• Level A recommendations. None specified.
• Level B recommendations. None specified.
• `Level C recommendations.

(1) In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (e.g, serum creatinine, urinalysis, ECG) is not required.

(2) In select patient populations (e.g, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (e.g, hospital admission).

While current literature and textbooks do not give a definitive answer to the question of “does screening for target organ injury in asymptomatic hypertension reduce rates of adverse outcomes,” recommendations can be derived from individual studies. Studies reviewed identified that screening was not routinely indicated, but showed that renal dysfunction of unknown immediate clinical significance could be detected in a small number of patients (up to 5%) by checking a serum creatinine. Unfortunately, the chronicity of this dysfunction was not always known and its impact on clinical outcomes was not evaluated. Further affecting the utility of the data was the limited generalizability of the patient populations and a lack of comparison data to patients without elevated blood pressure. Other screening, including the urinalysis, chest radiograph, and electrocardiogram were shown to be of no benefit.

Question 2: In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes?

• Level A recommendations. None specified.
• Level B recommendations. None specified.
• Level C recommendations.

(1) In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required.

(2) In select patient populations (e.g, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control. [Consensus recommendation]

(3) Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation]

Recommendations for this critical question are again limited by a paucity of data. Emergency physicians must be careful not to blindly extrapolate longitudinal data on the benefits of blood pressure control over time to the acute setting of emergency medicine. Exemplifying this is a Cochrane review that challenges the dogma to treat symptomatic patients with markedly elevated blood pressure finding insufficient evidence to support or refute the practice. In asymptomatic patients, studies reviewed showed that no serious blood pressure–related adverse events occurred when delaying medical intervention until follow-up out to three months. This, in addition to a general acceptance that the rapid lowering of markedly elevated blood pressure in the asymptomatic patient has the potential to do harm, supports ACEP’s Level C recommendation. However, it must be noted that in selected social or clinical situations (e.g, poor follow-up, limited access to care), emergency physicians may choose to initiate treatment for markedly elevated blood pressure in the asymptomatic patient before discharge in order to gradually lower the blood pressure and/or initiate long-term control.