Last year, the American College of Cardiology (ACC)/American Heart Association (AHA) and several other organizations released a joint clinical practice guideline that addressed a wide set of issues related to prevention, detection, evaluation, and management of asymptomatic

hypertension in adults, including redefining the concept of “hypertensive urgency.”¹

“In the past we used this term ‘hypertensive urgency’ and primary care doctors, if they saw someone with a [blood pressure] BP of 180/120 or higher, would reflexively send them to the emergency department (ED),” said Joseph Miller, MD, MS, an emergency physician at Henry Ford Health in Detroit.

In fact, an older study showed that from 2006 to 2015, hypertension was the primary complaint in 0.6 percent of all ED visits—more than 6.2 million visits—whether referred from a physician or through self-referral.²

What was called hypertensive urgency is now referred to as severe hypertension and is defined as a BP >180/120 mm Hg without evidence of acute target organ damage.

“The ACC/AHA guideline has gotten rid of that term and encouraged that it be wiped from the medical lexicon,” Dr. Miller said. “And, fortunately, the number of referrals to the ED already appears to be dropping and will hopefully continue to drop.”

That is because the guideline recommends that these patients should not receive aggressive BP lowering in the short term or be given parenteral antihypertensive drug therapy. Instead, it calls for a reinstitution or intensification of oral antihypertensive medications, ideally in an outpatient setting.¹

However, according to Curt Dill, MD, associate professor of emergency medicine at Weill Cornell Medical College in New York, “there is often a disconnect between what should be done ideally, and what can be done in the real world.”

Complexities

Despite this update from the ACC/AHA, practice patterns for addressing asymptomatic hypertension vary in emergency medicine. In its 2013 Clinical Policy, ACEP did not recommend routine ED medical interventions for these patients, unless the patient had poor follow-up or was considered high risk.³ However, in an update published in 2025, ACEP amended this recommendation based on a more recent study that showed that initiating antihypertensive medications in the ED lowered BP in the short term without any increase in adverse events.^4,5 The guideline gives a Level C recommendation to consider the initiation of outpatient antihypertensive medications, with a referral for outpatient follow-up.

“The [ACC/AHA] guidelines are good, but in practice clinicians have to assess what kind of access each individual patient has to good general primary care—that is also a key driver,” Dr. Dill said. “Working in an urban environment, for example, most of the patients we see are not going to call their primary care doctor to see them in a week for a resting BP.”

There are situations where the clinician may have to vary from the strict guidelines, and that occurs on a gradient. For example, a homeless patient given a starter pack of 5 mg amlodipine may take the pills initially, Dr. Dill said, but when they run out, is done with treatment.

“Starting a short course of antihypertensives in someone without continuity of care or a safe place to store medications can create more risk than benefit,” Dr. Dill said. “In contrast, some patients can get an appointment with a primary care provider in a month or so, making a starter pack of antihypertensives a reasonable way to proceed.”

The ACC/AHA guideline also emphasized avoiding parenteral BP lowering therapy or intensified oral therapy in the acute setting in patients with no evidence of end-organ damage. In fact, a rapid decrease in BP in a patient whose brain’s blood supply has adjusted to chronically elevated levels can result in low blood flow and ischemic strokes.⁶

“Unfortunately, this still happens, even in places where people have been educated for years not to treat asymptomatic hypertension,” Dr. Miller said. “There is no proven benefit to doing so, and there is potential for harm.”

Dr. Miller emphasized if severe hypertension is identified in the ED, inpatient versus outpatient treatment depends on indications other than BP alone.

“If a patient comes in with severely elevated BP it is worth screening them to make sure, based on their symptoms or other findings, that they don’t have evidence of acute organ injury due to hypertension because that would push them into a category called hypertensive emergency,” Dr. Miller said.

Patients in hypertensive emergency require immediate reduction of BP to limit further organ damage.

There are situations where a hospital or health system has rules, written or unwritten, that impede that patient from being admitted because their BP is elevated.

“That used to be the case in our hospital,” Dr. Miller said. “It took years of re-education for inpatient nursing and physicians to understand that it is okay for patients to go up with those kinds of BPs, and that for us to artificially lower it in the ED is potentially harmful.”

According to Dr. Miller, pointing inpatient teams and medical directors to the recent ACC/AHA guidelines can facilitate culture change around these cases.

Ms. Lawrence is a freelance health writer and editor based in Delaware.

References

1. Writing Committee Members*, Jones DW, Ferdinand KC, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension. 2025;82(10):e212-e316.
2. Mullins PM, Levy PD, Mazer-Amirshahi M, Pines JM. National trends in U.S. emergency department visits for chief complaint of hypertension (2006-15). Am J Emerg Med. 2020;38(8):1652-1657.
3. Wolf SJ, Lo B, Shih RD, et al. American College of Emergency Physicians Clinical Policies Committee. Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013;62:59-68.
4. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Asymptomatic Hypertension, Gemme S, Meltzer AC, et al. Clinical Policy: A Critical Issue in the Outpatient Management of Adult Patients Presenting to the Emergency Department With Asymptomatic Elevated Blood Pressure: Approved by the ACEP Board of Directors January 22, 2025. Ann Emerg Med. 2025;86(1):e1-e11.
5. Brody A, Rahman T, Reed B, et al. Safety and efficacy of antihypertensive prescription at emergency department discharge. Acad Emerg Med. 2015;22(5):632-635.
6. Tryambake D, He J, Firbank MJ, et al. Intensive blood pressure lowering increases cerebral blood flow in older subjects with hypertension. Hypertension. 2013;61(6):1309-1315.