Severe Asymptomatic Hypertension: Evaluation and Treatment

492 American Family Physician www.aafp.org/afp Volume 95, Number 8

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April 15, 2017

Hypertension affects one-third of Americans and is a signiﬁcant modiﬁable risk factor for cardiovascular disease,

stroke, renal disease, and death. Severe asymptomatic hypertension is deﬁned as severely elevated blood pressure

(180 mm Hg or more systolic, or 110 mm Hg or more diastolic) without symptoms of acute target organ injury. The

short-term risks of acute target organ injury and major adverse car-

diovascular events are low in this population, whereas hyperten-

sive emergencies manifest as acute target organ injury requiring

immediate hospitalization. Individuals with severe asymptomatic

hypertension often have preexisting poorly controlled hypertension

and usually can be managed in the outpatient setting. Immediate

diagnostic testing rarely alters short-term management, and blood

pressure control is best achieved with initiation or adjustment of anti-

hypertensive therapy. Aggressive lowering of blood pressure should

be avoided, and the use of parenteral medications is not indicated.

Current recommendations are to gradually reduce blood pressure

over several days to weeks. Patients with escalating blood pressure,

manifestation of acute target organ injury, or lack of compliance with

treatment should be considered for hospital admission. (Am Fam

emy of Family Physicians.)

ILLUSTRATION BY JOHN KARAPELOU

Severe Asymptomatic Hypertension:

Evaluation and Treatment

ROBERT GAUER, MD, Womack Army Medical Center, Fort Bragg, North Carolina

ypertension affects more than

30% of adults in the United

States and is a signiﬁcant

modiﬁable risk factor for car-

diovascular disease, stroke, renal disease,

and death.

1,2

Several high-quality studies

have shown that treatment of hypertension

reduces long-term hypertension-related

adverse outcomes and all-cause mortality.

3-5

Severe asymptomatic hypertension, or

hypertensive urgency, is deﬁned as severely

elevated blood pressure (180 mm Hg or

more systolic, or 110 mm Hg or more dia-

stolic) without acute target organ injury.

Patients may still have headache, lighthead-

edness, nausea, shortness of breath, palpi-

tations, epistaxis, or anxiety, depending on

the acuity and severity of blood pressure

elevation.

Hypertensive emergency is deﬁned as

severe blood pressure elevation in the pres-

ence of acute target organ injury, such as

encephalopathy, cerebrovascular or car-

diovascular events, pulmonary edema,

renal injury, or aortic dissection.

These

patients require urgent evaluation and

hospitalization.

A retrospective cohort study from a single

multispecialty outpatient health care system

showed that in 4.6% of patients, initial blood

pressure measurements met diagnostic cri-

teria for severe asymptomatic hypertension.

Approximately 4% of emergency department

(ED) visits are for the management of severe

asymptomatic hypertension,

9,10

and more

than 4.5% of adult inpatients receive intra-

venous antihypertensive medications for

management of blood pressure elevations.

Severe asymptomatic hypertension most

often occurs in patients previously diag-

nosed with hypertension. More than 60%

of patients have persistent uncontrolled

hypertension six months after a documented

clinic visit with a systolic blood pressure of

180 mm Hg or more, or a diastolic blood

pressure of 110 mm Hg or more.

Medication

noncompliance has been reported in up to

65% of patients prescribed antihypertensive

CME

This clinical content

conforms to AAFP criteria

for continuing medical

education (CME). See

CME Quiz Questions on

page 483.

Author disclosure: No rel-

evant ﬁnancial afﬁliations.

mercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.

Severe Asymptomatic Hypertension

April 15, 2017

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Volume 95, Number 8 www.aafp.org/afp American Family Physician 493

medications and is a major cause of severe

asymptomatic hypertension.

In rare cases,

unrecognized secondary hypertension (e.g.,

renal vascular hypertension; sympathetic

crisis from cocaine toxicity, pheochromocy-

toma, or acute alcohol withdrawal; primary

hyperaldosteronism) can present with severe

blood pressure elevations.

There is insufﬁcient evidence to dictate

the most appropriate management for severe

asymptomatic hypertension. Most guide-

lines focus on hypertensive emergency.

Evaluation

HISTORY AND PHYSICAL EXAMINATION

A comprehensive history is essential in the

initial evaluation of patients with severe

asymptomatic hypertension (Table 1).

A medication history should include any

new medications; illicit substances (e.g.,

sympathomimetics, cocaine); and, most

importantly, compliance with current pre-

scriptions.

A targeted symptom history

should be obtained to identify a potential

hypertensive emergency. Severe blood pres-

sure elevations may cause mild symptoms

(e.g., headache, lightheadedness, nausea,

shortness of breath, palpitations, epistaxis,

anxiety) without acute target organ injury,

although patients with chest pain should

receive appropriate evaluation for chest pain,

not severe asymptomatic hypertension.

Physical examination ﬁndings are often

normal in patients with severe asymp-

tomatic hypertension. However, attention

should be directed toward signs of target

organ injury. These signs can be neurologic

(motor or sensory deﬁcits), ophthalmologic

(arteriolar narrowing, hemorrhage, papill-

edema), cardiovascular (arrhythmia, dis-

placed point of maximal impulse, murmur,

third heart sound gallop), pulmonary (rales,

hypoxia, tachypnea), or vascular (dimin-

ished or absent peripheral pulses, abdomi-

nal bruits, unequal pulses or blood pressure,

jugular venous distension).

4,10,13

Clinical

examination ﬁndings that suggest acute tar-

get organ injury (new or evolving neurologic

deﬁcits, papilledema, pulmonary edema) are

regarded as a hypertensive emergency until

proven otherwise.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation

Evidence

rating References

Patients with severely elevated blood pressure should have a history and

physical examination to distinguish between severe asymptomatic

hypertension and hypertensive emergency.

C 6, 10, 13

A 30-minute rest period is recommended when the initial blood pressure

reading is severely elevated. In more than 30% of patients, the blood pressure

will lower to an acceptable level without intervention following the rest period.

C 15

An immediate diagnostic evaluation is not required in the initial management of

severe asymptomatic hypertension.

C 8, 17, 18

Aggressive lowering of blood pressure can be harmful and should be avoided

in patients with severe asymptomatic hypertension. Gradual reduction over

several days to weeks is recommended.

C 10, 21

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence;

C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the

SORT evidence rating system, go to http://www.aafp.org/afpsort.

WHAT IS NEW ON THIS TOPIC: SEVERE ASYMPTOMATIC

HYPERTENSION

The U.S. Preventive Services Task Force recommends out-of-ofﬁce blood

pressure monitoring (using home and ambulatory blood pressure monitoring

devices) as an important adjunct to in-ofﬁce measurements for diagnosing

hypertension.

A recent trial of an outpatient population referred to the emergency

department for severe asymptomatic hypertension showed that only 5%

of tests ordered had abnormal results, and 2% of patients had evidence

of target organ injury. Less than 1% of patients had a major adverse

cardiovascular event within six months.

Severe Asymptomatic Hypertension

494 American Family Physician www.aafp.org/afp Volume 95, Number 8

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April 15, 2017

Proper technique should be used for all

blood pressure measurements

6,10,14

(Table 2

If the blood pressure measurement is severely

elevated, the patient should be allowed to qui-

etly rest. In more than 30% of patients with

severe asymptomatic hypertension, blood

pressure lowers to an acceptable level (mean

of 160/89 mm Hg) without intervention fol-

lowing a 30-minute rest period.

HOME AND AMBULATORY BLOOD PRESSURE

MONITORING

The U.S. Preventive Services Task Force rec-

ommends out-of-ofﬁce blood pressure mon-

itoring (using home and ambulatory blood

pressure monitoring devices) as an impor-

tant adjunct to in-ofﬁce measurements for

diagnosing hypertension.

A major advan-

tage of out-of-ofﬁce monitoring is the abil-

ity to obtain multiple readings over time.

Speciﬁc indications for out-of-ofﬁce moni-

toring in the setting of severe asymptomatic

hypertension include suspected white coat

hypertension (isolated clinic hypertension)

and highly variable in-ofﬁce blood pressure

readings. Additionally, out-of-ofﬁce moni-

toring is useful to assess compliance with

antihypertensive therapy.

DIAGNOSTIC EVALUATION

Patients presenting with severe asymptomatic

hypertension rarely require diagnostic evalu-

ation, although subsequent ofﬁce visits should

include evaluation for long-term hyperten-

sion risks based on current guidelines.

4,6

Patients with symptoms or clinical ﬁndings

suggesting acute target organ injury require

appropriate diagnostic testing and evaluation

for possible hypertensive emergency. A recent

trial of an outpatient population referred to

the ED for severe asymptomatic hypertension

showed only 5% of tests ordered had abnormal

results, and only 2% of patients had evidence

of target organ injury. The most commonly

ordered tests were basic or complete meta-

bolic panel (64% of patients; abnormal in

ﬁve out of 247 patients), urinalysis (30% of

patients; abnormal in 20 out of 115 patients),

cardiac enzymes (35% of patients; abnormal

in two out of 137 patients), chest radiography

(35% of patients; abnormal in ﬁve out of 137

patients), and computed tomography of the

head (13% of patients; no abnormalities).

Electrocardiography was performed in less

than 1% of patients.

A cross-sectional study of two urban EDs

enrolled 167 asymptomatic patients with triage

Table 1. Medical History in the Evaluation of Severe

Asymptomatic Hypertension

Previous hypertension (duration and levels)

Personal history: coronary artery disease, congestive heart failure,

cerebrovascular disease, chronic kidney disease, peripheral vascular disease,

diabetes mellitus, sleep apnea

Risk factors: family history of hypertension, hyperlipidemia, diabetes, tobacco

use, dietary habits, weight gain, sedentary lifestyle

Secondary causes: family history of kidney disease, personal history of renal

disease, medications and illicit drug use, clinical features of metabolic

disorders (e.g., thyroid disease, pheochromocytoma, hyperaldosteronism)

Target organ injury: neurologic (headache, vision changes, seizure, neurologic

deﬁcits), cardiovascular (chest pain, shortness of breath, myocardial

infarction, syncope, history of palpitations or arrhythmias), renal (oliguria,

anuria), peripheral arteries (claudication, cold extremities, weak distal pulses),

pulmonary (sleep apnea, chronic lung disease)

Concurrent medication/drug use: nonsteroidal anti-inﬂammatory drugs,

antidepressants, oral contraceptives, cold medications, sympathomimetics

(amphetamines, cocaine, phencyclidine), corticosteroids, herbal remedies

Compliance with antihypertensive therapy

Information from reference 6.

Table 2. Proper Technique for Blood Pressure Measurements

An appropriately sized automated electronic arm cuff device should be used.

Initially, a measurement should be obtained in both arms, and the higher blood

pressure should be used (signiﬁcant differences between arms occur in aortic

coarctation, subclavian artery stenosis).

The patient should have an empty bladder and remain seated with legs

uncrossed for ﬁve minutes before the measurement.

The measurement should occur at the level of the heart with the arm resting

on a table.

Postural blood pressure should be obtained in older adults.

A minimum of two readings should be obtained one to two minutes apart and

averaged.

The diagnosis of hypertension should be conﬁrmed at a subsequent visit unless

the blood pressure reading is very high or the patient is symptomatic.

Evaluation of white coat hypertension (elevated clinic blood pressure and

normal ambulatory blood pressure) and masked hypertension (normal

clinic blood pressure and elevated ambulatory blood pressure) should be

considered as clinically indicated.

Information from reference 14.

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Volume 95, Number 8 www.aafp.org/afp American Family Physician 495

diastolic blood pressure of 100 mm Hg or

more. A basic metabolic panel was performed

for all patients, of which 12 (7%) had unan-

ticipated abnormalities resulting in hospi-

talization, primarily for renal dysfunction.

The American College of Emergency Physi-

cians does not recommend routine laboratory

testing in patients with severe asymptomatic

hypertension.

No other organization or pol-

icy guideline has provided recommendations

to assist in the diagnostic evaluation. Without

sufﬁcient clinical evidence, diagnostic evalua-

tion for severe asymptomatic hypertension is

largely anecdotal.

Treatment

There are currently no validated policies or

nationally recognized clinical guidelines to

assist in the management of severe asymp-

tomatic hypertension. A suggested approach

is shown in Figure 1. When managing severe

asymptomatic hypertension, several impor-

tant key questions should be considered.

DOES ACUTE MEDICAL MANAGEMENT AFFECT

SHORT-TERM ADVERSE OUTCOMES?

Serious adverse events related to poorly con-

trolled hypertension (e.g., death, acute renal

injury, cardiovascular complications, rup-

tured aortic aneurysms) are rare even when

follow-up is delayed for several months.

A retrospective outpatient study (n =

58,535) evaluated the short-term outcomes

of patients with severe asymptomatic hyper-

tension. Patients had a mean systolic blood

pressure of 183 mm Hg (10% of patients had

a measurement greater than 200 mm Hg)

and mean diastolic blood pressure of 96 mm

Hg (6% of patients had a measurement of

120 mm Hg or more). From the outpatient

clinic, 426 patients (0.7%) were referred to

the hospital (387 went to the ED, and 39 were

directly admitted) for blood pressure man-

agement. The remainder of patients were sent

home. Outcomes measured were the rate of

major adverse cardiovascular events within

seven days, eight to 30 days, and six months.

The overall rate of major adverse cardiovas-

cular events in both groups was low (less

than 1%) with no signiﬁcant differences at

seven days, eight to 30 days, and six months.

Patients who were sent home had a lower rate

of subsequent hospital admission at seven

days and at eight to 30 days compared with

those originally sent to the hospital. Less

than 1% of patients were referred to the hos-

pital, validating that outpatient management

is an appropriate, cost-effective approach. A

limitation of this study is that 20% of patients

were lost to follow-up, and their outcomes were

not included in the analysis.

A prospective observational study (n = 146)

investigated the risk of short-term adverse

effects of severe asymptomatic hypertension

(mean blood pressure of 217/112 mm Hg at

presentation) following discharge from the

ED. Antihypertensive treatment was given

to 90% of patients in the ED, and 92% were

discharged with prescriptions (80% got pre-

scriptions for two medications). More than

35% of patients still had blood pressure of

more than 190/100 mm Hg at discharge,

regardless of whether they were treated or

observed in the ED. At the 10-day follow-up,

the mean blood pressure signiﬁcantly

improved (160/90 mm Hg) with no serious

adverse outcomes. The authors concluded

that attempts to lower blood pressure acutely

may not be necessary. Discharging patients

with antihypertensive medications is a rea-

sonable and safe option.

Despite the lack of evidence of an imme-

diate increase in risk of major adverse car-

diovascular events, primary care physicians

often are hesitant to send patients with severe

blood pressure elevations home. As a result,

it remains common practice to acutely lower

blood pressure using short-acting antihy-

pertensives. Patients with symptoms such

as headache, lightheadedness, shortness of

breath, epistaxis, or anxiety are more likely

to beneﬁt from these agents.

14,15,21

When

blood pressure improves, long-acting anti-

hypertensive therapy should be initiated,

restarted, or adjusted.

Table 3 includes

selected oral antihypertensives for the treat-

ment of severe asymptomatic hypertension.

HOW QUICKLY SHOULD BLOOD PRESSURE

BE LOWERED?

In the absence of acute target organ injury,

blood pressure should be lowered gradually

Severe Asymptomatic Hypertension

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Management of Severe Asymptomatic Hypertension

*—Repeat blood pressure measurement after a 30-minute rest period.

†—These include neurologic deﬁcits, altered mental status, chest pain, shortness of breath, and oliguria.

‡—New sensory/motor deﬁcits, arteriolar hemorrhage/papilledema, S3 heart sound, rales, jugular venous distention,

pulsating abdominal bruit.

§—Headache, lightheadedness, dyspnea, anxiety, epistaxis, nausea, palpitations.

Patient presents with severely elevated

blood pressure (180 mm Hg or more

systolic, or 110 mm Hg or more diastolic)*

Signs or symptoms of

acute target organ injury?†

Obtain history

Abnormal physical

examination ﬁndings?‡

Hospitalize for

hyper tensive

emergency

Yes

Mild symptoms§

Administer short-

acting anti hyper-

tensive medication

Symptoms and blood

pressure improve?

Consider basic metabolic panel

and other testing as indicated

to assess for target organ injury

Acute target organ injury?

Initiate/adjust anti-

hypertensive treatment

Follow up in 1 week

Yes

Initiate/adjust anti-

hypertensive treatment

Follow up in 1 week

NoYes

Hospitalize for

hypertensive

emergency

Asymptomatic

Previous hypertension?

Adjust anti hyper-

tensive treatment

Follow up in

2 to 4 weeks

Consider out-of-ofﬁce

monitoring with ambulatory

or home monitoring devices

Follow up in

2 to 4 weeks

NoYes

Figure 1. Suggested approach to the management of severe asymptomatic hypertension.

Severe Asymptomatic Hypertension

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Volume 95, Number 8 www.aafp.org/afp American Family Physician 497

to less than 160/100 mm Hg, but not acutely

by more than 20% to 25% of the mean

arterial blood pressure over several days to

weeks.

Every two to four weeks, antihyper-

tensive intensiﬁcation is recommended to

achieve target blood pressure goals.

Aggres-

sive blood pressure lowering in patients with

severe asymptomatic hypertension can lead

to adverse events, such as myocardial infarc-

tion, cerebrovascular accident, or syncope.

Table 3. Selected Oral Antihypertensive Medications for the Treatment

of Severe Asymptomatic Hypertension

Medication Dosage Comments

Onset of action over several days

Angiotensin-converting enzyme inhibitors

Lisinopril 10 mg once per day Consider alternative in patients with acute

kidney injury or severe renal disease; may cause

hyperkalemia and angioedema

Ramipril (Altace) 2.5 to 10 mg once per day

Angiotensin receptor blocker

Telmisartan

(Micardis)

40 mg once per day Consider alternative in patients with acute kidney

injury or severe renal disease; may cause

hyperkalemia

Beta blockers

Atenolol 25 to 50 mg once per day Avoid in patients with bradycardia; may cause

bronchospasm

Metoprolol succinate

(Toprol XL)

25 to 100 mg once per day

Calcium channel blockers

Amlodipine (Norvasc) 2.5 to 5 mg once per day May cause ﬂushing and edema

Nifedipine* 30 mg once per day

Diuretic

Hydrochlorothiazide 12.5 to 25 mg once per day Use with caution in patients with gout; may cause

hypokalemia and hyponatremia

Onset of action over several hours

Alpha blocker

Prazosin (Minipress) 1 to 2 mg twice per day May cause syncope, typically with the ﬁrst dose;

tachycardia; and orthostatic hypotension

Angiotensin-converting enzyme inhibitor

Captopril 25 mg two or three times

per day

Consider alternative in patients with acute kidney

injury or severe renal disease; may cause rash,

hyperkalemia, and angioedema

Beta blocker

Labetalol 100 mg twice per day May cause orthostatic hypotension and nausea

Calcium channel blocker

Diltiazem 30 mg four times per day† May cause edema and headache

Central alpha

adrenergic agonist

Clonidine 0.1 to 0.2 mg twice per day May cause drowsiness, headache, fatigue, rash,

and xerostomia

*—Extended release only; sublingual administration is contraindicated in this setting.

†—May switch to once-daily extended release when blood pressure is controlled.

Severe Asymptomatic Hypertension

498 American Family Physician www.aafp.org/afp Volume 95, Number 8

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April 15, 2017

Parenteral medication is not indicated and

should be reserved for the management of

hypertensive emergencies.

Patients who have not been compliant

often can safely resume their outpatient med-

ications.

Dosing adjustments and additions

are recommended for those already on anti-

hypertensive therapy. No speciﬁc medication

classes are recommended for the initial man-

agement of severe asymptomatic hyperten-

sion. The Eighth Joint National Committee

Report on Prevention, Detection, Evaluation,

and Treatment of Hypertension (JNC 8) rec-

ommendations for the treatment of essential

hypertension, which are based on quality

randomized controlled trials, should be con-

sidered when initiating long-term therapy for

severe asymptomatic hypertension.

In the general nonblack population,

thiazide-type diuretics, calcium channel

blockers, angiotensin-converting enzyme

inhibitors, or angiotensin receptor blockers

are recommended for initial treatment. In

the black population, thiazide-type diuretics

or calcium channel blockers are recom-

mended. In patients with chronic kidney

disease, an angiotensin-converting enzyme

inhibitor or angiotensin receptor blocker

improves renal outcomes.

Additionally, a

patient’s preexisting comorbid conditions

may dictate the preference of antihyperten-

sive class

6,25

(Table 4

). Severe asymptomatic

hypertension generally requires two-drug

therapy, and several meta-analyses clearly

show superior blood pressure reduction with

combination therapy vs. monotherapy.

WHO SHOULD BE HOSPITALIZED?

Hospitalization is rarely required for patients

with severe asymptomatic hypertension.

However, those with escalating blood pres-

sure measurements, progressive symptoms

of target organ injury, or evolving clinical

evidence of acute target organ injury should

be hospitalized.

There are no published data to determine

what blood pressure measurement is too high.

A Veterans Administration Cooperative trial

from 1967 followed patients with diastolic

blood pressure averaging between 115 and

129 mm Hg. No patients had a major adverse

cardiovascular event within two months of

enrollment.

Although scientiﬁc evidence

is lacking, patients with sustained diastolic

blood pressure of 130 mm Hg or more should

be considered for treatment with short-acting

antihypertensives followed by long-acting

agents. Symptomatic patients with persistent

systolic blood pressure elevations exceed-

ing 240 mm Hg or diastolic blood pressure

greater than 130 mm Hg despite appropriate

rest and treatment with short-acting antihy-

pertensives may beneﬁt from hospitalization.

HOW SHOULD HOSPITALIZED PATIENTS WITH

SEVERE ASYMPTOMATIC HYPERTENSION BE

MANAGED?

Inpatient treatment of acute hypertension

is often aggressive, and intravenous antihy-

pertensives are commonly used when blood

pressure readings are only modestly elevated

(151 to 170/101 to 110 mm Hg). However,

there is no evidence that acute inpatient

treatment of severe asymptomatic hyper-

tension improves outcomes, and one study

Table 4. Medication Preferences for Severe Asymptomatic

Hypertension Based on Known Preexisting Factors

Condition Preferred medication class

Angina pectoris Beta blockers, calcium channel blockers

Aortic aneurysm Beta blockers

Asian or black race Diuretics, calcium channel blockers

Atrial ﬁbrillation Beta blockers, calcium channel blockers

(nondihydropyridine)

Cerebrovascular accident All classes

Chronic obstructive

pulmonary disease

All classes except beta blockers

Congestive heart failure Diuretics, beta blockers, ACE inhibitors, ARBs,

mineralocorticoid receptor antagonists

Diabetes mellitus ACE inhibitors, ARBs

Left ventricular hypertrophy ACE inhibitors, ARBs, calcium channel

blockers

Myocardial infarction Beta blockers, ACE inhibitors, ARBs

Peripheral vascular disease ACE inhibitors, calcium channel blockers

Stable chronic kidney disease ACE inhibitors, ARBs

ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker.

Adapted with permission from Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/

ESC guidelines for the management of arterial hypertension: the Task Force for the

Management of Arterial Hypertension of the European Society of Hypertension (ESH)

and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34 (28 ):2190.

Severe Asymptomatic Hypertension

April 15, 2017

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Volume 95, Number 8 www.aafp.org/afp American Family Physician 499

demonstrated increased hospital stays when

intravenous antihypertensives were used.

Blood pressure elevations during hospital-

ization are often exacerbated by pain, anxiety,

or acute illness. When these factors have been

excluded and the patient remains hyperten-

sive, it is best practice to reinitiate or adjust

oral antihypertensive therapy in those with

preexisting hypertension. In patients without

previous hypertension, oral antihypertensive

therapy can be initiated during the hospi-

talization with close outpatient follow-up.

Although there is often reluctance to dis-

charge patients with systolic blood pressure

of more than 180 mm Hg or diastolic blood

pressure of more than 100 mm Hg, these val-

ues in the ambulatory clinic are appropriately

managed in the outpatient setting.

A sig-

niﬁcant beneﬁt for hospitalized patients is the

opportunity to recognize severe blood pres-

sure elevations and improve transitional care

for the primary care physician.

This article updates a previous article on this topic by

Kessler and Joudeh.

Data Sources: We searched OvidSP, PubMed, Essential

Evidence Plus, National Guideline Clearinghouse, UpTo-

Date, and U.S. Preventive Services Task Force guidelines

using the key words asymptomatic, elevated blood pres-

sure, hypertension, hypertensive urgency, hypertensive

emergency, emergency department, guidelines, antihy-

pertensive agents, resistant hypertension, cardiovascular

risk, assessment, management, pharmacologic, treat-

ment, white-coat hypertension, screening, compliance,

prevalence, evaluation, inpatient. Search dates: Novem-

ber 27, 2015; August 4, 2016; and January 25, 2017.

The opinions and assertions contained herein are the

private views of the author and are not to be construed as

ofﬁcial or as reﬂecting the views of the U.S. Army Medical

Department or the U.S. Army Service at large.

The Author

ROBERT GAUER, MD, is an assistant professor of fam-

ily medicine at the Uniformed Services University of the

Health Sciences, Bethesda, Md. He is also a hospitalist at

Womack Army Medical Center, Fort Bragg, N.C.

Address correspondence to Robert Gauer, MD, Womack

Army Medical Center, Bldg. 4-2817, Riley Rd., Fort Bragg,

NC 28310 (e-mail: robertgauer@yahoo.com). Reprints

are not available from the author.

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