When Will We Learn?


Hey, its ERP from ER stories doing a guest rant post.

OK, I have blogged about this before, but nearly every shift, I have cases which emphasize the need to repeat myself.

When the hell with doctors learn to stop obsessing about hypertension?  I don’t mean to say that we should not treat it – of course we should. I am talking about blaming every symptom a patient is having on it.  I am talking about aggressive lowering of the BP in the acute setting.  It is just stupid.

If I had a nickle for every time a patient’s headache or dizziness is attributed to hypertension I would be a millionaire.  The sad truth is that it almost never is!  The BP is a REACTION to the symptoms not the cause.  This is obviously true in people who are chronically hypertensive – it took years for them to develop it so why do we think we need it lowered in 5 minutes?  Of course their pressure will go up to 200 when they have pain.  And guess what, lowering it fast will probably make new problems – like syncope and rebound hypertension caused by crappy old drugs like Clonidine.

This is different than when a young person has hypertensive encephalopathy or when someone has a big head bleed (where you want to lower the pressure only a small amount) or an aortic dissection.  They people do need IV treatment but almost no one else does!

I just had a patient who was admitted to three days in England (where he was visiting I assume)  for “hypertensive emergency” because he was having a room spinning sensation and a systolic pressure of over 200.  Guess what, they lowered his pressure and gave him new drugs to go home with but he still had dizziness! Why? He had obvious benign positional vertigo!  I gave him antivert (an antihistamine that works well for it) and it went away!   And as a bonus, his pressure came down on its own!

So, patients do not check your BP when you feel pain or dizziness (unless you are on the verge of passing out – in which case you are looking to see if your BP is LOW), check it when you feel normal and have been chilling out for 10-15 minutes.  Do that over several weeks and show the numbers to your doctors and let him or her decide treatment.

Doctors, do not attribute every headache, vertiginous episode, or other discomfort referable to the head to hypertension.  Do not agressively lower it in the ER or your office and then discharge the patient.  Do not give someone labatelol because the have a nose bleed.  Do not fail to examine someone and miss benign positional vertigo.  Don’t just treat the number to make yourself feel better!  Treat hypertension for the long term!


  1. AMEN.

    and don’t send them from the ENT office, dentist office, work comp office, urgent care, dermatology office, etcetera because the BP is high. I don’t care

  2. I agree with your post about hypertension not being an ED problem except in certain circumstances but why did you then illustrate this with a patient who had been in UK? He was not in the ED and had been admitted for 3 days where he would have been thoroughly investigated.

  3. GrumpyRN,
    This patient said he had just gotten back from the UK – where less than a week prior had been in hospital for three days for “severe hypertension”. He said he presented with similar complaints of dizziness and was admitted for the BP. He stated he did not get a CT of the head or neurological examination and it sounds like vertigo was not considered as a cause of his symptoms. However, he was given BP meds and what sounds like cardiac testing (I assume seriel enzymes and echo but no stress test)during his stay. Of course his symptoms never really abated and thus he came to me shortly after his return to the states. Antivert was the trick!

  4. The reverse can also hold true. I had a patient whose doctor had stopped her BP med because she reported dizziness. She was not hypotensive, and she had been taking the same medication for years. Patient falls, goes to ER, gets diagnosed with viral labrynthitis. And, her BP, which had been controlled for years, is now high. Hhmmmm…wonder how that happened. Sigh…

  5. “Severe hypertension” is not a reason to admit a patient to hospital in the UK, this is managed in the community by the patients own GP.
    My comment was purely in response to you stating ED then giving an example which was not ED. Patients in UK who go through ED have to be admitted to a ward within 4 hours of arrival.
    Impossible to comment on any particular patient without seeing FULL history and notes.

  6. True GrumpyRN, I had no access to the hospital notes – only what the guy told me. However, it sounds like they admitted him for a BP of over 200 systolic – so I guess you may call it “malignant” or “accelerated” or whatever. However, I maintain it was a response to his vertigo and headache and not a cause.

  7. i would be interestd to know your opinion about immediately wanting to treat a patient with apparent hypertension in the primary care field… this included ekg, echocardiogram, and renal ultrasound. how do you differentiate chronic hypertension from that related to anxiety?

  8. I agree.

    However, I get “Peer Review” feedback for not giving an Urgent Care patient clonidine when their BP is 180-200+ systolic! If I get enough of these then I get sent to Peer Review committee to explain why I did not follow the “Standard of Care”. If I get enough of these reviews then I get questioned every 2 years when I re-credential for the hospital.

    And I am the Credentials Chair!!

    • Our goofy hospital had some consultant (God knows who that was) come in and declare that patients with hypertension should have that “addressed” in the documentation in the ER.

      Guess what happened? Everyone with a broken arm and some pain got to stay a long time getting dose after dose of clonidine.

      I would maybe think that putting a note in the chart to follow-up in your clinic when pain-free for a BP recheck would suffice, but everyone freaked out and is now acutely lowering htn for whatever reason. Toothacheurs with htn are getting put on monitors and given IV lopressor.

      I kid thee not.

  9. Hashmd, I hear of this sort of thing all the time. It is completely out of date thinking. Remember when people gave that sublingual Procardia back in the day? People did not do well! I see other docs -in the ER especially, give people Clonidine just to get the number down before discharge. Guess what, if that person does not continue on it or misses a dose, it goes flying back up even higher! When they come back the next day with persistent dizziness (because they have vertigo!) the BP is 220!
    If course you need to “address” high BP before discharge but that can mean starting them on something PO gentler (like Norvasc or whatever) or telling them to increase their dose of whatever they are on. Giving IV Hydralizine and sending them on their way is both not necessary and dangerous!

  10. So, is Clonidine not a good drug to use at all or just not good to use in an emergency situation with possible causes other than high BP? My mom had renal failure last month (luckily was reversed quickly) that is suspected to have been caused by Lisinopril and so she was taken off of this and put on Clonidine. I’m wondering if we need to ask our family doc to review this decision.

  11. Clonidine is just a bad drug. It is very old and very powerful. It should be reserved for those who are refractory to everything else. It works centrally (ie in the brain) and causes the BP to drop fast – but it rebounds quickly (often higher than it was originally) as soon as it starts to wear off. It is popular for people in renal failure who don’t respond well to other drugs but if your mother’s kidneys are good, it might be worth trying her on something like a calcium channel blocker or beta blocker. Of course if they don’t work on her, you can stay on Clonidine – just make sure she is compliant with taking it. The problem I see is doctors just giving a dose of it in the ER or office just to get the number down lower before they go home – probably done out of ignorance and well as medical-legal fears. I just start people on something gentler and tell them to get the pressure checked at their doctor’s in a week.
    As for other testing in the acute setting, I think if someone is poorly controlled for a long time but asymptomatic, a urine looking for protein and casts as well as an EKG to look for LVH (but that is not really specific) is probably all they need. The only other thing I would check if there was time was a BUN and Creatinine – if they are elevated, or if there is a lot of protein or casts in the urine I would not give an ACE inhibitor and urgently refer them for follow up. If they are a diabetic and have only microalbuminuria (trace amt of protein on the UA most likely), then an ACE inhibitor is a good choice presuming creatinine is OK.

  12. I am always amazed at the number of people who come in because they did a blood pressure at home and it was high. It usually isn’t when they get to the ER.

    MY ADVICE: throw out your blood pressure measuring device and just live your life…

  13. From a patient’s perspective: I sure wish you doctor’s would get this worked out. It is confusing and frustrating as a patient to be ping-ponged this way. By ping-ponged, I mean your PCP sends you to the ER, and the ER doc says go home…and as the patient there you are in that stupid gown trying to figure out which doctor to believe…Yes, I am speaking from experience. My blood pressure which is normally well controlled (with meds)started going up (over a couple days) and then I got a migraine type headache (which was entirely new for me). So which came first the chicken or the egg?

  14. Hi Girlvet – I respectfully disagree with the throw out the bp cuff.

    I have a little wrist one that hardly gets used, but I had a headache all day that exacerbated to borderline migraine by the time I got home in the evening.

    Turned out all I had was some left over percocet from a kidney stone a few months earlier and so I took one. It took the edge off, but it never went away. I rested all night, watching tv on sofa but by 11 pm ..using that cuff ..I could see my bp was somewhere around 227/115 (highly unusual. It had been climbing during the evening.

    I got scared, went to the ED, they did a head ct (normal) and gave me clonidine. All better.

    If I had not see my bp ..I would’ve just gone to sleep and I don’t know if that would’ve been a good thing to do.
    ***This post and comments has added to my confusion regarding this med.

    I was put on 50 mg of spironolactone for hypertension a few years prior to that incident. Doc chose that because I was worried about the hair loss associated with bp meds. I don’t think it was effective as I know other people’s bp meds to be because I seemed to remain in what was considered borderline in the early 90s .. like 140/92 ..kind of like that. But ..I didn’t want to lose my hair and so I remained quiet.

    I followed up with pcp a couple days later and so he felt that since the clonidine worked ..he put me on 0.1 mg at bedtime. Then a gyne doc asked why I was on those because there are much better meds to control blood pressure. Still..I didn’t say anything ..(hair)

    But then last spring I had an echocardiogram (normal)but my bp was up. So I did say I didn’t think the spironolactone (50mg) was effective fro me. HE switched and put me on 0.1 mg in the am too. So ..i did tell him about what the gyne doc said and he said clonidine was a good drug. (It doesn’t cause hair loss either 🙂

    I don’t see a cardiologist either ..I just wanted to go to a specialist to be sure with the echo.

    Anyway ..the clonidine does manage the bp pretty well… certainly better than the other one.

    When I looked side effects up ..I thought it said something about causing blood clots or stroke if stopped abruptly. Is that true?

    Also ..does anyone know if there are any better alternatives to the clonidine (that will NOT cause hair loss), that I can then discuss with my pcp next time I go in?

    A bald SeaSpray would be a very STRESSED SeaSpray,which would negate any lowered bp from said bald inducing med.

  15. Seapray, Your HTN and your headache were unrelated. The Clonidine had nothing to do with the headache- it just brought yout BP down and I bet it went back up later that night when it wore off. If you went to sleep your BP being high was just a matter course. If you are really concerned, get continuous ambulatory BP monitoring ordered by your PMD and see what it is as you go about your day/week. The results will surprise you I bet.

  16. Hi ERP – that was back in summer 04. It is managed well now ..with the 2 doses (am/pm)of 0.1 mg clonidine.

    Of course I don’t know if it goes back up in between morning and night but, I think it’s way better than when on 50mg of spironolactone.

    I did think the headache started it. It also was gone by the time I left the ED ..but I also fell asleep there and so perhaps that is why.

    I know no one may want to answer this but is there a better alternative than clonidine that would also be hair sparing? Of course we all respond differently.. but what are the popular/preferred blood pressure meds?

  17. Well, Clonidine should be reserved for people with refractory severe HTN that does not respond to other drugs – or if other drugs are otherwise contraindicated. ACE inhibitors, ARB’s, Beta Blockers, and Calcium Channel Blockers are commonly started first. Some people may need or respond well to diurectics. There are many choices before resorting to these old 1960’s drugs like Clonidine, Reserpine, Methyldopa, Minoxidil, etc.
    Spirinolactone is usually an adjunctive drug for people who have an issue with losing potassium in the urine since it spares K+.

  18. Thank you ERP. I don’t pretend to understand it all ..but it would seem then that I should be saving the Clonidine if God forbid ..it was a last ditch effort. The Hair though… I like my hair and want to keep it. 🙂

    My understanding is that is that I take a low dose of clonidine and so maybe that is better regarding the concerns. ?

    The 50mg spironolactone wasn’t initially for htn, but a water pill because we thought the diazide was causing a rash. I do remember pcp saying it would be potassium sparing… but I never had an issue with potassium loss.

    Anyway.. this spring..when I saw the other doc (1 time) he said spironolactone wasn’t as effective as a diuretic then some diazide he put me on. Then I go back to pcp and he started to say “but the spironolactone is better because” ..and then he stopped himself. I adore my doc, but I hate when docs do that! They don’t want to step on their colleague’s toes.

    I think it would be better for the *patient* if they said what *they* think and then let the patient decide. If they have a strong opinion about something they should just say it because the colleague is not their patient ..their patient is and if they believe something is better for their patient then a colleagues does … then they should speak up regardless… even though the colleague weighed in with a different opinion. Then present all the facts to the patient..wade through it with them and let the patient decide what’s best… assuming they have the capability to do so.

    I have a great rapport with my pcp and I could’ve pushed for an explanation.

    That being said ..I did not push for his opinion because the diazide worked more effectively. Then because I swim and am in the sun a lot ..I switched back to the spironolactone in the summer then back to the diazide one in the fall.

    What I need to do (admittedly a struggle), is LOSE weight and this would all be a moot point!

    Guess I should suck it up about the hair and have a talk with my pcp again. I also know another cardiologist from work ..maybe I could just run it by him and get a 4th opinion in the mix. 😉

    ERP ..I appreciate being able to have read your informative post Thank you for sharing your thoughts about the med! Hopefully some ED docs will rethink their use of the drug too.

  19. A – fu*king – men !!!
    This idea that high BP causes headaches is so entrenched, it can cripple an ED. I bet (not exaggerating) that 10-15% of the patients in our ED every day are there because their BP is high. Some will flat out state that they came because their BP was high; others will make up some complaint like headache or, worse, dizziness…oh, the time and money wasted!!
    I nearly lost it last week. A 50-something female c/o worst headache of life (vitals wnl except mild tachcardia and BP 160s/90s). CTH neg. Multiple attempts at the LP by junior then senior residents and an attending were unsuccessful.
    A neurology consult was placed for planned admission for fluroscopic LP.
    The neuro attending’s assesment? Headache caused by hypertension! The neuro attending stated, “She (the patient) tells me she knows when her pressure is high because she always gets a headache then.”
    I didn’t know what to do beyond stare blankly.

  20. Sorry, I have been away and thought this thread had finished.

    A patient attending an A&E(ED) in UK with a BP of 200+ systolic would NOT be admitted for that, there has to have been another reason. He should have had a discharge letter from the hospital stating why he was admitted, what his diagnosis was and what medication he was discharged on. One reason I can think of is that he went to a private hospital which would do anything if it was being paid, NHS is a bit more selective.

    A personal observation, had a lady appear at triage one Sunday morning who stated that the reason she was there was because her BP was high and she wanted it “checked”. She was informed by me that under no circumstances would I check her BP unless it was clinically indicated – it wasn’t. She had no symptoms of any kind but she thought it was high. She was advised that she should see her own doctor and that an A&E department was not the place to deal with this. Very unhappy lady whose BP probably got even higher after she had moaned at me and I had refused to do anything for her.

  21. I reread my comments as well as the new ones and would not go to the ED because of a *headache* ..well unless a migraine didn’t subside, But I always managed to get rid of those with 600 mg I-buprofen and 50 mg of Benadryl ..then wake up perfectly fine.

    I didn’t think the elevated BP caused my headache ..but because I was hurting so much I checked the bp. Still no need to go to ED and hoped it would pass.

    Again ..please bear with me because I have no idea whether or not bp would go up with an impending stroke.

    But what eventually freaked me out ..yes ..I admit it did ..but not until going through denial first ..I then became scared I could stroke out because the bp was climbing. NEVER did that before… or since. (aug 2004) The headache was minimal at that point. I was resting and yet bp was 227/115 (ballpark -was at least that high). I didn’t know if it would keep climbing or what that would mean. My concern was stoke.

    Not having any medical expertise … I thought I *should* be evaluated by an emergency physician.

    Now after reading the comments here tonight..I wonder if I even needed the head CT or was that just done for CYA purposes?

    Because as a patient..I was not seeking specific tests or treatment because I did not know what they would or should be. I thought if the ED doc orders it ..then he must’ve thought I needed it.

    Was I *WRONG* to seek the medical expertise of the ED physician around midnight on a Friday night?

    Should I have called my pcp who I have never gotten on a weekend because he always has a doc from another county covering? And should I have waited for the return call? And then ..I am going to guess that the doc who does not know me from Adam..would have TOLD me to go to the ED.

    Regarding my bp going back up after the clonidine wore off ..I followed up with my pcp the following Monday (3 days later) afternoon and it went to where it usually was with the spironolactone .. 140s or 150 over 90 something. Don’t recall now.

    **** Is there any reason a patient with escalating bp as mine was in the 200s should go to an emergency room if their private docs aren’t available? *****

    ***Or was I wrong to seek treatment in the ED when my bp was so high and seemed to be at a steady climb while at rest?

    I worked with an ED for 20 years (reception) and would *never* go and waste their time for something I knew was not important.

    Most patients (not talking about the frequent fliers who use the ED as a clinic), go to the ED because they are concerned they have an *emergency* and their doc is NOT available. I have seen the other side of that and do know how frustrating stupid things are to the medical staff, especially when it is bogging down the ED, etc. How many times do patients call into the ED seeking advice for something simple, which of course staff can’t risk advising for(for fear of error and lawsuit)and so they tell the patient they can’t give advice over the phone but if they would like to come in the staff will be happy to see them?

    Most patients coming into the ED ..think *their* emergency *is* an emergency. Even the 3 week arm pain that comes in at 2 am.

    I really would have thought that a bp climbing like that was a *potential* emergency. if it wasn’t ..I would’ve preferred sleeping in my bed… seriously.

  22. Seaspray, No I don’t think it is wrong for you to ask for the ER doc’s advice-after all if you are not a doctor, how can you know? However, I fault MD’s who perpetuate the myth that acute BP rise is the cause of all symptoms and must be brought down immediately. We need to concern ourselves with BP over the long term.
    And GrumpyRN, you are probably right – the patient did not have d/c papers but this sort of thing (admission for “HTN” when in fact the cause of the HTN is not addressed) happens here all the time – and I think all over the world!

  23. One last question.

    I thought I’ve heard the ED nurses, concerned about a patient’s high bp say they were concerned about the patient stroking out ..but maybe they were reacting to something else that I am unaware of.

    ***Is there a correlation to excessively high bp and strokes? If so what are the parameters of elevated bp that if a patient goes over ..you would want them to come in?

    Out of the blue ..my numbers went wackadoodle and were climbing. As I said ..never did it again.

    ***What is the DANGER ZONE of BP readings?

    ***Also ..regarding the head ct ..it’s easy to Monday morning quarterback ..normal ct ..thus I didn’t need the head ct.

    Everyone talks about lawsuits and cya medicine.

    ***What is the criteria used to determine if indeed the patient should get the head ct?

  24. Seaspray, this is not an easy question to answer. The important thing is that any PERSISTENT readings of over 140/90 are considered hypertension and thus are of concern (although some are recommending treatment for numbers as high as 135/85). It is defined (at least as I remember) as three readings of over this number over at least a three week period.
    In reality, I think the important thing is to know what your BP randomly over a week or more – randomly meaning at all times of the day and night. This is accomplished by something called continuous ambulatory blood pressure monitoring. Basically you wear a small machine and cuff for a week or more and it randomly goes off, taking and recording the readings. The data is then reviewed at the end and the determination is made if you are running high often enough to call it Hypertension – either meds and/or lifestyle modifications are then instituted.
    Again, there is no specific number at any particular time that is dangerous with a few exceptions. One being when a young, otherwise health person suddenly gets a very high BP (like well over 200 systolic) and, not normally being hypertensive, develops altered mental status and encephalopathy (like what a pheochromocytoma can cause). Other true hypertensive emergencies are if you have an aortic dissection, acute renal failure (not chronic), or an intracranial haemorrhage. Other than in those instances, you want to bring the BP down slowly over days to weeks or more in a safe fashion.
    And yes, RN’s, Doctors, and the community at large over treat HTN in the acute setting, getting all worked up over a particular number when in fact we need to “amortise” it over time and be concerned at what those average numbers are. I think it is partially due to ignorance and partially due to medical malpracise fears as well. In any case, it is not good medicine.

  25. Oh and the criteria for head CT is totally different. It is based on a clinical suspicion of a bleed or tumour or something else bad, not just the blood pressure. And that is a separate discussion, but suffice it to say that abrupt, sudden onset severe crushing headaches are worrisome and deserve imaging (regardless of the BP), as well an abnormal neurological findings in the set of a bad headache.

  26. I didn’t present with the severe crushing headache at that point (it was earlier)and I would guess my neuro eval was normal.

    Maybe my uttering the words fear of stroke was enough to warrant the ct. 🙂

    When I go in for my next physical ..I will diplomatically question the clonidine with my pcp.

    Still concerned about hair though. I really like having hair and it’s down on my shoulders and below and if I bald on top ..then this SeaSpray will look like one of those weird balding with tufts of long hair Dr Seuss critters ..and I’m just not ready for that. 😉

    I truly appreciate being better informed through what I have learned through your post and comments.

    Thank you ERP. 🙂

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