A Best Practice from the College of Urgent Care Medicine

^{Date Reviewed}

^{February 28, 2024}

^Subject

^{Diagnosis and Initial Treatment of Hypertension in Urgent Care}

^{Patient Population}

^{Otherwise healthy, asymptomatic, nonpregnant adults}

^Rationale

^{Hypertension can have major health consequences and may often go undiagnosed and untreated. As a chronic health issue, ongoing management of hypertension (HTN) is usually managed by primary care clinicians, cardiologists, nephrologists and other specialists. Many patients’ most frequent access to healthcare, however, is through Urgent Care (UC), and the diagnosis of HTN and lack of treatment may be apparent in this setting. Also, the “silent” nature of HTN as a risk factor, and less ready access to primary or specialty care may impede patient follow-up for this issue subsequent to an UC visit. High-quality guidance exists to enable UC clinicians to diagnose and begin treatment for this disease, thereby reducing morbidity and mortality for the patient.}  

^Introduction

^{HTN is a major risk factor for myocardial infarction, stroke, and heart and kidney failure. Even small reductions in blood pressure benefit patients. Diagnosis is based on multiple elevated blood pressure (BP) readings over time, which may be apparent in the UC setting. The College of Urgent Care Medicine has previously created a Best Practice Summary for the Management of Asymptomatic Elevated Blood Pressure1, emphasizing confirming elevated BP levels and reasonable time intervals for referrals to primary care. Once HTN is diagnosed in otherwise healthy adults, initiation of treatment is relatively straightforward and does not require additional testing beyond vital signs and, at most, basic lab work. Though ongoing follow-up and optimized HTN management may take more time and be better performed in primary care, many patients access healthcare more readily in UC, and the initial treatment for HTN can be within the purview of the acute care clinician. Such treatment could be expected to improve long-term health outcomes for patients. This Best Practice Summary provides evidence- and guideline-based interventions for those UC clinicians and practices desiring to begin such treatment for these patients.}

^{The management of elevated BP in patients with significant or multiple comorbidities and with resistant HTN typically requires specialty care and referral. Hypertension is considered resistant when 4 or more medications at optimal doses are required to achieve a goal/target BP, or blood pressure continues to be above goal/target with the patient taking 3 or more medications at optimal doses.} 

^{Evidence based guideline with strength of evidence}

^{A multi-specialty conjoint clinical practice guideline2 was published in 2017 summarizing the best evidence for the treatment of HTN. Recommendations were comprehensive and most recommendations were strong, though level or quality of evidence varied based on the recommendation.}  

^{A practical review3 published in 2022 analyzed data published after the conjoint guideline to provide a more recent high-quality summary of evidence to inform practice.} 

^{The American Academy of Family Physicians (AAFP) published clinical practice guidelines4 specifically with respect to BP target range, recommending slightly higher-goal blood pressures than the other two references. An earlier Cochrane Review5 supported the AAFP BP target ranges, finding that benefits do not outweigh potential harms with any more aggressive BP target than recommended by AAFP.}

^Discussion

^{The information in this Best Practice Summary applies to asymptomatic adults. Patients who present to Urgent Care with any level of elevated blood pressure and symptoms worrisome for acute end-organ changes, including focal neurological symptoms or signs, shortness of breath, chest discomfort or equivalents, dark urine, etc., should be safely referred and transported to the emergency department in most cases. Also, the evaluation and treatment of elevated blood pressures in children and in pregnant patients should follow different guidance than explained here.} 

^{This Best Practice Guideline should not be construed to create an obligation for UC clinicians to treat patients with hypertension but rather to provide evidence- and guideline-based interventions for those clinicians and practices which desire to do so. In situations where elevated blood pressures are found in patients without acute-end organ effects, evidence-based recommendations1 do allow for an acute-care specialist referral to primary care with no need for treatment to be started immediately. Patients without end-organ symptoms with elevated BP < 159 systolic and <99 diastolic should be referred within a few weeks. Those with elevated BP 160-180 systolic and 100-110 diastolic should be seen in referral within a few days to a week. “Prompt” referral is recommended for those with average BPs >180 systolic or >110 diastolic if treatment is not initiated in UC.}  

^{Some patients may have markedly elevated blood pressures (e.g., < 220/120) in UC, either as their main concern or found incidentally. Existing guidelines do not make specific recommendations for patients other than the > 180/>110 threshold, but clinician judgement may always be exercised regarding ED referral, incorporating shared decision-making with patients.} 

^{If initiating blood pressure medication, the expectation is that blood pressure will be observed to gradually decrease over days to weeks. At no point in any patient’s treatment is there a need to rapidly normalize blood pressure in the Urgent Care setting. Overly aggressive treatment in this regard can cause more patient harm than benefit.}

^{Basic diagnostic and evaluation recommendations}

^{BP should be measured using appropriate techniques. (See Table 1)}

^{Home BP readings should utilize a similarly proper technique, and home BP devices (preferred to home auscultation) should be calibrated with BP measurement devices or auscultation in the UC or primary care clinic. Home BP readings may be used to help with the diagnosis of HTN, as well as determining whether “white coat hypertension” or “masked hypertension” (high BP existing out of a medical setting, with normal BPs in the medical setting) exists. Home BP readings can also be used to assess response to BP interventions and medications. Average blood pressure, ideally measured in a variety of settings, is used to make treatment decisions.} 

^{Based on two or more averaged blood pressure readings and other cardiovascular risk factors, clinicians should recommend follow-up for patients with BP above 120/80. It is recommended that all patients with averaged BP > 140/90 (either systolic or diastolic) begin treatment with medication. According to the cited guidelines2,3,4, those with known vascular disease or events or a 10-year risk of cardiovascular disease (CVD) of > 10% and BP 130-139/80-89 should also be treated. (See Table 2 for initial treatment details and recommended follow-up). Many online and other calculators exist to help determine 10-year CVD risk (e.g., https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/ or https://www.mdcalc.com/calc/3398/ascvd-atherosclerotic-cardiovascular-disease-2013-risk-calculator-aha-acc). If access to timely subsequent care is limited, initiation of treatment may be considered in the UC setting.} 

^{Several medical issues – renal disease, sleep apnea, drug, and alcohol use – can raise blood pressure and complicate management. Also, though most patients with elevated BP will have primary HTN, a small but important percentage will have secondary HTN, and the underlying cause will need to be sought. Clinicians should consider and screen for these factors (See Table 3) as blood pressure medication alone may not be sufficient, and further evaluation and management is beyond the scope of UC. Appropriate referrals should be made in these cases.} 

^{A basic metabolic panel may be considered in conjunction with prescribing medication with possible renal or electrolyte effects or precautions. Urinalysis and EKG can assess for end-organ changes of HTN and fine-tune medication selection and are useful to obtain as a baseline, but they do not affect initial prescribing. Lipid panels, as well, can help with assessing overall cardiovascular risk but are not essential prior to initial prescribing. More extensive lab-work is needed in cases of resistant or suspected secondary HTN.} 

^{HTN treatment recommendations}

^{Certain lifestyle measures (See Table 4) should be recommended to all patients. These measures can be considered nonpharmacological treatment for hypertension and have been shown to reduce blood pressure between 4- and 11-mm Hg when consistently followed. BP should still be checked over time because these measures alone may be insufficient to reduce BP to goal levels. Even so, these measures promote good health in general and may lessen the need for higher dose medications.}  

^{Goal or target BP for nonpharmacological and pharmacological treatment according to the conjoint clinical practice guideline2 and cited review3 is < 130/80. The AAFP guidelines4 recommend a standard BP target of < 140/90. This is a strong recommendation based on high-quality evidence. AAFP states that treating to a lower blood pressure target of < 135/85 mm Hg may be considered based on patient preferences and values, but this was a weak recommendation and is based on moderate-quality evidence. As a rationale for the different recommended goal BP, AAFP cites evidence that treatment to lower targets does reduce the risk of myocardial infarction but not stroke or mortality, and the rate of side effects may be higher.} 

^{In patients for whom lifestyle measures alone have not lowered BP adequately (based on the chosen target or goal as shown above) within the follow-up interval, clinicians may begin a first-line medication at the starting dose (See Table 5). If, at subsequent follow-up, BP is still not controlled adequately, the dose of the initial medication should be increased toward the maximum before starting another agent. Clinical follow-up is recommended at monthly intervals until a goal/target BP is reached. Patients not achieving adequate BP control at the maximum dose of the initial agent can be started on a second first-line medication at the starting dose. The combination of thiazide diuretics with either ACE-inhibitors or angiotensin receptor blockers is often quite effective. First-line agents are all available in generic forms but may differ in price; patient cost considerations are reasonable to factor into decision-making.} 

^{Patients should be informed that, different than most medications prescribed for acute care problems, medications for HTN do not cure the condition, but that they constitute ongoing treatment and may need to be taken lifelong. Clinicians should monitor for compliance and for side effects and consider changing agents if undue side effects occur. Clinicians should prescribe sufficient quantities/refills of effective medications to bridge primary or specialty care appointments.} 

^{Patients who have already documented vascular disease or events (e.g., myocardial infarction, stroke) or other comorbidities (chronic renal disease, congestive heart failure) may be treated to lower BP goals in primary care or specialty settings.} 

^{For patients 65 years of age and older, the conjoint clinical practice guideline2 and cited review3 recommend a systolic BP goal of < 130 without respect to diastolic blood pressure. The AAFP guideline recommends no specific change in target BP of < 140/90 with aging.} 

^{At some point, patients started on medication for HTN in UC should have primary care established, even if their BP comes under good control, to begin general health maintenance, cancer screening, etc., which is beyond the scope of UC.} 

^{Patient Education}

^{Patient education may include informing patients of the adverse consequences of inadequately controlled HTN; the possibility of side effects and options to change to other medications if these occur; and the potential lifelong need for lifestyle modification and BP medications to reduce morbidity and mortality. Informational handouts or links to these can be curated and/or given to patients, for example:}

^{https://www.heart.org/-/media/Healthy-Living-Files/LE8-Fact-Sheets/LE8_How_To_Manage_Blood_Pressure.pdf}

^{https://www.heart.org/-/media/Files/Health-Topics/Answers-by-Heart/What-Is-High-Blood-Pressure.pdf}

^{There are several, varied elements to lifestyle modification that can be communicated via similar handouts, for example:}

^{https://www.heart.org/-/media/Files/Health-Topics/High-Blood-Pressure/What-can-I-do-to-improve-my-blood-pressure.pdf}

^{https://www.heart.org/-/media/Healthy-Living-Files/Infographics/Prevention_Infographic.pdf}

^{Patient education information may be available in many languages and, to have the greatest impact, clinicians should consider the patient’s primary language when offering such education.}

^Summary

^{HTN is a common and major health issue. Its silent nature makes BP measurement and mindfulness of the numeric values important. There are many effective first-line HTN medications which can be started in UC. Ideally, patients will connect to primary care for ongoing management and health maintenance unless those services are provided by the UC practice.} 

^References

^{1. Best Practice. Management of Asymptomatic Elevated Blood Pressure https://urgentcareassociation.org/wp-content/uploads/2022/10/ManagementofAsymptomaticElevatedBloodPressure.pdf}

^{2. Whelton  PK, et al.  2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA 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 Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):e13-e115. doi:10.1161/HYP.0000000000000065}

^{3. Carey M et al. Treatment of Hypertension A Review. JAMA. 2022:328(18):1849-1981. Doi:10.1011/jama.2022.19590}

^{4. Coles S et al. Blood pressure targets in adults with hypertension: a clinical practice guideline from the AAFP. Am Fam Phys 2022 Dec;106(6) online. Link}

^{5. Arguedas, JA et al. Blood pressure targets in adults with hypertension. Cochrane Database of Systematic Reviews 2020, Issue 12. Art. No.: CD004349. DOI: 10.1002/14651858.CD004349.pub3}

^Reviewers

^{This document has been extensively peer reviewed by the members of the Clinical Response Committee.}

^{Attachments (flow charts, graphics, tables, etc.)}

^{Table 1. Accurate Blood Pressure (BP) Measurement}

^{Table 2: HTN Treatment and Follow-up based on BP Level}

^{Table 3. Considerations for Secondary Hypertension or Complicating Conditions}

^{Table 4. Lifestyle Measures to Help Hypertension}

^{Table 5: First-line Antihypertensive Medications and Clinical Considerations}

^{Figure 1: Summary Algorithm for HTN Diagnosis and Treatment}

^{Patient positioning and preparation}

^{·    Patient should be relaxed, sitting (not recumbent) in a chair with feet on floor and back supported (i.e., not sitting on the exam table) for at least 5 min.}

^{·    Patient should avoid caffeine, exercise, and smoking for at least 30 min before BP measurement.}

^{·    Patient should not have the feeling to use the bathroom or be otherwise uncomfortable.}

^{·    Neither the patient nor staff should talk during BP measurement or in the > 5 min rest period beforehand.}

^{·    BP cuff should be placed directly on the skin with no clothing in between.}

^{Proper Machine, Cuff and Auscultation Technique}

^{·    BP measurement devices should be validated and periodically calibrated based on manufacturer recommendations.}

^{·    Patient’s arm should be supported (e.g., resting on a desk).}

^{·    The middle of the BP cuff should be positioned on the patient’s upper arm at the level of the right atrium (the midpoint of the sternum).}

^{·    The airbladder of a correctly sized BP cuff should encircle 80% of the patient’s arm; if a larger or smaller than correctly sized cuff is used, it should be noted.} 

^{·    For auscultated (vs automated) BP measurements, either the stethoscope diaphragm or bell may be used.}

^{Proper determination of BP reading}

^{·    At the time of first visit, take the BP in both arms and determine which is higher. This should be noted and be the arm for all subsequent BP measurements.}

^{·    If repeat BP readings are needed, wait 1-2 minutes between measurements.}

^{·    Before auscultated BP measurements, inflate the cuff and use the disappearance of the radial pulse to estimate the systolic pressure; then inflate the cuff 20-30 mm Hg above this, letting the cuff delate at a rate of 2 mm Hg per second during auscultation.} 

^{Proper BP documentation}

^{·    Record both systolic and diastolic measurements.}

^{·    For auscultation, use the nearest even numbers for recording systolic and diastolic measurements.} 

^{·    Note the time of day that the most recent BP medication had been taken by the patient.}

^{Use the average of multiple readings}

^{Use the average of 2 or more readings on 2 or more occasions to estimate a patient’s BP.}

^{Provide BP reading to the patient}

^{Provide BP readings to patients verbally and in writing.}

^{Average BP Threshold}

^{Recommended treatment and follow-up}

^{Normal BP (< 120/80 mm Hg)}

^{Promote healthy lifestyle habits (nonsmoking, proper diet and exercise, weight control) and reassess annually.} 

^{Elevated BP (120-129/<80 mm Hg)}

^{Recommend Lifestyle Measures (See Table 4) and reassess in 3-6 months.}

^{Stage 1 HTN (130-139/80-89 mm Hg)}

^{If there is no known cardiovascular (CV) disease or prior event (e.g., myocardial infarction, stroke), and 10-year CV disease risk* is < 10%, Lifestyle Measures can be recommended with 3–6-month reassessment.} 

^{If there is known CV disease or prior event, or CV risk is > 10%, Lifestyle Measures should be recommended, and antihypertensive medication started with reassessment in 1 month.}

^{Stage 2 HTN (> 140/90 mm Hg)}

^{Lifestyle Measures should be recommended, and antihypertensive medication started with reassessment in 1 month.}

^{Consider secondary HTN}

^{Complicating issues/conditions}

^{Hypertension starting < 30 years old}

^{Known renal or renovascular disease}

^{Diastolic HTN starting > 65 years old}

^{Obstructive sleep apnea}

^{Abrupt onset of HTN}

^{Use of nonsteroidal anti-inflammatory drugs}

^{Worsening of previously controlled HTN}

^{Use of corticosteroids}

^{Difficult-to-control HTN}

^{Use of stimulant drugs (cocaine, meth)}

^{Presence of acute end-organ effects}

^{Unprovoked hypokalemia}

^{Lifestyle Measure}

^Goals

^{Weight loss (if overweight)}

^{Use diet and exercise to reduce body weight close to ideal body weight.}

^{Reduce sodium intake} 

^{Less than 2-2.3 g Na per day; in general, avoid overtly salt food and added salt; eat home-cooked food rather than at restaurant or fast food.}

^{Healthy diet}

^{Consider DASH, Mediterranean, vegan or low carbohydrate diet.}

^{Physical activity}

^{Engage in aerobic activity and/or resistance training 30-60 minutes per session, 5-7 times per week.}

^{Alcohol consumption}

^{Limit alcohol to < 2 standard drinks per day for men and < 1 standard drinks per day for women.}