Aymptomatic HTN...that actually has damage

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How would you guys manage the following patient?

mid-60s lady comes in via EMS for chest pain. Received NTG en route w/o significant change. MAP persistantly in the 130s. She looks completely comfortable but has ongoing central chest pressure. Has a long history of resistant hypertension (last visit was two years ago for visual changes and her pressure was 250/90 then) but states it had been pretty well controlled until she ran out of her meds a month ago. EKG shows LVH w/ lateral ST depression and TWI (looks like lvh w/ strain but no previous to compare). CXR shows some cardiomegaly w/o any other signs of failure and trop (high sens) is negative.

Do you have a prior EKG? If there's a recent one and these are new changes, I'd probably do IV nitroglycerin and admit to tele. If there's no recent EKG, I would repeat in 20 or so minutes. If the second EKG is stable I would give oral BP meds (or a push of 20 mg labetalol if my hospitalist would freak out at the BP number) and admit to obs for serial trop and stress/ECHO.

 

[WheezyBaby]

How would you guys manage the following patient?

mid-60s lady comes in via EMS for chest pain. Received NTG en route w/o significant change. MAP persistantly in the 130s. She looks completely comfortable but has ongoing central chest pressure. Has a long history of resistant hypertension (last visit was two years ago for visual changes and her pressure was 250/90 then) but states it had been pretty well controlled until she ran out of her meds a month ago. EKG shows LVH w/ lateral ST depression and TWI (looks like lvh w/ strain but no previous to compare). CXR shows some cardiomegaly w/o any other signs of failure and trop (high sens) is negative.

Work up I'm going to skip over, some would scan some not. But immediate mgmt I'd put on cardene. NTG sucks for BP mgmt and this sounds more BP primary than secondary. Afterload reduce, reassess sx. Hospitalist can resume home meds and wean the cardene

 

[turkeyjerky]

Do you have a prior EKG? If there's a recent one and these are new changes, I'd probably do IV nitroglycerin and admit to tele. If there's no recent EKG, I would repeat in 20 or so minutes. If the second EKG is stable I would give oral BP meds (or a push of 20 mg labetalol if my hospitalist would freak out at the BP number) and admit to obs for serial trop and stress/ECHO.

No prior EKG.

Work up I'm going to skip over, some would scan some not. But immediate mgmt I'd put on cardene. NTG sucks for BP mgmt and this sounds more BP primary than secondary. Afterload reduce, reassess sx. Hospitalist can resume home meds and wean the cardene

Yeah, this is basically exactly what I was thinking/did. Pharmacy gave me pushback about starting a drip and wanted me to use pushes of hydalazine. This is a new hospital for me and evidently that's still a 'thing' here.

It was kinda irritating--I'm usually the last person in the world to worry about someone's BP, but I feel like when it's indicated, you should do it the right way.

 

[WheezyBaby]

No prior EKG.


Yeah, this is basically exactly what I was thinking/did. Pharmacy gave me pushback about starting a drip and wanted me to use pushes of hydalazine. This is a new hospital for me and evidently that's still a 'thing' here.

It was kinda irritating--I'm usually the last person in the world to worry about someone's BP, but I feel like when it's indicated, you should do it the right way.

Nope, in the exact same boat. Hypertensive urgency gets po meds even for "scary" numbers (up to some personal threshold where I'd chicken out and just put them on a gtt to ensure safety... Not sure exactly where that is but probably systolic 240ish.. No science and not really good medicine necessarily there, just... Chicken). Hypertensive emergency gets gtt only, except when you need truly rapid lowering eg associated ICH or aortic dissection which gets stat pushes then gtt's. This is nearly slam dunk emergency to me. The fact they somehow havent leaked a trop with that is a borderline miracle. Hydralazine is bad medicine for this (and in general imo, but that's neither here nor there) and I'd correct a trainee that wanted to go that route. Tell pharmacy to get ****ed (politely).

 

[DocEspana]

Nope, in the exact same boat. Hypertensive urgency gets po meds even for "scary" numbers (up to some personal threshold where I'd chicken out and just put them on a gtt to ensure safety... Not sure exactly where that is but probably systolic 240ish.. No science and not really good medicine necessarily there, just... Chicken). Hypertensive emergency gets gtt only, except when you need truly rapid lowering eg associated ICH or aortic dissection which gets stat pushes then gtt's. This is nearly slam dunk emergency to me. The fact they somehow havent leaked a trop with that is a borderline miracle. Hydralazine is bad medicine for this (and in general imo, but that's neither here nor there) and I'd correct a trainee that wanted to go that route. Tell pharmacy to get ****ed (politely).

"please excise your cranium from your distal rectal vault. Thank you. Have a good day."

 

[bravotwozero]

It actually says verbatim in Rivers Board Review that 'treating asymptomatic hypertension with IV medications is a practice that should be condemned'. That part got burned into my brain lol.

The general public seems to have this idea that if your blood pressure goes up even for an instant, your head will explode into a million tiny pieces, you will stroke out and die.

Had a patient come in with asymptomatic HTN the other day. I treated with po meds and re-assured him. He came back with 'I'm a retired chemical engineer, and when the pressure in the pipes of my chemical plant was too high, the pipes would explode in a matter of minutes'. I wanted to tell him that our blood vessels are not like pipes, and every single person i've seen that suffered the sequelae of uncontrolled HTN did so after years of non compliance and uncontrolled blood pressure, but I felt like I was wasting my breath at that point...

 

[VA Hopeful Dr]

It actually says verbatim in Rivers Board Review that 'treating asymptomatic hypertension with IV medications is a practice that should be condemned'. That part got burned into my brain lol.

The general public seems to have this idea that if your blood pressure goes up even for an instant, your head will explode into a million tiny pieces, you will stroke out and die.

Had a patient come in with asymptomatic HTN the other day. I treated with po meds and re-assured him. He came back with 'I'm a retired chemical engineer, and when the pressure in the pipes of my chemical plant was too high, the pipes would explode in a matter of minutes'. I wanted to tell him that our blood vessels are not like pipes, and every single person i've seen that suffered the sequelae of uncontrolled HTN did so after years of non compliance and uncontrolled blood pressure, but I felt like I was wasting my breath at that point...

I hate engineers with high blood pressure

 

[turkeyjerky]

It actually says verbatim in Rivers Board Review that 'treating asymptomatic hypertension with IV medications is a practice that should be condemned'. That part got burned into my brain lol.

The general public seems to have this idea that if your blood pressure goes up even for an instant, your head will explode into a million tiny pieces, you will stroke out and die.

Had a patient come in with asymptomatic HTN the other day. I treated with po meds and re-assured him. He came back with 'I'm a retired chemical engineer, and when the pressure in the pipes of my chemical plant was too high, the pipes would explode in a matter of minutes'. I wanted to tell him that our blood vessels are not like pipes, and every single person i've seen that suffered the sequelae of uncontrolled HTN did so after years of non compliance and uncontrolled blood pressure, but I felt like I was wasting my breath at that point...

I actually preemptively incorporate something about how your head not exploding into my usual spiel about BP. Sometimes I'll also add in something about how "some people think if you're BP goes to high you'll *finger quotes* 'Stroke Out', but that's not actually a thing".

Could also retort that 250 mmHg is less than 5 psi...

 

[Vandalia]

He came back with 'I'm a retired chemical engineer, and when the pressure in the pipes of my chemical plant was too high, the pipes would explode in a matter of minutes'.

"Yes, but the piping system in your body was designed by a better engineer."

They can figure out for themselves later if that means God, millions of years of random heuristic design, or a combination of both.

 

[TwistedTea]

I find these patients are pretty easy to admit. Internists seem to be way more worried about hypertension than we are anyways. A lot of internist will admit someone for sufficiently high blood pressure even in the absence of ANY end organ dysfunction.

The unfortunate truth

 

[GeneralVeers]

The unfortunate truth

It's also fun when floor nurses refuse to accept a patient with a BP of 170/100 cuz "It's too high for the floor!". Never mind I'd have no problem sending a patient home with pressures higher than that.

 

[thegenius]

The general public seems to have this idea that if your blood pressure goes up even for an instant, your head will explode into a million tiny pieces, you will stroke out and die.

I wish it did. Maybe people would take better care of themselves. The threshold for head explosion is SBP > 200.

I blame patients AND PCPs for this one. There are more people these days buying automatic blood pressure cuffs recording their BP many times a day when they feel a little cramp or dizzy, and then come in when the cuff says 70/65. Or 162/149. I try to tell them those numbers are impossible and they don't believe me.

So I take their money and discharge them.

So stupid

 

[thegenius]

I would love to see a study showing that people's pertinent health care outcomes are improved over decades by taking a daily their blood pressure at home, vs getting it checked 1-2 times a year by their doc.

 

[DrDrummer]

For patients willing to listen and who can more or less follow this sort of thing, I like explaining to them the inferior nature of automated BP cuffs which only measure a MAP and then use a proprietary algorithm to determine the systolic/diastolic BP. Then I tell them their MAP is acceptable and is generally what matters and that the algorithm can be fooled by things like atrial fibrillation, any sort of valvular disease, or the "stiff, calcified arteries" like many of these worried patients have. Then I take their blood pressure by hand and they feel better when I tell them the manual cuff number is better. (It often is.)

You'd think this would take longer than checking labs and discharging, but it really doesn't and seems to result in better satisfaction than just telling them it's not an emergency and that they'll be fine.

 

[GeneralVeers]

For patients willing to listen and who can more or less follow this sort of thing, I like explaining to them the inferior nature of automated BP cuffs which only measure a MAP and then use a proprietary algorithm to determine the systolic/diastolic BP. Then I tell them their MAP is acceptable and is generally what matters and that the algorithm can be fooled by things like atrial fibrillation, any sort of valvular disease, or the "stiff, calcified arteries" like many of these worried patients have. Then I take their blood pressure by hand and they feel better when I tell them the manual cuff number is better. (It often is.)

You'd think this would take longer than checking labs and discharging, but it really doesn't and seems to result in better satisfaction than just telling them it's not an emergency and that they'll be fine.

That takes too much time. Just use the patient-satisfying, burnt-out doctor approach and give them a dose of hydralazine/clonidine followed by discharge an hour later after the numbers are "better". For bonus points send "labs" just to "make sure".

 

[RustedFox]

That takes too much time. Just use the patient-satisfying, burnt-out doctor approach and give them a dose of hydralazine/clonidine followed by discharge an hour later after the numbers are "better". For bonus points send "labs" just to "make sure".

So much this.
We're taught for 3-4 years in residency "don't order labs to not do anything about it."

Now, HCA runs residencies teaching the precise opposite.

 

[TwistedTea]

It's also fun when floor nurses refuse to accept a patient with a BP of 170/100 cuz "It's too high for the floor!". Never mind I'd have no problem sending a patient home with pressures higher than that.

But they’ll sTrOkE OuT

 

[wareagle726]

But it's Scroke levvelll!!!

 

[GeneralVeers]

Anyone else annoyed by nurses who get EKGs on patients with high blood pressure but no complaints?

 

[WheezyBaby]

Anyone else annoyed by nurses who get EKGs on patients with high blood pressure but no complaints?

If it makes you feel better, if it's "new diagnosis" they eventually needed the EKG anyway

 

[DocEspana]

It's also fun when floor nurses refuse to accept a patient with a BP of 170/100 cuz "It's too high for the floor!". Never mind I'd have no problem sending a patient home with pressures higher than that.

I remind my med students that this is a bastardization of a good policy. Hypertensive *emergencies* shouldn't be downgraded from the ICU until they are under 180/110 or whatever the recommendation is. Thats good policy, only because you want to get them to a point where they can reasonably be controlled with less labor-intensive methods and Id argue that is a point where po meds and iv meds that dont need titration become reasonable options. This is a good policy specific to those with documented end organ damage and trying to decide when those people get downgraded.

It became bastardized to any person above 180/110 needs to be in the ICU. Which.... the principle of hypertensive people who needed to be in the ICU for complications of htn can be downgraded below 180 systolic isnt reflexive. It doesnt work the other way. Hypertensive patients do not need to go to the ICU simply BECAUSE they are above it. But when every hospital is out there making the same ass-backwards policy everyone just leans back on 'we cant all have the same wrong policy'. Except... yes.... you could. Because you do. Its just a hospital policy thing and has nothing to do with actual science.

 

[DocEspana]

I would love to see a study showing that people's pertinent health care outcomes are improved over decades by taking a daily their blood pressure at home, vs getting it checked 1-2 times a year by their doc.

Last place I worked had a cardiologist who would tell his patients to give their BP cuffs to their neighbors because "you dont need to check your BP ever again. Thats my job. I'll look at it every 3 months until I'm confident I can look at it every 6 months or every year. You dont ever need to check it. But since you bought it, you can give it to your neighbor and they can check theirs. If they dont like the numbers THEY can come to me."

I liked his policy until the very end where he turns BP fears into a business-expanding model for him.

 

[DocEspana]

So much this.
We're taught for 3-4 years in residency "don't order labs to not do anything about it."

Now, HCA runs residencies teaching the precise opposite.

I work in a series nightmare scenario in this sense. 10 of us. 3 are old schoolers who cant resist ordering labs on everyone for everything because of that one anecdote of silent NSTEMI that was probably just a poor physical exam by them. and four out of the remaining six people I work with are HCA trained and order labs for everything because "you never know what treatable thing you'll find and we need to service the patient." They dont realize they are literally spewing out the HCA kool-aid that is overflowing from their body. They know the recommendation is essentially dont test/don't treat, but they believe everyone who registers is entitled to a labwork screening to 'see what is latent.' I end up fighting my own partners over asymptomatic htn management more than the nurses, since I've FLOODED this ED with literature on the matter and the nurses are receptive-ish. The doctors are stubborn and will bend themselves into pretzels to find a way to avoid acknowledging the data.

<facepalm through skull and out the back>

 

[WheezyBaby]

I remind my med students that this is a bastardization of a good policy. Hypertensive *emergencies* shouldn't be downgraded from the ICU until they are under 180/110 or whatever the recommendation is. Thats good policy, only because you want to get them to a point where they can reasonably be controlled with less labor-intensive methods and Id argue that is a point where po meds and iv meds that dont need titration become reasonable options. This is a good policy specific to those with documented end organ damage and trying to decide when those people get downgraded.

It became bastardized to any person above 180/110 needs to be in the ICU. Which.... the principle of hypertensive people who needed to be in the ICU for complications of htn can be downgraded below 180 systolic isnt reflexive. It doesnt work the other way. Hypertensive patients do not need to go to the ICU simply BECAUSE they are above it. But when every hospital is out there making the same ass-backwards policy everyone just leans back on 'we cant all have the same wrong policy'. Except... yes.... you could. Because you do. Its just a hospital policy thing and has nothing to do with actual science.

Hypertensive emergency regardless of the number -> gtt antihtn to goal 25% below peak presenting, resume po antihtn at any time (combination of po meds to be resumed dependent on what they are and the global picture of the patient) as long as otherwise OK for po, goal to not drop below 25% in first 24 hr, then titrated PO's to come off gtt if not already off and further to get to goal. There's no hard number I'd target for every patient outside again of something like dissection which case **** the autoregulatory curve and drop til normal

 

[DocEspana]

Hypertensive emergency regardless of the number -> gtt antihtn to goal 25% below peak presenting, resume po antihtn at any time (combination of po meds to be resumed dependent on what they are and the global picture of the patient) as long as otherwise OK for po, goal to not drop below 25% in first 24 hr, then titrated PO's to come off gtt if not already off and further to get to goal. There's no hard number I'd target for every patient outside again of something like dissection which case **** the autoregulatory curve and drop til normal

Wasn't talking about our management (which is approximate 25% drop in the acute setting). Talking about how the inpatient team looks at their recommendations. Namely JNC 7, recommending hitting <160/100 with "parenteral drugs" before switching to "gradual normalization." That second term isnt further clarified. Terms quoted because the only distinction JNC 7 spells out is parenteral above 160 and something different that.... isnt?... parenteral but would count as "gradual" after that. I think we all know how your average internist and/or intensivist reads that recommendation, and I think the JNC 7 wording selected was done extremely aware that the outcome would be exactly what it was, I dont think they're anticipating anyone reads that and gives small labetalol doses and calls that parenteral therapy.

My big point being: That recommendation has become bastardized into the bizarre need to send everyone above those values to the ICU. Its a reasonable (we can argue. but no point in doing so here) recommendation if you have HypeEmerg. Its a stupid misunderstanding of science to make it into a blanket hospital bed assignment rule to anyone with "red" numbers.