asymptomatic" is totally irrelevant without labs. The patient may feel fine but if they are walking around with a pressure of 240/120 for months they are going to have end organ dysfunction that warrants intervention, preferably before it is irrevocable.

Well, yes. But zzyzx is correct to note that most of the damage associated with hypertension, even in most cases impressive hypertension like this, is due to chronic "exposure." If they prove to have, say, kidney disease from their hypertension, that proves it needs to be fixed, but not necessarily normalized today. As I said, we tend to hedge a little; get a foot in the door, make a good faith effort to show we care, and then let an ongoing (outpatient) process continue to work on it.

 

[E tank]

Well, yes. But zzyzx is correct to note that most of the damage associated with hypertension, even in most cases impressive hypertension like this, is due to chronic "exposure." If they prove to have, say, kidney disease from their hypertension, that proves it needs to be fixed, but not necessarily normalized today. As I said, we tend to hedge a little; get a foot in the door, make a good faith effort to show we care, and then let an ongoing (outpatient) process continue to work on it.

Thanks for your CC posts. They're thorough and informative...as to this scenario, I think there was a kind of "straw man" that was presented in part with the suggestion of NTG and hydralazine, the implication being that if someone were in favor of taking a more active stance, it would involve these two drugs. Also, of the three of us that have generally disagreed, none of us are suggesting normalizing the blood pressure, certainly not with the agents suggested. If someone was determined to treat then and there, taking the diastolic to 100 would be pretty defensible given the likelihood of comorbidity. An IV beta blocker is a very gentle and gradual way to do that.

 

[Brandon O]

Thanks for your CC posts. They're thorough and informative...as to this scenario, I think there was a kind of "straw man" that was presented in part with the suggestion of NTG and hydralazine, the implication being that if someone were in favor of taking a more active stance, it would involve these two drugs. Also, of the three of us that have generally disagreed, none of us are suggesting normalizing the blood pressure, certainly not with the agents suggested. If someone was determined to treat then and there, taking the diastolic to 100 would be pretty defensible given the likelihood of comorbidity. An IV beta blocker is a very gentle and gradual way to do that.

I think the agent is a matter of style and convenience. If there's not much evidence on the practice itself, there certainly isn't on the drug to use. In most cases I would usually do nicardipine for true HTN emergency and probably PRN hydralazine or labetalol for nuisance "urgency." Special cases abound, of course.