Optometrists and their staffs are measuring blood pressure in the office more often than ever before. This is partly a consequence of the ever-increasing number of patients with hypertension.
The American Heart Association, the American College of Cardiology, and nine other medical groups recently published the new guideline that would increase the number of adults with hypertension from 32 percent to 46 percent in U.S.1
In addition, the Centers for Medicare & Medicaid Services (CMS) has reinforced reporting of certain exam information, including blood pressure values. To do this, CMS initially provided incentives for those who reported and now penalize those who don’t. As ODs routinely measure blood pressure in the office, they face challenges of how to manage patients with abnormally high blood pressure readings.
Blood pressure emergency
ODs may wonder what blood pressure reading requires an emergency room referral.
The answer may be when the patient’s reading reaches the level of “severely elevated blood pressure.”
Because the eighth report of the Joint National Committee (JNC) in 2014 does not modify the definition of hypertensive crises, the healthcare field still refers to the old definition given by the seventh JNC report.2
This report considers a blood pressure reading that is greater than 180 mm Hg (systolic) or 120 mm Hg (diastolic) as severely elevated. Patients with severely elevated blood pressure are considered to be at risk of hypertensive crisis.
It is estimated that 1 to 2 percent of patients with hypertension experience hypertensive crisis at one point in their lives.3
Emergency vs. urgency
There are two stages of hypertensive crisis: emergency and urgency.
Hypertensive emergency is a true life-threatening emergency with impending target-organ-damage (TOD) in the heart, brain, kidney, and large blood vessels. Serious conditions, such as ischemic heart failure, acute renal failure, and aorta rupture, are suspected in such patients. Emergency admission to intensive care unit is mandatory for prompt reduction of blood pressure by approximately 20 to 25 percent,4 depending on suspected conditions.
While hypertensive emergency is considered a true life-threatening condition, its appearance in optometric offices is relatively uncommon. Because of their manifested systemic signs and symptoms, patients tend to seek care at the ER.
On the other hand, patients with hypertensive urgency may be completely asymptomatic and more likely make a visit to an optometric office. The dilemma lies in how to assess the risk of immediate TODs.
Hypertensive urgency is lacking definitive consensus in its spectrum. While some patients may hold relatively lower risk, a certain degree of hypertensive urgency can pose an immediate threat. Thus, it is critical to have clear standards on when to send hypertensive patients to the ER.
It is tempting to create an oversimplified numerical cutoff for triaging hypertension. For example, how about referring patients with systolic pressure >180 mm Hg or diastolic pressure >120 mm Hg?
This “number approach” has a potential flaw: you may end up referring patients who don’t truly need care at ER and would receive better care by primary-care physicians (PCPs). After ER visits, the rate of follow-up at PCP offices is often poor.5,6 Optometrists should also be sentient of the fact that hypertension is a chronic disease, and long-term success for patients is built by continuous follow-up with PCPs.
A better approach is to assess the risk based on clinical features and tailor the referral.
The following three steps ensure the proper risk assessment of patients who are in danger of hypertensive crises in your optometric offices:
• Symptomatology check
• Fundus examination
• Review of medical history and chronicity of hypertension
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