Patients with systolic BP over 200 - How common is this?

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pithy84

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I'm currently applying to med school and I have been shadowing a Family Medicine doctor.

A 49 y/o male came in for his first doctor's visit in over 10 years. He looked totally normal and healthy, but BMI was maybe 28.

His blood pressure was 205 / 130 mmHg, roughly. The doctor took a few readings to see if it would go down as he remained seated and motionless, but it did not.

How common is this? I mean, I thought a systolic above 180 mmHg was considered an emergency. This guy got sent home with a scrip for chlorthalidone, advice to come back soon (which honestly wasn't worded that strongly), and also a prediction that he would need to have a second antihypertensive agent added at the next visit.

This guy had no symptoms at all. He came in because his wife was hounding him about his 50th birthday. The big Five-Oh. He's not immortal anymore.

How high does blood pressure get in people who are asymptomatic? Have you seen higher?

How high does blood pressure go during a cocaine or methamphetamine overdose? Or maybe a pheochromocytoma?
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Are these patients often characterized by really, really long necks? :laugh:
 
Highest I've seen was 210. It was abroad and they considered it an emergency, but the person left before they could be treated. Though as VA Hopeful said, I'd assume that if there's no end-organ damage you could send them home with meds, tell them to be conscious of any serious symptoms, and schedule a follow-up in the next few weeks to ensure the meds are working.
 
What I'm seeing is you being skeptical of the doc you are following. What you witnessed what excellent doctoring.

You see there is the pretend thing (that people who are 20 years behind the times) call hypertensive urgency. It's a blood pressure high enough to make a doctor nervous, but doesn't meet the definition of emergency. These often get sent to the ER or overly treated.

The treatment for elevated BP with no evidence of symptoms or end organ damage is to start an oral agent for BP control, typically chlorthalidone or lisinopril. Sounds like the FM doc you are with is really sharp and with the times. Stick with what he does for now!

As for how high can BP's get, there is an excellent chart of FDR's BP's during his presidency. https://theskepticalcardiologist.files.wordpress.com/2014/11/fdrbp.jpg

A lot of people get caught early because we check BP's so often now, but yes totally untreated hypertension can be >200 even >300.
 
And contrary to popular belief, hypertensive emergency is not systolic 180 and a headache or "I don't feel good". It's 180s+ symptoms of myocardial infarctions, aortic dissections, hypertensive encephalopathy, etc.
 
pkwraith said:
And contrary to popular belief, hypertensive emergency is not systolic 180 and a headache or "I don't feel good". It's 180s+ symptoms of myocardial infarctions, aortic dissections, hypertensive encephalopathy, etc.
Click to expand...

What would have to manifest for you as far as encephalopathy to admit from the ED if it's the sole possible organ dysfunction? First answer as perceived medical indication, then answer medicolegally. Medicolegally I'd have a hard time sending urgency range + headache/malaise home, but I haven't seen what id call frank hypertensive encephalopathy. Lots of soft admits for the vague sx though
 
metopic said:
What I'm seeing is you being skeptical of the doc you are following. What you witnessed what excellent doctoring.

You see there is the pretend thing (that people who are 20 years behind the times) call hypertensive urgency. It's a blood pressure high enough to make a doctor nervous, but doesn't meet the definition of emergency. These often get sent to the ER or overly treated.

The treatment for elevated BP with no evidence of symptoms or end organ damage is to start an oral agent for BP control, typically chlorthalidone or lisinopril. Sounds like the FM doc you are with is really sharp and with the times. Stick with what he does for now!

As for how high can BP's get, there is an excellent chart of FDR's BP's during his presidency. https://theskepticalcardiologist.files.wordpress.com/2014/11/fdrbp.jpg

A lot of people get caught early because we check BP's so often now, but yes totally untreated hypertension can be >200 even >300.
Click to expand...

The only thing I would have done differently is start two agents right away - and go looking for secondary causes.

People with BPs this high are rarely going to be controlled on one medication.
 
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Cytarabine said:
If it took a year to kill him, it's probably a rather good example of not being hypertensive emergency, no?
Click to expand...

certainly not the medical definition of emergency, didn't mean to imply otherwise.
 
dozitgetchahi said:
The only thing I would have done differently is start two agents right away - and go looking for secondary causes.

People with BPs this high are rarely going to be controlled on one medication.
Click to expand...

That would be a terrible idea. If you had a bad outcome, you'd be hosed in court. You'd have doc's lining up the block to say you deviated from the standard of care. If someone has a BP this high chronically, correcting it dramatically and rapidly is about the stupidest thing you can do. Good way to get an iatrogenic stroke, which I have seen done and never want to see again. Oh it just gives me the heebie jeebies thinking about it. Start with one pill, monitor, add more as needed.

And you really shouldn't be looking for secondary causes until therapy fails.

QualityProcess said:
not really a great example when his BP hit 180 systolic and he was dead a year later
Click to expand...

No it's a great example, you can slowly titrate non emergencies down not dropping them more than 20 systolic /24hr. If someone is going to die a year later if you do nothing by a year from now that's a great example of something that's not an emergency. And it's just a fun historical anecdote.
 
Cytarabine said:
What would have to manifest for you as far as encephalopathy to admit from the ED if it's the sole possible organ dysfunction? First answer as perceived medical indication, then answer medicolegally. Medicolegally I'd have a hard time sending urgency range + headache/malaise home, but I haven't seen what id call frank hypertensive encephalopathy. Lots of soft admits for the vague sx though
Click to expand...
I would argue there is a vast difference between a patient coming in to a doctor's office with vague complaints and a high BP, versus someone who felt bad enough they were willing to wait in an ED to be seen. The outpatient doc should be able to think instead of just react, and pick the patient where starting a med and having them come back for recheck with advice to go to the er if things worsen or specific symptoms occur is reasonable. And for the one this doesn't seem reasonable they should admit the patient (perhaps discussing things with their local hospitalist group if they don't actually admit people) rather than just sending them to the ED. The EM doc doesn't have the same options so of course will be forced to admit more.
 
metopic said:
That would be a terrible idea. If you had a bad outcome, you'd be hosed in court. You'd have doc's lining up the block to say you deviated from the standard of care.
Click to expand...

UptoDate: "Some experts initiate therapy with two drugs or a combination agent in such patients. The rationale is that most patients with a blood pressure ≥20/10 mmHg above goal will require two or more chronic antihypertensive agents to achieve the goal blood pressure [1,5,18,19]. If, in a previously untreated patient with severe asymptomatic hypertension, the goal is to lower the blood pressure over a period of days (rather than hours) and to use a combination of drugs that will be continued as long-term antihypertensive therapy, we would begin a long-acting dihydropyridine calcium channel blocker plus a long-acting ACE inhibitor/ARB. This choice is based upon the results of the ACCOMPLISH trial, which is discussed elsewhere. (See "Choice of drug therapy in primary (essential) hypertension", section on 'First-line combination therapy' and "Choice of drug therapy in primary (essential) hypertension", section on 'ACCOMPLISH trial'.)

It is unlikely that a combination of two long-acting drugs in modest doses will cause a rapid and dangerous reduction in the blood pressure. However, initiation of two agents simultaneously must be done with close blood pressure follow-up since the full effects of both agents may not occur for a few days and adverse consequences may ensue if the blood pressure is lowered too quickly. This is particularly true among patients with cerebrovascular disease in whom more cautious blood pressure reduction is generally warranted."
 
If it's chronic hypertension with no symptoms of end-organ damage, I send these people home from the ED. I don't do testing, and don't start anything. I advise that is what their PCP is for.

Routinely discharge BP of 250/140 to home every day of the week.
 
Super common. If it's not symptomatic, I'd start him on two blood pressure pills and check again in 2 weeks. Don't send him to the ED without symptoms, the ED will just hate you.

Two blood pressure pills is the standard of care, and will not get you sued.
 
pkwraith said:
And contrary to popular belief, hypertensive emergency is not systolic 180 and a headache or "I don't feel good". It's 180s+ symptoms of myocardial infarctions, aortic dissections, hypertensive encephalopathy, etc.
Click to expand...

Too true. My girlfriend had been having headaches for a couple of weeks. She wasn't sure if she was maybe getting a sinus infection, so she decided to get checked out. She wasn't able to get an appointment with her PCP that week, so I took her to the urgent care affiliated with the nearby hospital. Her pressures there were 180-190s/110-120s. They completely freaked out and insisted that we had to go to the emergency room right away. They started setting up ambulance transport to the ER (literally across the street!), but she insisted that she could walk, thanks.

In the ED, I overheard one of the nurses snarking about why didn't we go to the urgent care across the street instead of using the ED for primary care BS. I might have told her off just a little. After a few hours of sitting on a stretcher, she got an oral lisinopril. After a couple more hours, having still not died of stroke or MI, we were allowed to walk out with a script for 14 days of lisinopril, instructions to see her PCP in 1-2 weeks, and a big bill.

No advanced testing was done in the ED, nothing. Heck, they didn't even give her a tylenol for the headache. I get that the urgent care is limited in what they can address and BP issues fall outside that range... but it is still a shame that avoiding liability can so often mean doing the wrong thing in terms of providing efficient care.
 
Promethean said:
Too true. My girlfriend had been having headaches for a couple of weeks. She wasn't sure if she was maybe getting a sinus infection, so she decided to get checked out. She wasn't able to get an appointment with her PCP that week, so I took her to the urgent care affiliated with the nearby hospital. Her pressures there were 180-190s/110-120s. They completely freaked out and insisted that we had to go to the emergency room right away. They started setting up ambulance transport to the ER (literally across the street!), but she insisted that she could walk, thanks.

In the ED, I overheard one of the nurses snarking about why didn't we go to the urgent care across the street instead of using the ED for primary care BS. I might have told her off just a little. After a few hours of sitting on a stretcher, she got an oral lisinopril. After a couple more hours, having still not died of stroke or MI, we were allowed to walk out with a script for 14 days of lisinopril, instructions to see her PCP in 1-2 weeks, and a big bill.

No advanced testing was done in the ED, nothing. Heck, they didn't even give her a tylenol for the headache. I get that the urgent care is limited in what they can address and BP issues fall outside that range... but it is still a shame that avoiding liability can so often mean doing the wrong thing in terms of providing efficient care.
Click to expand...

What did you expect, a ct stroke study and an mri brain? If she turned out to have a head tumor and they "missed it" who would be sued? If your girlfriend stubbed her toe while walking across the street, who would be on the hook? I don't blame the urgent care at all
 
Psai said:
What did you expect, a ct stroke study and an mri brain? If she turned out to have a head tumor and they "missed it" who would be sued? If your girlfriend stubbed her toe while walking across the street, who would be on the hook? I don't blame the urgent care at all
Click to expand...

No, I wouldn't have expected a CT or an MRI. But since those weren't performed at the ED, that demonstrates that their reason for sending us across the street (to a separate building of the same hospital) was not because they couldn't do what was necessary. Rather, it was because they sought to dodge a perceived liability (when probably none existed anyway.) She was a stable, ambulatory patient with an incidental finding of high, but not critical, blood pressure. The standard of care for that really is just: "Here, take one of these every day and follow up with someone to see if it is helping." Are you actually saying that you think that patient is too high a liability for any clinic to manage?

It is true, if you turf every patient who actually seems to have a medical condition, you will surely save yourself from ever being sued. But at that point, why even pretend to be offering medical care in the first place?
 
You could have waited for the pcp appointment
Who did you see at the urgent care? a PA?
 
metopic said:
That would be a terrible idea. If you had a bad outcome, you'd be hosed in court. You'd have doc's lining up the block to say you deviated from the standard of care. If someone has a BP this high chronically, correcting it dramatically and rapidly is about the stupidest thing you can do. Good way to get an iatrogenic stroke, which I have seen done and never want to see again. Oh it just gives me the heebie jeebies thinking about it. Start with one pill, monitor, add more as needed.
Click to expand...

Actually, 2 drugs are the standard of care with SBP above 160. And it has been the recommendations for the last 20 years as well... In JNC VII, VIII and recommended by ACC/AHA. If you're really worried about it give 2 scripts, have them start the first when they get home and the second a few days later.

And a 49 year old shouldn't have a BP in the 200s- especially with a BMI of 28. Looking for secondary causes, especially before you're going to F your lab readings up by putting him on meds, is probably not so bad of an idea.
 
Promethean said:
Too true. My girlfriend had been having headaches for a couple of weeks. She wasn't sure if she was maybe getting a sinus infection, so she decided to get checked out. She wasn't able to get an appointment with her PCP that week, so I took her to the urgent care affiliated with the nearby hospital. Her pressures there were 180-190s/110-120s. They completely freaked out and insisted that we had to go to the emergency room right away. They started setting up ambulance transport to the ER (literally across the street!), but she insisted that she could walk, thanks.

In the ED, I overheard one of the nurses snarking about why didn't we go to the urgent care across the street instead of using the ED for primary care BS. I might have told her off just a little. After a few hours of sitting on a stretcher, she got an oral lisinopril. After a couple more hours, having still not died of stroke or MI, we were allowed to walk out with a script for 14 days of lisinopril, instructions to see her PCP in 1-2 weeks, and a big bill.

No advanced testing was done in the ED, nothing. Heck, they didn't even give her a tylenol for the headache. I get that the urgent care is limited in what they can address and BP issues fall outside that range... but it is still a shame that avoiding liability can so often mean doing the wrong thing in terms of providing efficient care.
Click to expand...

its cause the ED has no experience in this particular area. they probably would not know where to begin if you were looking for them to work up secondary causes of HTN... and there is nothing wrong with that. their purpose is different.
 
pithy84 said:
I'm currently applying to med school and I have been shadowing a Family Medicine doctor.

A 49 y/o male came in for his first doctor's visit in over 10 years. He looked totally normal and healthy, but BMI was maybe 28.

His blood pressure was 205 / 130 mmHg, roughly. The doctor took a few readings to see if it would go down as he remained seated and motionless, but it did not.

How common is this? I mean, I thought a systolic above 180 mmHg was considered an emergency. This guy got sent home with a scrip for chlorthalidone, advice to come back soon (which honestly wasn't worded that strongly), and also a prediction that he would need to have a second antihypertensive agent added at the next visit.

This guy had no symptoms at all. He came in because his wife was hounding him about his 50th birthday. The big Five-Oh. He's not immortal anymore.

How high does blood pressure get in people who are asymptomatic? Have you seen higher?

How high does blood pressure go during a cocaine or methamphetamine overdose? Or maybe a pheochromocytoma?
Click to expand...


i currently work in the ED a scribe. What you're saying is right. Over 180 is an emergency. They would usually try to give some meds like the doctor you're speaking about did. But It's mostly urgency not necessarily emergency. It becomes emergency when the patient has sxs like HA or chest pain then they will admit you eventually to make sure everything is fine and bring it down eventually. A lot of people walk around with high BP and dont even know it. Which is why it's called the silent killer... The unlucky ones end up in PRESS which is no bueno,


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Psai said:
You could have waited for the pcp appointment
Who did you see at the urgent care? a PA?
Click to expand...

You are right. In hindsight, we should have waited for the PCP appointment. But, when you are the patient/family member, and a physician is telling you that you have a problem you didn't expect, and that you need to go to the ED right away... it is really hard not to take that advice, even if you think it is maybe an over-reaction. I hope you never have to find that out first hand.

No, it wasn't a PA. It would be comforting, wouldn't it, if you could just assign the blame for turfing to a midlevel? But no, it was an physician, who presumably was no less adequately trained to prescribe lisinopril and d/c to home than the ED physician.
 
varens1 said:
i currently work in the ED a scribe. What you're saying is right. Over 180 is an emergency. They would usually try to give some meds like the doctor you're speaking about did. But It's mostly urgency not necessarily emergency. It becomes emergency when the patient has sxs like HA or chest pain then they will admit you eventually to make sure everything is fine and bring it down eventually. A lot of people walk around with high BP and dont even know it. Which is why it's called the silent killer... The unlucky ones end up in PRESS which is no bueno,


Sent from my iPhone using SDN mobile
Click to expand...

As previously mentioned, simply being over 180mmHg is not an emergency...

pkwraith said:
And contrary to popular belief, hypertensive emergency is not systolic 180 and a headache or "I don't feel good". It's 180s+ symptoms of myocardial infarctions, aortic dissections, hypertensive encephalopathy, etc.
Click to expand...
 
varens1 said:
i currently work in the ED a scribe. What you're saying is right. Over 180 is an emergency. They would usually try to give some meds like the doctor you're speaking about did. But It's mostly urgency not necessarily emergency. It becomes emergency when the patient has sxs like HA or chest pain then they will admit you eventually to make sure everything is fine and bring it down eventually. A lot of people walk around with high BP and dont even know it. Which is why it's called the silent killer... The unlucky ones end up in PRESS which is no bueno,


Sent from my iPhone using SDN mobile
Click to expand...

Headache or chest pain do not suddenly make high blood pressure an emergency. The sheer volume of people who come into the ER with chest pain or headache or hypertension make it very likely that there is going to be many people coming in with chestpain and hypertension or headache/hypertension. There needs to be end organ damage not just symptoms which could be seen in those with end organ damage.

Also it's PRES not PRESS.
 
dpmd said:
I would argue there is a vast difference between a patient coming in to a doctor's office with vague complaints and a high BP, versus someone who felt bad enough they were willing to wait in an ED to be seen. The outpatient doc should be able to think instead of just react, and pick the patient where starting a med and having them come back for recheck with advice to go to the er if things worsen or specific symptoms occur is reasonable. And for the one this doesn't seem reasonable they should admit the patient (perhaps discussing things with their local hospitalist group if they don't actually admit people) rather than just sending them to the ED. The EM doc doesn't have the same options so of course will be forced to admit more.
Click to expand...

That's a good point and one that didn't come to mind. My clinical years were extremely inpatient geared so I'm kind of stuck in that mindset
 
Instatewaiter said:
Headache or chest pain do not suddenly make high blood pressure an emergency. The sheer volume of people who come into the ER with chest pain or headache or hypertension make it very likely that there is going to be many people coming in with chestpain and hypertension or headache/hypertension. There needs to be end organ damage not just symptoms which could be seen in those with end organ damage.

Also it's PRES not PRESS.
Click to expand...
Point being you knew what I was talking about despite the extra "S" which is far enough for me.


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Did that FM doc make the right call? What is the consensus here?

Based on how high that BP was, I think the doc should have used a dCCB or an ACE-I instead of a thiazide-like diuretic. If the individual in question is an AA, I could see why the doc used chlorthalidone.
 
W19 said:
Did that FM doc make the right call? What is the consensus here?

Based on how high that BP was, I think the doc should have used a dCCB or an ACE-I instead of a thiazide-like diuretic. If the individual in question is an AA, I could see why the doc used chlorthalidone.
Click to expand...
Guidelines, in a non-AA patient without CKD or DM, make no distinction between a thiazide, an ACE/ARB, or a CCB. The only place the physician mentioned in the OP went against guidelines is that in stage II HTN, the patient should have been started on two agents, not one.
 
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I wonder why OP didn't ask the physician its reasoning behind using only one agent instead of two.... Most physicians I have interacted with like to teach... and would probably use a moment to explain it to OP.

Someone above mentioned that we should also be concerned about causing iatrogenic stroke when starting this patient on 2 agents concomitantly; I did not think of that, but I think it's a valid concern. However, if the guidelines say it's ok, I guess it is.
 
Last edited:
W19 said:
I wonder why OP didn't ask the physician its reasoning behind using only one agent instead of two.... Most physicians I have interacted with like to teach... and would probably uses a moment to explain it to OP.

Someone above mentioned that we should also be concerned about causing iatrogenic stroke when starting this patient on 2 agents concomitantly; I did not think of that, but I think it's a valid concern. However, if the guidelines say it's ok, I guess it is.
Click to expand...

Pardon my dimness, but I don't understand the mechanism that would bring about a stroke just based upon starting two antihypertensive agents at once. Illuminate?
 
W19 said:
global cerebral ischemia due to dangerously low BP
Click to expand...
I think it doesn't even need to get super low, just lower than what the brain was used to (so if they have bad carotids that the higher pressure was getting enough through but a normal pressure doesn't then they could stroke with a normal pressure)
 
dpmd said:
I think it doesn't even need to get super low, just lower than what the brain was used to (so if they have bad carotids that the higher pressure was getting enough through but a normal pressure doesn't then they could stroke with a normal pressure)
Click to expand...

Just to elaborate a bit because it's an important point. The carotids are designed to maintain consistent cerebral blood flow across a range of pressures. Outside that range you lose the regulation and can either get ischemic or intracranial hypertension.

B978143771369500051X_f042-02-97814377136951.jpg


Chronic hypertension shifts the cerebral autoregulatory curve. That's why recommendations are to not drop BP more than xyz per unit time (don't remember the numbers offhand). Over time as you lower pressure, you correct the autoregulatory curve as well
 
Cytarabine said:
Just to elaborate a bit because it's an important point. The carotids are designed to maintain consistent cerebral blood flow across a range of pressures. Outside that range you lose the regulation and can either get ischemic or intracranial hypertension.

B978143771369500051X_f042-02-97814377136951.jpg


Chronic hypertension shifts the cerebral autoregulatory curve. That's why recommendations are to not drop BP more than xyz per unit time (don't remember the numbers offhand). Over time as you lower pressure, you correct the autoregulatory curve as well
Click to expand...
Recommendation (assuming you don't have something like an aortic dissection or head bleed already happening) is not to drop BP by more than 25% per day to give the autoregulation time to adjust.

Even starting 2 oral agents at typical starting dose won't work that quickly. Unless one of them happens to be clonidine or minoxidil (which aren't recommended for this purpose anyway). Or (as all the guidelines like to point out) sublingual nifedipine, which I've never actually heard of someone using. It takes a few days for the usual CCB/ACEI/ARB to be at full effectiveness.
 
Blood pressure. Oy.

They vary - some with stress, some with being measured, some with being in the ED.

Asymptomatic hypertension - "Doc, my BP is 220/110" no chest pain, no shortness of breath, no end organ damage on HPI - does NOT need a workup. It needs gradual reduction and OP workup. BP elevation without symptoms is common. We need to stop freaking out, and by we, I mean all primary care. It also includes ER docs (some ER docs still treat with clonidine to get a "happy" BP. Is an elevated BP an emergency? Read the EM literature and recommendations. If there are no symptoms, the patient has acclimated to high BP - as mentioned, dropping the BP precipitously will lead to stroke.

Symptoms of high BP in the context of abnormal vital signs, abnormal mentation should be referred to an ER. Don't treat a number.

Again, DON'T TREAT A NUMBER, treat your patient. A patient with elevated BP and chest pain needs the ER. A patient with elevated BP and no symptoms needs a good primary doc.
 
Cytarabine said:
What would have to manifest for you as far as encephalopathy to admit from the ED if it's the sole possible organ dysfunction? First answer as perceived medical indication, then answer medicolegally. Medicolegally I'd have a hard time sending urgency range + headache/malaise home, but I haven't seen what id call frank hypertensive encephalopathy. Lots of soft admits for the vague sx though
Click to expand...
Encephalopathy is...encephalopathy.


Headache is not caused by HTN unless the spontaneous ICH train has left the station, and that's unlikely to manifest as just a bit of headache.
 
dpmd said:
I would argue there is a vast difference between a patient coming in to a doctor's office with vague complaints and a high BP, versus someone who felt bad enough they were willing to wait in an ED to be seen. The outpatient doc should be able to think instead of just react, and pick the patient where starting a med and having them come back for recheck with advice to go to the er if things worsen or specific symptoms occur is reasonable. And for the one this doesn't seem reasonable they should admit the patient (perhaps discussing things with their local hospitalist group if they don't actually admit people) rather than just sending them to the ED. The EM doc doesn't have the same options so of course will be forced to admit more.
Click to expand...

We send these home from the ED all the time.

Asymptomatic? Don't go fishing for trouble (I.e. don't identify the elevated troponin because it makes the chart look dirty). Home with lisinopril 10 mg 2 week supply / amlodipine / HCTZ and primary care follow-up.
 
Raryn said:
Super common. If it's not symptomatic, I'd start him on two blood pressure pills and check again in 2 weeks. Don't send him to the ED without symptoms, the ED will just hate you.

Two blood pressure pills is the standard of care, and will not get you sued.
Click to expand...
We won't hate, we'll just turf right back *random smiley face*
 
TooMuchResearch said:
We send these home from the ED all the time.

Asymptomatic? Don't go fishing for trouble (I.e. don't identify the elevated troponin because it makes the chart look dirty). Home with lisinopril 10 mg 2 week supply / amlodipine / HCTZ and primary care follow-up.
Click to expand...
I am thinking more of the vague symptom person (hoping there aren't a lot of I feel fine but my doc said to go to the er because my home bp monitor showed a high number-but maybe I am overly optimistic. Not necessarily that they need to be admitted, but I understand why they would be in that setting.
 
The research is actually sparse and not real clear.

Pg 63
"Since 2005, a limited number of studies have been published directly addressing appropriate indications for medical treatment of asymptomatic markedly elevated blood pressure in the ED."

http://www.annemergmed.com/article/S0196-0644(13)00445-9/pdf

I agree that dropping the bp precipitously could cause a stroke. That's med school 101. However, not treating 220/110 could also put the patient at risk for a hemorrhagic stroke. You cannot just assume that since the patient is asymptomatic during your exam that he/she will remain unaffected. More than likely the patient will be fine before seeing their pcp, but maybe not. If you discharge them from the ED on Friday and they stroke out on Saturday, that's an issue. An attorney will then look at your plan for this very elevated bp and it would basically read "no treatment, f/u with pcp". Not good. Those are two of the main reasons why some choose to treat.

If anyone has any distinct guideline or schematics post them.
 
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