A 49-year-old woman with no known medical history presents to urgent care for evaluation of new-onset hypertension discovered during a health screening at work. She is asymptomatic. Her blood pressure readings in urgent care are consistently 152/94 mm Hg on repeat measurements. She does not have an established primary care provider but has an appointment scheduled with a new internist in 6 weeks, which was the soonest available appointment she could find with a clinician who accepts her insurance plan. She is concerned about waiting that long and asks if you can start her on medication today. She has no known drug allergies and her physical examination is unremarkable.
What is the most appropriate management approach for this patient?
- Advise her to keep the appointment with the internist for further evaluation and provide reassurance that her elevated blood pressure readings do not need to be addressed immediately.
- Calculate her 10-year CVD risk using PREVENT before making any decisions.
- Counsel her on lifestyle modifications, consider initiating a first-line antihypertensive medication, and arrange follow-up in 2 to 4 weeks.
- Refer her to the emergency department for urgent blood pressure management.
Click to see the answer
Correct Answer: c. Counsel her on lifestyle modifications, consider initiating a first-line antihypertensive medication, and arrange follow-up in 2 to 4 weeks.
This patient has stage 2 hypertension (ie, systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg), so treatment with both lifestyle modifications and pharmacologic therapy is indicated by the current guidelines, regardless of her 10-year CVD risk per PREVENT. She is asymptomatic and has no evidence of acute end-organ damage, so ED transfer is not indicated. She should be counseled on lifestyle modifications, and initiation of antihypertension medication in urgent care should be considered because she is not able to obtain prompt follow-up care. Waiting for 6 weeks for her appointment with the internist without any intervention would be a missed opportunity to initiate appropriate management.
After explaining the diagnosis of stage 2 hypertension to the patient, you agreed to initiate antihypertensive treatment due to the 6-week delay until her primary care appointment. You obtained baseline laboratory studies, including a comprehensive metabolic panel, lipid panel, and urinalysis, to screen for secondary causes of hypertension and assess her baseline renal function before starting medication. After reviewing her laboratory results, which were normal, and confirming there were no contraindications, you prescribed amlodipine. You educated her on potential side effects of amlodipine, particularly peripheral edema, and recommended that she purchase a home blood pressure monitor to measure her blood pressure daily, at the same time each day, and keep a log to bring to follow-up appointments. You also counseled her on dietary modifications, physical activity, weight management, alcohol moderation, and stress management.
You reviewed red flag symptoms that would warrant seeking emergency care, including severe headache, chest pain, shortness of breath, visual changes, focal weakness or numbness, or altered mental status. She planned to return to your urgent care clinic in 2 weeks for blood pressure recheck and medication titration if needed and confirmed that she will keep the appointment with the new internist in 6 weeks for long-term management.
For an in-depth review of this topic, access the full course.
Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
