Bed Rest First for Hypertensive Urgencies?

The article by Grassi and colleagues ¹ (page 662) evaluates the blood pressure (BP) response to rest and to different antihypertensive drugs in hypertensive urgencies, defined as BP levels >180/110 mm Hg without evidence of acute target organ damage. Many experts might not consider a BP level <200–210/110–120 mm Hg as a hypertensive urgency. Nevertheless, 180/110 mm Hg was the cutoff in the definition that was used. The authors advise rest as initial treatment before the use of specific medications. While a decrease in BP may occur, any BP response during a 30‐minute rest period may lead to a false sense of security on the part of the treating physician.

It has long been recognized that the use of agents to lower BP quickly (within 1 or 2 hours or sooner) in patients with accelerated or malignant hypertension with high levels of BP (>200/110 mm Hg) and acute target organ damage (ie, heart failure, hypertensive encephalopathy, or dissecting aneurysms) is acceptable therapy. However, this is probably unnecessary and may be hazardous in patients with BP values even >200/110 mm Hg who do not have signs or symptoms of acute organ damage. The authors correctly state that the use of intravenous therapy to lower BP rapidly may not be necessary in these patients and may pose some risk of hypotension: most experts will agree.

It is also well known that rest will lower BP regardless of the initial level. Grassi and associates described a mean reduction after 30 minutes of rest in responders of approximately 22 mm Hg systolic BP and approximately 14 mm Hg diastolic BP to levels that average about 160/90 mm Hg (31% of patients). This is not unusual; many patients will experience this type of response. However, this approach is quite impractical and may not represent the best treatment. If a poor response is noted (nonresponders), the authors suggest that drug therapy be undertaken.

It would appear more logical given the crowded conditions of most emergency departments in hospitals to begin drug therapy as soon as possible, avoiding intravenous therapy and sudden decreases in BP. Admittedly, some of the initial decrease in BP noted with medication may be secondary to a “rest” component, but overall lowering of BP will be more satisfactory than waiting to see what happens without specific treatment. Of importance, specific therapy is almost always necessary. There is another problem if BP is reduced by rest. The patient may not be given further treatment, even if the decrease in BP is not optimal. There is abundant evidence that patients who present with BP levels >180/100 mm Hg will always require specific medical therapy. In Grassi's study, responders were discharged without specific therapy.

Most of the agents used (calcium channel blockers, angiotensin‐converting enzyme inhibitors, diuretics, angiotensin receptor blockers, or α–β‐blockers) can be given orally and safely in these patients with an expectation that BP will decrease. Above all, after BP has been reduced to levels of 140 to 160/90 to 100 mm Hg, patients must be given medication to continue at home with a short‐term follow‐up.