Study Addresses Appropriate Treatment Setting for Hypertensive Urgency Interview with:
Krishna Patel, MD, PG Y3 Resident
Internal Medicine Residency Program
Cleveland Clinic
Cleveland, OH 44195 What is the background for this study? What are the main findings?

Dr. Patel: In our outpatient resident clinic practice, we found that patients with poorly controlled hypertension presenting with blood pressures in the hypertensive urgency range (SBP>=180mmHg or DBP >=110 mmHg) but with no symptoms of end-organ damage were common, however there was no clear cut manner in which these patient’s blood pressures were treated. According to the comfort level of the physician, these patients were managed in the office and on serial outpatient visits and some of the patients would be referred to the emergency department for management of these elevated blood pressures. Given there was not much prior literature on this topic, we decided to study the prevalence and short term cardiovascular outcomes for this population of patients.

We found that hypertensive urgency is quite common in the office setting (4.6% in our study). In absence of symptoms of end organ damage, the short term risk of major cardiovascular events was very low around 1%, and patients who were referred to the ED for management of blood pressures had a lot of unnecessary testing and more hospital admissions than those who were managed as an outpatient. What should readers take away from your report?

Dr. Patel:  For the practicing clinician, our results support treating these patients by following them serially as an outpatient. High blood pressures by themselves should not trigger immediate referral to the emergency department. At the same time, we found that physicians did a poor job of controlling these same patients’ blood pressures over the next six months. It seems that they were too worried about short term complications and not worried enough about longer term ones. More emphasis should be placed on better closer outpatient follow up for these very difficult to control hypertensive patients. What recommendations do you have for future research as a result of this study?

Dr. Patel:  We need to understand why these patients get referred to the hospital and how to prevent such referrals. We also need to understand how to consistently manage difficult-to-control hypertensives so that we can prevent the long- term complications of this condition. We’d also like to study the treatment of blood pressure while patients are hospitalized. We expect that doctors there, too, are overly aggressive in the short term and not aggressive enough after discharge. Is there anything else you would like to add?

Response: Managing blood pressure isn’t sexy. It isn’t an emergency, but it’s one of the most important things that we do for our patients. Because most patients have no symptoms until serious disease develops, it can be difficult to convince them to take medications, usually for life. At the Cleveland Clinic we’ve undertaken a quality-improvement project to get all of our patients’ blood pressures under control. We hope the rest of the country will follow. Thank you for your contribution to the community.


Patel KK, Young L, Howell EH, et al. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA Intern Med. Published online June 13, 2016. doi:10.1001/jamainternmed.2016.1509.

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on June 16, 2016 by Marie Benz MD FAAD