In the July issue of the Annals of Emergency Medicine, ACEP published a clinical policy focusing on critical issues in the emergency department evaluation and management of adult patients with asymptomatic elevated blood pressure. This is a revision of a clinical policy on asymptomatic hypertension that was published in 2006.

This clinical policy can also be found on ACEP’s website, www.acep.org, and has been accepted for inclusion on the National Guideline Clearinghouse website, www.guidelines.gov.

This clinical policy takes an evidence-based approach to answering two frequently encountered questions related to emergency department decision making.

Recommendations (Level A, B, or C) for patient management are provided based on the strength of evidence using the Clinical Policies Committee’s well-established methodology:

• Level A recommendations represent patient management principles that reflect a high degree of clinical certainty;
• Level B recommendations represent patient management principles that reflect moderate clinical certainty;
• Level C recommendations represent other patient management strategies based on Class III studies, or in the absence of any adequate published literature, based on consensus of the members of the ACEP Clinical Policies Committee.

During development, this clinical policy was reviewed and expert review comments were received from emergency physicians, family physicians, cardiologists, nephrologists, and individual members of the American Academy of Family Physicians, the American Heart Association Council for High Blood Pressure Research, the American Society of Nephrology, and the Emergency Nurses Association. Their responses were used to further refine and enhance this policy; however, their responses do not imply endorsement of this clinical policy.

Hypertension is a highly prevalent condition worldwide, carrying significant risk for cardiovascular, renal, and neurologic morbidity and mortality. Markedly elevated blood pressure can result in acute target organ injury (e.g. cardiovascular, renal, or neurologic) if left untreated over time. Acutely, when these complications are clinically apparent, evaluation and treatment of the elevated blood pressure is often initiated expeditiously. However, commonly, emergency department patients are found to have markedly elevated blood pressure in the absence of clinical signs or symptoms of acute target organ injury. In this latter situation recommendations for evaluation, treatment, and follow-up are less clear for emergency physicians. This ACEP policy focuses on patients with asymptomatic elevated blood pressure by reviewing the literature and making evidence-based recommendations relevant to the care of these patients in the emergency department.

Question 1: In ED patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce rates of adverse outcomes?