Hypertension is a medical condition commonly seen in the outpatient setting. Primary care providers should be aware that asymptomatic hypertension, despite the degree of elevation, is rarely an emergency. Based on consensus guidelines from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the lack of any evidence showing harm, extreme blood pressure elevations do not need acute treatment. This article provides evidence for the argument that hypertension is rarely an emergency at all; even patients who have exceedingly high blood pressure can be treated as outpatients.

Hypertension is a common medical condition seen in the outpatient setting. For the most part, evaluation and treatment of high blood pressure takes place in the office setting. Less commonly, patients require immediate transportation to an emergency department for the treatment of hypertensive urgency or emergency. In addition to meeting evidence-based goals for blood pressure targets, the primary care practitioner must recognize when a hypertensive emergency exists and when patients need to be sent to a higher level of care for blood pressure evaluation and acute treatment. Primary care providers also should be aware that asymptomatic hypertension, despite the degree of elevation, is rarely an emergency.

Common misconceptions among many physicians are that severely elevated blood pressure should be treated aggressively and that, despite lack of symptoms, extremes of hypertension must be dealt with on an emergency basis. Based on consensus guidelines from the seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) and lack of any evidence showing harm, extreme blood pressure elevations generally do not require acute treatment.

The purpose of the following discussion is to provide evidence for the argument that hypertension is rarely an emergency at all and that even a patient who has very high blood pressure can be treated as an outpatient without the need for transportation to an emergency department. The underlying assumption of this discussion is that these patients are truly asymptomatic without evidence of an underlying condition that could be exacerbated by the presence of severely elevated blood pressure (eg, a history of myocardial infarction, stroke, congestive heart failure). A detailed discussion of management of specific hypertensive emergencies is beyond the scope of this article.

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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

Larkin, K. T., and Zayfert, C.
Published with assistance from the foundation established in memory of Amasa Stone Mather of the Class of 1907, Yale College.