On January 22, 2025, the ACEP Board of Directors approved a clinical policy developed by the ACEP Clinical Policies Committee on the outpatient management of adult patients presenting to the emergency department (ED) with asymptomatic elevated blood pressure. This Clinical Policy was published in the July 2025 issue of the Annals of Emergency Medicine, can be found on ACEP’s website, and will be included in the ECRI Guidelines Trust, upon its acceptance.

Approximately half of adults in the United States (119.9 million) are affected by hypertension, but only an estimated 25 percent (27.0 million) have effectively controlled blood pressure. Hypertension, defined as blood pressure more than 130/80 mm Hg, is the primary risk factor for cardiovascular disease, and good blood pressure control reduces the likelihood of subsequent stroke and heart attack. There are more than six million ED visits annually in the United States for a primary chief complaint of hypertension, and of those patients, approximately 64 percent receive a primary diagnosis of hypertension.

Recognizing Asymptomatic Hypertension

Emergency physicians, in general, excel at identifying acute life-threatening emergencies such as stroke or myocardial infarction but have less experience with the long-term treatment for chronic illness such as asymptomatic hypertension. Wide variation in practice patterns exist among emergency physicians for the management of patients with asymptomatic increased blood pressure, despite the reliability of blood pressure measurements taken in the ED.

The benefits of starting or modifying blood pressure medications for asymptomatic high blood pressure in the ED may be countered by potential risks. For example, some emergency physicians believe that blood pressure treatment should be left to the primary care physician because of the need for long-term management and titration. Other emergency physicians believe that treating asymptomatic high blood pressure in the ED represents an opportunity to provide education and initiate treatment to a patient who does not have access to reliable outpatient care.

The 2013 ACEP Clinical Policy on asymptomatic hypertension does not recommend routine ED medical interventions for asymptomatic elevated blood pressure unless the patient had poor follow-up or the patient was part of a select high-risk patient population. This current ACEP Clinical Policy supplements the 2013 policy, which is in the process of revision, by incorporating new evidence with the aim of providing guidance for ED physicians to determine if initiation of antihypertensive medications is safe and effective at and/or prior to discharge from the ED.

A writing committee reviewed the eligible literature related to the critical question, a systematic review of the evidence was conducted, and the Clinical Policies Committee made recommendations (Level A, B, or C) based on the strength of evidence available. This Clinical Policy underwent internal and external expert review and was available for review by ACEP membership during an open comment period. Responses received were used to refine and enhance the final policy.

Critical Question

In adult ED patients being discharged with asymptomatic elevated blood pressure, is initiation of outpatient antihypertensive medications from the ED safe and effective?

Patient Management Recommendations

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations. Consider the initiation of outpatient antihypertensive medications for patients being discharged from the ED with asymptomatic elevated blood pressure.

Patients with asymptomatic elevated blood pressure should be referred for outpatient follow-up (Consensus recommendation).

More on ACEP’s Class of Evidence framework and Recommendation Levels can be found at https://www.acep.org/patient-care/clinical-policies.

Dr. Gemme is chair and associate professor of emergency medicine at the University of Massachusetts Chan Medical School – Baystate in Springfield, Mass. In addition to emergency medicine, Dr. Gemme’s passion includes writing and composing music, playing ice hockey, and spending time with his partner and two daughters.