Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure

Wolf, Stephen J.; Lo, Bruce M.; Shih, Richard D.; Smith, Michael D.; Fesmire, Francis M.

doi:10.1016/j.annemergmed.2013.05.012

Cited by 110 publications

(89 citation statements)

References 21 publications

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“…7,9,10 Currently, however, there are few data to guide the number of days within which such patients should be seen; ACEP has identified this as an area in need of future study. 8 In our study, recommendations for timing of follow-up care varied by patient presentation, but the large majority of participants endorsed follow-up within seven days.…”

Section: Discussionmentioning

confidence: 67%

“…16 The current ACEP (American College of Emergency Physicians) guidelines are concordant with the JNC 7, with the caveat that they deemed treatment could be warranted in certain patient populations, such as those with poor follow-up care. 8 A 1967 study found that among 143 discharged men with a diastolic BP between 115 and 130 mm Hg, those who were not given an antihypertensive prescription had an adverse event rate 6% higher at 4 months and 36% higher at 20 months, compared to those who were provided a prescription. 17 However, the confidence intervals of this finding were wide and the data are not current.…”

Section: Discussionmentioning

confidence: 99%

“…8 We suspect that this results in wide practice variation amongst emergency physicians. Whether or not emergency physicians routinely offer new antihypertensive prescriptions (or increase the dose of pre-existing prescriptions) is unknown, as is the timeframe within which they advise patients to obtain follow-up care.…”

Section: Introductionmentioning

confidence: 99%

“…Most of the existing emergency medicine literature on this topic has extrapolated from primary care guidelines to the ED setting. 8,9 The 2006 American College of Emergency Physicians (ACEP) policy statement indicates that patients with asymptomatic hypertension require "prompt... follow up with their primary physician;" however, a specific timeframe was absent. 10 In the absence of evidence, the practice of one's peers forms a de facto standard.…”

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Cho

Austin

Atzema

2015

CJEM

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Introduction: Many patients are seen in the emergency department (ED) for hypertension, and the numbers will likely increase in the future. Given limited evidence to guide the management of such patients, the practice of one's peers provides a de facto standard. Methods: A survey was distributed to emergency physicians during academic rounds at three community and four tertiary EDs. The primary outcome measure was the proportion of participants who had a blood pressure (BP) threshold at which they would offer a new antihypertensive prescription to patients they were sending home from the ED. Secondary outcomes included patient-and providerlevel factors associated with initiating an antihypertensive based on clinical vignettes of a 69-year-old man with two levels of hypertension (160/100 vs 200/110 mm Hg), as well as the recommended number of days after which to follow up with a primary care provider following ED discharge. Results: All 81 surveys were completed (100%). Half (51.9%; 95% CI 40.5-63.1) of participants indicated that they had a systolic BP threshold for initiating an antihypertensive, and 55.6% (95% CI 44.1-66.6) had a diastolic threshold: mean systolic threshold was 199 mm Hg (SD 19) while diastolic was 111 mm Hg (SD 8). A higher BP (OR 12.9; 95% CI 7.5-22.2) and more patient comorbidities (OR 3.0; 95% CI 2.1-4.3) were associated with offering an antihypertensive prescription, while physician years of practice, certification type, and hospital type were not. Participants recommended follow-up care within a median 7.0 and 3.0 days for the patient with lower and higher BP levels, respectively. Conclusions: Half of surveyed emergency physicians report having a BP threshold to start an antihypertensive; BP levels and number of patient comorbidities were associated with a modification of the decision, while physician characteristics were not. Most physicians recommended follow-up care within seven days of ED discharge.

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Section: Discussionmentioning

confidence: 67%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Cho

Austin

Atzema

2015

CJEM

View full text Add to dashboard Cite

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“…In the specific case of hypertension, the American College of Emergency Physicians' most recent clinical policy reflects this uncertainty, stating that it cannot recommend for or against any medical intervention for hypertension in the ED, beyond referral to primary care (19). Emergency physicians have the potential to drastically improve patients' lives by diagnosing, evaluating, treating and referring for follow-up the many patients with chronic, uncontrolled conditions who come through our doors.…”

Section: Future Directionsmentioning

confidence: 99%

Primary Care in the Emergency Department – An Untapped Resource for Public Health Research and Innovation

Brody¹,

Clark²,

Flack³

et al. 2014

West Indian Med J

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Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting

et al. 2016

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IMPORTANCEThe prevalence and short-term outcomes of hypertensive urgency (systolic blood pressure Ն180 mm Hg and/or diastolic blood pressure Ն110 mm Hg) are unknown. Guidelines recommend achieving blood pressure control within 24 to 48 hours. However, some patients are referred to the emergency department (ED) or directly admitted to the hospital, and whether hospital management is associated with better outcomes is unknown.OBJECTIVES To describe the prevalence of hypertensive urgency and the characteristics and short-term outcomes of these patients, and to determine whether referral to the hospital is associated with better outcomes than outpatient management. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study with propensity matching included all patients presenting with hypertensive urgency to an office in the Cleveland Clinic Healthcare system from January 1, 2008, to December 31, 2013. Pregnant women and patients referred to the hospital for symptoms or treatment of other conditions were excluded. Final follow-up was completed on June 30, 2014, and data were assessed from October 31, 2014, to May 31, 2015.EXPOSURES Hospital vs ambulatory blood pressure management. MAIN OUTCOMES AND MEASURESMajor adverse cardiovascular events (MACE) consisting of acute coronary syndrome and stroke or transient ischemic attack, uncontrolled hypertension (Ն140/90 mm Hg), and hospital admissions. RESULTSOf 2 199 019 unique patient office visits, 59 836 (4.6%) met the definition of hypertensive urgency. After excluding 851 patients, 58 535 were included. Mean (SD) age was 63.1 (15.4) years; 57.7% were women; and 76.0% were white. Mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 31.1 (7.6); mean (SD) systolic blood pressure, 182.5 (16.6) mm Hg; and mean (SD) diastolic blood pressure, 96.4 (15.8) mm Hg. In the propensity-matched analysis, the 852 patients sent home were compared with the 426 patients referred to the hospital, with no significant difference in MACE at 7 days (0 vs 2 [0.5%]; P = .11), 8 to 30 days (0 vs 2 [0.5%]; P = .11), or 6 months (8 [0.9%] vs 4 [0.9%]; P > .99). Patients sent home were more likely to have uncontrolled hypertension at 1 month (735 of 852 [86.3%] vs 349 of 426 [81.9%]; P = .04) but not at 6 months (393 of 608 [64.6%] vs 213 of 320 [66.6%]; P = .56). Patients sent home had lower hospital admission rates at 7 days (40 [4.7%] vs 35 [8.2%]; P = .01) and at 8 to 30 days (59 [6.9%] vs 48 [11.3%]; P = .009). CONCLUSIONS AND RELEVANCEHypertensive urgency is common, but the rate of MACE in asymptomatic patients is very low. Visits to the ED were associated with more hospitalizations, but not improved outcomes. Most patients still had uncontrolled hypertension 6 months later.

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Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure

Cited by 110 publications

References 21 publications

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Primary Care in the Emergency Department – An Untapped Resource for Public Health Research and Innovation

Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting

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