Part of the problem in dealing with pertains who have severely uncontrolled hypertension pertains to standard, commonly used definitions. The definition of a hypertensive emergency is well accepted in the medical community and is defined as severely elevated blood pressure in the setting of acute, end-organ damage. What about hypertensive urgency? Traditionally, hypertensive urgencies were thought to exist when a patient, regardless of symptoms, had a blood pressure in excess of a diastolic of 115 mm Hg. Studies never have been performed that support this as a definition _[5]. In addition, reliance on the patient’s blood pressure alone never has been shown to be adequate as a screening tool for the presence or severity of end-organ dysfunction _[6].

By definition, patients who have hypertensive urgency should have their blood pressure reduced over 24 to 48 hours. The literature on this topic is relatively unhelpful, because no evidence-based recommendations are given on where to treat a patient and whether acute treatment is helpful, harmful, or even necessary. In a review article, Shayne and Pitts _[7] tackle this topic. They propose a newer category of hypertension, called “severely uncontrolled hypertension.” This definition is restricted to asymptomatic patients who have high blood pressure, regardless of the degree of elevation. The authors propose that the term “hypertensive urgency” be reserved for patients who have elevated blood pressure and a history of a cardiovascular event or known end-organ damage. Thus, an asymptomatic patient who has a history of a myocardial infarction and a blood pressure of 200/130 mm Hg would need to be treated differently than the same asymptomatic patient without any medical problems. Although the terminology proposed by Shayne and Pitts is not evidence-based, it makes intuitive sense and is less likely to lead to patient harm. Primary care providers must remember that hypertension terminology is poorly defined.

References

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Robert L. Rogers MD, FAAEM, FACEP, FACP and Robert S. Anderson, Jr. MD
Department of Emergency Medicine, The University of Maryland School of Medicine, 110 South Paca Street, Suite 200, 6th floor, Baltimore, MD 21201, USA
Department of Medicine, The University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA

Manuck, S. B., Kasprowicz, A. L., Monroe, S. M., Larkin, K. T., and Kaplan, J. R.
Published with assistance from the foundation established in memory of Amasa Stone Mather of the Class of 1907, Yale College.