American Journal of Emergency Medicine 33 (2015) 1831-1839

Correspondence

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

An approach to markedly elevated blood pressure in Hypertensive patients without acute organ damage?

To the Editor,

We read the article “Blood pressure treatment and outcomes in hy- pertensive patients without acute organ damage: a retrospective co- hort” written by Levy et al [1] with great interest. They concluded that there was no evidence of benefit with treatment to acutely lower blood pressure in the patients with markedly elevated blood pressure and absent signs or symptoms of acute target organ damage [1].

Lowering blood pressure quickly has no proven benefit in patients without acute organ damage [2]. In contrast, there are studies showing the related complications of reducing blood pressure suddenly in this kind of patients [2]. The potential danger of acutely decreasing blood pressure is the risk of autoregulatory disorder of cerebral and renal perfusion that leads to cerebral and renal injury [3]. We have to treat patients, not numbers, but does that not mean we should be treating symptomatic patients as well as not overtreating asymptomatic patients? Are we realistic to conclude that symptomatic patients–albeit without end-organ damage–should not be treated in the emergency department (ED)? Blood pressure can be reduced slowly in patients who have headache, severe anxiety, respiratory distress, or ep- istaxis, by following them up for a few hours in the ED [4]. Start with the principle “do not harm the patient” and determining which patients can be discharged without treatment: the patients who are suitable for prima- ry care, whose precipitating factors are eliminated, who will eager to con- tinue with the previous effective medication, and who can return within 24 hours for control examination. The most logical approach is to pre- scribe the oral medication in the ED that the patient had already been on or discontinued. A consensus needs to be developed on the manage- ment of patients with markedly elevated blood pressure and lack of clin- ical evidence of acute target organ damage in the ED.

Hakan Sarlak, MD

Department of Internal Medicine, Diyarbakir Military hospital

Diyarbakir, Turkey Corresponding author. Department of Internal Medicine Diyarbakir Military Hospital, Seref Inaloz St. 21100 Yenisehir

Diyarbakir, Turkey Tel.: +90 412 2288225; fax: +90 412 2236732

E-mail address: hakansarlak@gmail.com

Salim Ozenc, MD

Department of Family Medicine, Diyarbakir Military Hospital

Diyarbakir, Turkey

Ibrahim Arziman, MD

Department of Emergency Medicine, Gulhane Military Medical Faculty

Ankara, Turkey

? There is no conflict of interests.

Mustafa Tanriseven, MD

Department of General Surgery, Diyarbakir Military Hospital

Diyarbakir, Turkey

http://dx.doi.org/10.1016/j.ajem.2015.06.050

References

1. Levy PD, Mahn JJ, Miller J, Shelby A, Brody A, Davidson R, et al. Blood pressure treat- ment and outcomes in hypertensive patients without acute organ damage: a retro- spective cohort. Am J Emerg Med 2015. http://dx.doi.org/10.1016/j.ajem.2015.05.036.
2. Yanturali S, Akay S, Ayrik C, Cevik AA. Adverse events associated with aggressive treatment of increased blood pressure. Int J Clin Pract 2004;58(5):517-9.
3. Varon J, Marik P. Clinical review: the management of Hypertensive crises. Crit Care 2003;7:374-84.
4. Adhikari S, Mathiasen R. Epidemiology of elevated blood pressure in the ED. Am J Emerg Med 2014;32(11):1370-2.

   Response to “An approach to markedly elevated blood pressure in hypertensive patients without acute organ damage”

   

   Thank you for your interest in our article. We are in agreement with you that a cautious approach to Blood pressure reduction in hypertensive patients without acute organ damage is warranted and acknowledge that this has been emphasized in several other publications. However, many emergency physicians still retain a level of discomfort withholding anti- hypertensive therapy for patients who have markedly elevated blood pressure and the purpose of our study was to show that outcomes are equivocal with such an approach. In doing so, we provide evidence to support the decision not to treat numbers alone. When symptoms potentially attributable to acute organ damage are present, further diagnostic workup and treatment directed at the causal factors, including Antihypertensive therapy, may be indeed be necessary. That said, there is no direct benefit associated with blood pressure reduction for conditions such as anxiety or headache, and instead treatment with anxiolytic or pain medication is more likely to achieve desired Therapeutic effects. We agree that for patients who have persistent blood pressure elevation posttreatment of such symptoms, initiation, reinitiation, or titration of oral antihypertensive therapy coupled with outpatient follow-up (though not necessarily within 24 hours) is warranted. As we have recently shown [1], emergency physicians can safely and efficaciously prescribe oral med- ication for management of hypertension and broader appreciation of this, perhaps through development of a consensus statement would be beneficial.

   Phillip D. Levy, MD, MPH* Robert D. Welch, MD, MS

   Department of Emergency Medicine, Wayne State University

   Detroit, MI

   ?Corresponding author.

   E-mail address: plevy@med.wayne.edu http://dx.doi.org/10.1016/j.ajem.2015.06.051

   0735-6757/(C) 2015