Rachel Beatty, ARNP
Typical Scenario
Let’s discuss a common scenario. You have a 50 year old male who has not been seen by a PCP in two years. His past medical history includes arthritis and hypertension. He does not smoke and has an occasional beer on the weekend. He has been off his medications for his hypertension for over a year. His BP in office is 182/110, HR 70, Temp 97.6, Respirations 16, 02 saturation 98%. His physical exam is unremarkable and he is asymptomatic. Your medical assistant asks you if you would like her to give him clonidine and do an EKG. She then asks if we will be sending him to the emergency room. The patient is now anxious and is wondering if he is going to have a stroke. What would you do?
Hypertensive Urgency vs Emergency
Well first lets discuss hypertensive urgency vs emergency. The big difference here to define urgency is elevated blood pressure greater than 180/110, and for emergency, pressure of 220/120 with SYMPTOMS of end organ damage. For example, neurological changes, chest pain, shortness of breath, any concern for aortic dissection, renal failure etc. These are the patients who need to be transferred to a higher level of care and sent to the ER. Of course there will be some other cases where ER is warranted but typically asymptomatic hypertension can me managed outpatient without any intervention in the office.
So your nurse has the clonidine in hand and is ready to do the EKG. You tell her that the EKG is not warranted so it will not be ordered and she can put the clonidine back as it will not be needed. You are able to educate your patient and calm him down regarding his concern for a stroke. You educate your patient on the risks of dropping his blood pressure suddenly such as an MI or stroke, more specifically a watershed stroke. You present him with evidence and data based outcomes to let him know he is safe to go home with a prescription and continue outpatient follow up. One study from the Cleveland Clinic shows that there was not a significant difference in outcomes for patients sent to the ER for asymptomatic hypertension who were admitted versus asymptomatic patients being sent home without intervention or immediate treatment. There was not any data to support that these patients were at greater risk for major cardiovascular events.
So do not get your pressure up over asymptomatic hypertension! Get a good history and physical from the patient. If there is no suspicion of any end organ damage or any significant medical history that warrants concern of their blood pressure then you can safely manage them outpatient without the need to send to the emergency department. Arrange close follow up and have the patient monitor blood pressure at home with parameters to contact their provider.
Clonidine
In regards to clonidine, many outpatient offices and urgent cares continue to implement this treatment for hypertension in the office. Yes, this will give you a “nice number” to document that makes you and the patient feel comfortable to discharge them home but it is likely doing more harm than good. There are not validated controlled studies that support any promising long term outcomes with acute treatment. These patients likely did not become hypertensive overnight so fixing them quickly with fast acting agents can lead to hypotension and drop the blood pressure below the autoregulatory zone which can lead to decreased perfusion to the brain.
Also, keep in mind that if you are still in the camp of the must send all patients with asymptomatic hypertension to the emergency department, there is a clinical policy from the American College of Emergency Physicians supporting discharge for these patients.
Are you still using clonidine in your office for asymptomatic hypertension? What is your most successful approach for these patients?
