Asymptomatic Hypertension
CHAD S. KESSLER, MD, and YAZEN JOUDEH, MD, University of Illinois at Chicago College of Medicine, Chicago, Illinois
Poorly controlled hypertension is a common finding in the outpatient setting. When patients
present with severely elevated blood pressure (i.e., systolic blood pressure of 180 mm Hg or
greater, or diastolic blood pressure of 110 mm Hg or greater), physicians need to differentiate
hypertensive emergency from severely elevated blood pressure without signs or symptoms of
end-organ damage (severe asymptomatic hypertension). Most patients who are asymptomatic
but have poorly controlled hypertension do not have acute end-organ damage and, therefore,
do not require immediate workup or treatment (within 24 hours). However, physicians should
confirm blood pressure readings and appropriately classify the hypertensive state. A cardiovas-
cular risk profile is important in guiding the treatment of severe asymptomatic hypertension;
higher risk patients may benefit from more urgent and aggressive evaluation and treatment.
Oral agents may be initiated before discharge, but intravenous medications and fast-acting oral
agents should be reserved for true hypertensive emergencies. High blood pressure should be
treated gradually. Appropriate, repeated follow-up over weeks to months is needed to reach
desired blood pressure goals. (Am Fam Physician. 2010;81(4):470-476. Copyright 2010
American Academy of Family Physicians.)
A
pproximately one third of adults in stage 1 hypertension as 140 to 159 systolic or
the United States have some degree 90 to 99 diastolic; and stage 2 hypertension
of hypertension,1-3 and up to 5 per- as 160 or greater systolic, or 100 or greater
cent of patients presenting to the diastolic.6 However, there is no universal
emergency department have severely elevated terminology to describe severe stages of
blood pressure.4 In one study, about one hypertension.7
fourth of patients presenting with diastolic For this article, we define severely elevated
blood pressure of 110 mm Hg or greater were blood pressure as 180 mm Hg or greater sys-
unaware of their hypertension, including tolic, or 110 mm Hg or greater diastolic.8
28 percent of those with severe asymptomatic Severely elevated blood pressure can be
hypertension and 8 percent of those with a classified as severe asymptomatic hyperten-
hypertensive emergency.5 There are few pro- sion or hypertensive emergency.9-11 Severe
spective, randomized controlled trials on the asymptomatic hypertension is defined as
treatment of severe asymptomatic hyperten- severely elevated blood pressure without
sion. Physicians should not expect to reduce signs or symptoms of end-organ damage.
blood pressure to desired levels before dis- Hypertensive emergency (sometimes called
charge. Instead, gradual reduction is achieved hypertensive crisis12) is the point when signs
over time with repeated follow-up visits. or symptoms of end-organ damage occur.
Although hypertensive emergency is usu-
Definitions ally associated with diastolic blood pressure
The Seventh Report of the Joint National greater than 120 mm Hg (except in children
Committee on the Prevention, Detection, and pregnant women),5,13 it can occur at any
Evaluation, and Treatment of High Blood hypertensive level.
Pressure (JNC 7) defines normal blood pres- Severe asymptomatic hypertension can be
sure as less than 120 mm Hg systolic or less further classified as hypertensive urgency
than 80 mm Hg diastolic; prehypertension or severe uncontrolled hypertension, based
as 120 to 139 systolic or 80 to 89 diastolic; on the patients medical history and global
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Severe Asymptomatic Hypertension
Evidence
Clinical recommendation rating References
February 15, 2010 Volume 81, Number 4 www.aafp.org/afp American Family Physician 471
Cerebral Autoregulation
Normal
Chronic hypertension
60 mm Hg 120 mm Hg 160 mm Hg
Mean arterial pressure
Figure 2. Cerebral blood flow is tightly regulated within a certain range of mean arterial pres-
sure (solid line). With chronic hypertension, cerebral autoregulation undergoes a rightward
shift (dotted line). Abruptly decreasing the mean arterial pressure can potentially lead to a
significant drop in cerebral blood flow and, thus, cerebral ischemia.
Adapted with permission from Varon J, Marik PE. Clinical review: the management of hypertensive crises. Crit Care.
2003;7(5):374.
472 American Family Physician www.aafp.org/afp Volume 81, Number 4 February 15, 2010
Severe Asymptomatic Hypertension
February 15, 2010 Volume 81, Number 4 www.aafp.org/afp American Family Physician 473
Severe Asymptomatic Hypertension
More extensive testing for secondary causes difference between the two treatment groups
is not generally indicated, unless the clinical was greatest. Of note, the difference in
or laboratory evaluation strongly suggests an adverse cardiovascular events between the
identifiable cause or blood pressure control two groups decreased as blood pressure con-
has been refractory despite multiple treat- trol became more similar.
ments over time.6 In the absence of other Although there is no evidence that treat-
signs of central nervous system dysfunction, ing poorly controlled hypertension within
an isolated, nonspecific headache has not hours or days is beneficial, the VALUE find-
been shown to be a risk factor for end-organ ings suggest that blood pressure goals should
central nervous system damage; therefore, be reached within a relatively short time
imaging is generally not recommended.8 (certainly within six months), at least in
patients at high cardiovascular risk. Thus,
Treatment a loading dose of an antihypertensive in the
Rapidly lowering blood pressure in the emer- physicians office or emergency department
gency department is usually unnecessary in is generally not warranted, and most patients
asymptomatic patients and may be harm- only need a maintenance dose with follow-up
ful.6,17 There are no controlled studies dem- after a few days. True hypertensive emergen-
onstrating long-term improved outcomes cies require admission to an intensive care
with acute treatment of severe asymptomatic unit and immediate treatment within one
hypertension. Severely elevated blood pres- to two hours. Even in the emergent setting,
sure likely does not develop abruptly, but blood pressure should not be acutely lowered
rather over days, weeks, or months. Aggres- because of the risk of hypoperfusion.
sive dosing with intravenous medications or
fast-acting oral agents, such as nifedipine Follow-up and Monitoring
(Procardia) or hydralazine, can lead to hypo- Recommendations for treatment and fol-
tension. Reducing severely elevated blood low-up of patients with severe asymptomatic
pressure below the autoregulatory zone too hypertension are shown in Table 3.8,12,15,22,23
quickly can result in markedly decreased Outpatient treatment is generally acceptable,
perfusion to the brain and eventually isch- with appropriate follow-up. If it is unclear
emia or infarction. whether the patient will comply with follow-
An early trial including 143 patients with up, a short hospital stay may be needed.
a diastolic blood pressure between 115 and Initiating treatment for asymptomatic
129 mm Hg compared hydrochlorothiazide, hypertension is optional with appropriate
reserpine, and hydralazine therapy with no follow-up. Previously treated patients usu-
treatment.20 No adverse events occurred in ally need adjustments in their long-term oral
the untreated group within the first three antihypertensive therapy, particularly the
months. Another study evaluated the ben- use of combination drugs, or reinstitution of
efit of initiating a loading dose of oral medi- medications if they have been nonadherent.6
cation before discharge in patients with If the patient has no history of hypertension,
severely elevated blood pressure.9 There was elevated blood pressure should be confirmed
no significant difference among groups in at a follow-up visit. However, a patient with
the degree of blood pressure improvement at severe asymptomatic hypertension can be
24 hours and one week. expected to have some degree of hyperten-
The VALUE (Valsartan Antihypertensive sion at follow-up. In one study, more than
Long-term Use Evaluation) trial compared one half of emergency department patients
valsartan (Diovan) with amlodipine (Nor- with two increased blood pressure readings
vasc) to determine their effects on cardio- and no history of hypertension met the defi-
vascular outcome in high-risk patients with nition of hypertension the following week
hypertension.21 Many of the cardiovascular based on home blood pressure monitoring.24
events occurred within the first six months If a maintenance dose of an oral antihy-
of treatment, when the blood pressure pertensive is initiated, the patient may be
474 American Family Physician www.aafp.org/afp Volume 81, Number 4 February 15, 2010
Severe Asymptomatic Hypertension
Type of severe
asymptomatic
hypertension Recommendations
NOTE: Severe asymptomatic hypertension is defined as SBP of 180 mm Hg or greater, or DBP of 110 mm Hg or greater
in a patient without signs or symptoms of end-organ damage.
DBP = diastolic blood pressure; SBP = systolic blood pressure.
*Presence of risk factors for progressive end-organ damage.
Absence of risk factors for progressive end-organ damage.
Information from references 8, 12, 15, 22, and 23.
sent home without waiting for normalization Author disclosure: Nothing to disclose.
of blood pressure. However, it is imperative
to educate patients about the importance of REFERENCES
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risks of uncontrolled hypertension. Over sociodemographic and cardiovascular health char-
acteristics of U.S. hypertensives. Am J Hypertens.
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of medications may be modified to achieve 2. Hajjar I, Kotchen JM, Kotchen TA. Hypertension: trends
desired goals. in prevalence, incidence, and control. Annu Rev Public
Health. 2006;27:465-490.
3. Ong KL, Cheung BM, Man YB, Lau CP, Lam KS. Preva-
The Authors lence, awareness, treatment, and control of hyper-
tension among United States adults 1999-2004.
CHAD S. KESSLER, MD, FACEP, is an assistant professor of Hypertension. 2007;49(1):69-75.
medicine at the University of Illinois at Chicago College of
4. Karras DJ, Wald DA, Harrigan RA, et al. 2001 SAEM
Medicine, and is associate program director of the univer-
annual meeting abstracts. Elevated blood pressure in an
sitys Internal Medicine/Emergency Medicine Residency urban emergency department: prevalence and patient
Program. He is also director of emergency medicine at the characteristics. Acad Emerg Med. 2001;8(5):559.
Jesse Brown Veterans Affairs Medical Center in Chicago.
5. Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P.
YAZEN JOUDEH, MD, is a fourth-year resident in the Medi- Hypertensive urgencies and emergencies. Preva-
cine/Pediatrics Residency Program at the University of Illi- lence and clinical presentation. Hypertension. 1996;
nois at Chicago College of Medicine. 27(1):144-147.
6. Chobanian AV, Bakris GL, Black HR, et al., for the
Address correspondence to Chad S. Kessler, MD, FACEP, National Heart, Lung, and Blood Institute Joint National
Jesse Brown VA Hospital, 820 S. Damen Ave., M/C 111 Committee on Prevention, Detection, Evaluation, and
Emergency Medicine, Chicago, IL 60612 (e-mail: chad. Treatment of High Blood Pressure; National High Blood
kessler@va.gov). Reprints are not available from the Pressure Education Program Coordinating Committee.
authors. The Seventh Report of the Joint National Committee
February 15, 2010 Volume 81, Number 4 www.aafp.org/afp American Family Physician 475
Severe Asymptomatic Hypertension
476 American Family Physician www.aafp.org/afp Volume 81, Number 4 February 15, 2010