Navigating Hypertensive Presentations in A&E: A Guide for Junior Doctors

Hypertension is a common presentation in the emergency department (A&E), but it requires a thorough and structured approach to ensure optimal patient outcomes. This blog post will guide junior doctors through the key aspects of history taking, examination, investigations, and management of hypertensive presentations.

History Taking

Effective history taking is the cornerstone of diagnosing and managing hypertension. Here are the crucial questions to ask:

1. Symptom Onset and Duration:

   • When did the symptoms start?

   • Are the symptoms persistent or intermittent?

2. Associated Symptoms:

   • Do you experience headaches, visual disturbances, chest pain, shortness of breath, or palpitations?

   • Any dizziness, nausea, or vomiting?

3. Medical History:

   • Have you been diagnosed with hypertension before?

   • Do you have a history of cardiovascular diseases, diabetes, or renal issues?

4. Medication History:

   • Are you currently on any antihypertensive medications?

   • Have you recently started or stopped any medications, including over-the-counter drugs or supplements?

5. Lifestyle Factors:

   • What is your diet like? Do you consume a lot of salt?

   • Do you smoke or consume alcohol? If so, how much?

   • Do you engage in regular physical activity?

6. Family History:

   • Is there a family history of hypertension, cardiovascular diseases, or strokes?

7. Recent Stressors:

   • Have you experienced any recent stress, anxiety, or significant life events?

Examination Findings

A systematic examination is essential to identify any complications of hypertension and to rule out secondary causes:

1. Vital Signs:

   • Measure blood pressure in both arms.

   • Check heart rate and respiratory rate.

   • Monitor oxygen saturation and temperature.

2. General Appearance:

   • Look for signs of distress, sweating, or pallor.

3. Cardiovascular Examination:

   • Inspect for jugular venous distension.

   • Palpate for peripheral pulses and any radio-femoral delay.

   • Auscultate for heart murmurs or abnormal heart sounds.

4. Respiratory Examination:

   • Listen for any crackles or wheezes that might indicate pulmonary edema.

5. Neurological Examination:

   • Assess for any focal neurological deficits.

   • Check for signs of hypertensive encephalopathy such as altered mental status or seizures.

6. Fundoscopy:

   • Examine the eyes for hypertensive retinopathy (e.g., flame hemorrhages, cotton wool spots, papilledema).

7. Abdominal Examination:

   • Palpate for renal masses or a pulsatile abdominal mass suggestive of an aneurysm.

Investigations

Timely investigations help in identifying the cause and complications of hypertension:

1. Blood Tests:

   • Full blood count (FBC)

   • Urea and electrolytes (U&Es)

   • Liver function tests (LFTs)

   • Blood glucose levels

   • Lipid profile

   • Thyroid function tests (if indicated)

2. Urine Tests:

   • Urinalysis for protein, blood, and glucose

   • Urine catecholamines (if pheochromocytoma is suspected)

3. Imaging:

   • Chest X-ray (CXR) to assess for cardiomegaly or pulmonary edema

   • Electrocardiogram (ECG) to look for signs of left ventricular hypertrophy or ischemia

   • Echocardiogram if heart failure or significant valvular disease is suspected

   • Renal ultrasound or CT if secondary causes like renal artery stenosis are suspected

4. Special Tests:

   • Ambulatory blood pressure monitoring (ABPM) for accurate BP readings

   • MRI or CT of the brain if there are neurological symptoms suggestive of a stroke or hypertensive encephalopathy

Management Plan

The management of hypertensive emergencies and urgencies involves prompt and effective intervention:

1. Hypertensive Emergency:

   • This is characterized by severe hypertension with evidence of end-organ damage (e.g., encephalopathy, myocardial infarction, pulmonary edema, aortic dissection).

   • Immediate Management:

     • Administer intravenous antihypertensives (e.g., labetalol, sodium nitroprusside, nicardipine).

     • Target a gradual reduction in blood pressure (not more than 25% within the first hour).

2. Hypertensive Urgency:

   • Severe hypertension without evidence of end-organ damage.

   • Management:

     • Oral antihypertensives (e.g., amlodipine, lisinopril, clonidine).

     • Aim for a gradual reduction in blood pressure over 24-48 hours.

     • Arrange follow-up within 24 hours to reassess.

3. Lifestyle Modifications:

   • Encourage a low-sodium diet, regular physical activity, weight loss, smoking cessation, and moderation of alcohol intake.

4. Long-term Management:

   • Initiate or adjust antihypertensive therapy according to current guidelines (e.g., NICE guidelines).

   • Monitor for adherence and side effects.

   • Educate the patient about the importance of regular follow-up and blood pressure monitoring.

Conclusion

Handling hypertensive presentations in A&E can be challenging, but a structured approach to history taking, examination, investigations, and management can make a significant difference. Always consider the potential for underlying causes and end-organ damage, and tailor your management plan to the individual patient's needs. Stay updated with guidelines and continue to refine your clinical skills to provide the best care possible.

For further reading, consult resources like the Oxford Handbook of Emergency Medicine, BMJ Best Practice, and NICE guidelines.