An Evidence-Based Approach to Asymptomatic Hypertension in Urgent Care (Pharmacology CME)

Table of Contents

 

About This Issue

Hypertension affects more than 100 million American adults but many of them will not be aware of their condition when they present to urgent care. To avoid both undertreatment and unnecessary ED referrals, urgent care clinicians should be familiar with clinical practice guidelines for managing hypertension, proper blood pressure measurement techniques, and practical strategies for identifying and counseling patients with asymptomatic hypertension. In this issue, you will learn:

The blood pressure categories and risk-stratified treatment thresholds established in the latest guidelines

How to distinguish severe hypertension from a hypertensive emergency

Which laboratory studies are indicated—if any—for an incidental finding of hypertension

When initiation of oral antihypertensive medication should be considered in urgent care

The first-line treatment options for asymptomatic hypertension

CODING & CHARTING: Documentation is key when coding for a visit that includes an incidental finding of hypertension. Learn more in our monthly coding column.

1. About This Issue
2. Acknowledgement
3. Abstract
4. Case Presentations
5. Introduction
6. Definitions
7. Epidemiology
8. Etiology and Pathophysiology
   1. Etiology
   2. Pathophysiology
   3. Effects of Long-Term Hypertension
9. Differential Diagnosis
10. Urgent Care Evaluation
    1. Measuring Blood Pressure
    2. History
    3. Physical Examination
11. Diagnostic Studies
    1. Laboratory Studies
    2. Electrocardiogram
    3. Chest Radiography
    4. Echocardiogram
12. Treatment
    1. Lifestyle Modifications
    2. Pharmacologic Treatment
       1. Treatment Thresholds
       2. Treatment Goal
       3. Urgent Care–Initiated Antihypertensive Treatment
13. Special Populations
    1. Racial and Ethnic Disparities
    2. Age Differences
    3. Sex Considerations
    4. Pregnancy
14. Controversies and Cutting Edge
    1. Urgent Care Diagnosis of Hypertension
    2. System-Wide Solutions To Address Hypertension
15. Disposition
    1. Discharge
    2. Readmission
16. Summary
17. 5 Things That Will Change Your Practice
18. Case Conclusions
19. Risk Management Pitfalls for the Management of Asymptomatic Hypertension in Urgent Care
20. Coding & Charting: What You Need to Know
21. Coding Challenge: Asymptomatic Hypertension in Urgent Care
22. Clinical Pathway for Management of Elevated Blood Pressure Measurements in Urgent Care
23. References

Acknowledgement

Portions of this content were previously published in: Goldberg E. An evidence-based approach to managing asymptomatic elevated blood pressure in the emergency department. Emerg Med Pract. 2015;17(2): 1-24. Used with permission of EB Medicine.

Abstract

Many patients presenting to urgent care are unaware of their hypertensive status, placing them at substantial risk for cardiovascular, renal, neurological, and ocular complications without appropriate recognition and follow-up. Urgent care clinicians must be prepared to address elevated blood pressure readings while also avoiding unnecessary emergency department referrals for patients who can be safely managed in the outpatient setting. This issue provides evidence-based guidance on the clinical approach to asymptomatic hypertension in adult patients in the urgent care setting, including differentiation of hypertensive emergency from poorly controlled hypertension. Current guidelines on acute care management of high blood pressure are reviewed, along with treatment, disposition, and follow-up recommendations.

Case Presentations

A 52-year-old woman is referred to UC by her primary care physician’s office for a blood pressure reading of 190/120 mm Hg...

• She had been previously diagnosed with hypertension and had presented at the PCP office for her annual physical today.
• When she arrives at UC, her blood pressure reading is 160/100 mm Hg.
• She denies headache, chest pain, shortness of breath, or any vision changes. Her physical examination is normal.
• She confesses that she has been poorly compliant with her hydrochlorothiazide.
• You wonder what you should do for her…

A 35-year-old man presents to UC with a complaint of severe ankle pain…

• His blood pressure is persistently elevated, with multiple readings of 220/110 mm Hg during the visit.
• He has never been diagnosed with hypertension and his only complaint today is of severe pain in his ankle.
• He shares that he has an unstable living situation and has had poor access to fluids recently.
• Despite treatment with analgesics and alleviation of his pain, he remains significantly hypertensive.
• You wonder if there is a secondary cause of his hypertension...

A 78-year-old woman is brought to UC by her family for a concern of new-onset hypertension…

• She has no recent medical history and is not taking any medications.
• She had her blood pressure checked at the pharmacy several times over the preceding weeks, and it was consistently around 150/90 mm Hg.
• Her physical examination is normal. She does not have a primary care physician, and the earliest appointment the family has been able to schedule with an internist is in 3 weeks.
• The family is appropriately concerned and asks if you could start her on medication, but you wonder if that is the best approach for this patient...

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Jones DW, Ferdinand KC, Taler SJ, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM guideline for the prevention, detection, evaluation and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension. 2025;82(10):e212-e316. (Clinical practice guideline) DOI: 10.1161/HYP.0000000000000249

2. * Taler SJ. Initial treatment of hypertension. N Engl J Med. 2018;378(7):636-644. (Review) DOI: 10.1056/NEJMcp1613481

3. * Carey RM, Moran AE, Whelton PK. Treatment of hypertension: a review. JAMA. 2022;328(18):1849-1861. (Review)

Wolf SJ, Lo B, Shih RD, et al. Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013;62(1):59-68. (Clinical policy statement) DOI: 10.1001/jama.2022.19590

5. * Peixoto AJ. Acute severe hypertension. N Engl J Med. 2019;381(19):1843-1852. (Review) DOI: 10.1056/NEJMcp1901117

6. * Bress AP, Anderson TS, Flack JM. The management of elevated blood pressure in the acute care setting: a scientific statement from the American Heart Association. Hypertension. 2024;81(8):e94-e106. (Scientific statement) DOI: 10.1161/HYP.0000000000000238

7. * Rossi GP, Rossitto G, Maifredini C. Management of hypertensive emergencies: a practical approach. Blood Press. 2021;30(4):208-219. (Systematic review; 18 studies) DOI: 10.1080/08037051.2021.1917983

8. * Gemme S, Meltzer AC, et al; American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Asymptomatic Hypertension. Clinical policy: a critical issue in the outpatient management of adult patients presenting to the emergency department with asymptomatic elevated blood pressure: approved by the ACEP Board of Directors January 22, 2025. Ann Emerg Med. 2025;86(1):e1-e11. (Clinical policy statement) DOI: 10.1016/j.annemergmed.2024.09.016

9. * US Centers for Disease Control and Prevention. Estimated hypertension prevalence, treatment, and control among U.S. adults. Million Hearts. Updated May 12, 2023. Accessed November 15, 2025.(Government statistical data)

32. * Whelton PK, Carey RM, Aronow WS. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APHA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College Of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71(19):e127-e248. (Clinical practice guideline) DOI: 10.1161/HYP.0000000000000066

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Keywords: elevated blood pressure, high blood pressure, hypertension, stage 1 hypertension, stage 2 hypertension, severe hypertension, hypertensive emergency, BARKH, primary hypertension, secondary hypertension, coarctation of the aorta, lifestyle modifications, DASH diet, antihypertensive, thiazide, diuretic, ACEI, ARB, calcium-channel blocker, PREVENT