“My dermatologist sent me to the ER for my blood pressure, and they told me I’m going to have a stroke.”
Sound familiar? Every day across the world, patients check in with a similar story. What was supposed to be a routine visit quickly turns into a hurried trip to the ED, ultimately ending in a frustrated patient going home, uttering the familiar phrase we all know far too well, “They didn’t even do anything!”
For emergency medicine clinicians, this is a tale as old as time. Worried patients and families stare with incredulous gazes as you calmly explain that there is nothing that needs to be done emergently, and they can follow up with their regular doctor. In this situation, the most important part of the visit is probably what happens after the patient leaves.
For many of us, our days are spent treating patients with poor health literacy, limited resources, and a lack of access to follow-up care. For these patients, the downstream risk of untreated hypertension is very real.
In this month's ERcast, Andy Little, DO, Drew Kalnow, DO, and Geoff Comp, DO sit down to discuss a new clinical policy from ACEP regarding the treatment of asymptomatic hypertension in the emergency department. While there is often no workup required in the ED other than a good history and physical exam, ACEP recommends that ED clinicians consider starting patients on blood pressure management and ensuring they have access to appropriate follow-up care.
Hyperpertension affects nearly half of U.S. adults, yet only 1 in 4 achieve adequate control.
The ED sees over 6 million hypertension-related visits annually, most without acute target organ injury.
Emergency physicians are highly skilled at ruling out hypertensive emergencies (stroke, MI, pulmonary edema), but long-term blood pressure management traditionally falls outside ED practice.
Given disparities in access to primary care, the ED represents a critical touchpoint for initial intervention and education.
In July 2025, ACEP released a clinical policy update about the approach to adult patients presenting to the ED with asymptomatic hypertension. This update replaces the 2013 guideline and focuses on a single critical question: Is it safe and effective to initiate outpatient antihypertensive medications at ED discharge for patients with asymptomatic hypertension?
Applies to adults (≥18 years) presenting with asymptomatic elevated BP (≥130/80 mmHg by current definitions).
Exclusion criteria:
- Patients with hypertensive emergencies (stroke, ACS, pulmonary edema, encephalopathy, CHF)
- Pregnant patients
- Patients with end-stage renal disease or acute conditions causing transient BP elevation (e.g., trauma, pain)
1,017 studies screened → only 1 Class III study (Brody et al.) met methodological criteria.
Study population: 217 patients, mostly African American (96%), majority with pre-existing hypertension.
Findings:
1. ED prescription of antihypertensives at discharge led to a mean 11 mmHg reduction at follow-up.
2. There was no increase in adverse events (hypotension, ischemic events, neurologic deficits).
3. Classes prescribed most often: thiazide-like diuretics (54%), ACE inhibitors (26%), calcium channel blockers (10%), and beta blockers (6%).
- Consider initiating outpatient antihypertensive therapy at ED discharge in select patients with asymptomatic elevated BP
- Refer all patients for outpatient follow-up (consensus)
- Earlier BP control
- Reduced long-term cardiovascular risk
- Opportunity to reduce disparities in populations with poor access to primary care
Potential harms:
- Medication side effects
- Overtreatment of falsely elevated BP (leading to hypotension)
- Challenges in ensuring follow-up
Take the time to perform a thorough history and physical exam to confirm the absence of target organ damage and identify any reversible causes for the patient's hypertension.
Every discharged patient should have a clear and realistic plan for follow-up care.
Initial therapy should align with JNC-8-style targets and take into account any patient comorbidities.
Provide thorough written discharge instructions for follow-up, as well as education on medication use, side effects, and red flags that should prompt a return visit.
Remember that this is not a universal mandate; it is a recommendation. Clinical judgement and the context of the individual patient should be the driving force for any clinical decisions.