Institutional Pathways to Improve Care of Patients with Elevated Blood Pressure in the Emergency Department

Abstract

Results from the recent SPRINT trial, and the subsequent publication of the American Heart Association updated guidelines for the treatment of HTN, significantly lower both the diagnostic threshold and the treatment goals for hypertensive patients. This change will drastically increase the proportion of patients presenting to EDs with newly diagnosed and uncontrolled HTN. Several recent studies emphasize the safety in outpatient management of patients with severely elevated BP in the absence of acute end-organ damage and, conversely, the long- and intermediate-term risk associated with these patients. System-based approaches, particularly those led by non-physicians, have shown the greatest promise in reducing population level uncontrolled HTN. Evidence-based approaches, such as those described in emergency medicine and cardiology society guidelines, can guide appropriate management of ED and inpatient BP elevations. Translating these patient oriented guidelines into institutional policy, and maintaining provider adherence, is a challenge across healthcare institutions. We present here several examples of successful policies developed and implemented by the authors. While brief inpatient and ED encounters cannot replace long-term outpatient care, they have the potential to serve as a crucial inlet to health care and an opportunity to optimize care.

2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension

“…However, the clinical significance of a BP elevation in the Emergency Department is not entirely clear, and available evidence is not univocal. In many patients, even a marked BP elevation is restored to normal when pain, distress and anxiety are relieved, thus originating from an alerting reaction [1120,1121]. However, some studies have not shown a close relationship of BP with pain, stress or anxiety in the Emergency Department.…”

The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association

“…For patients with asymptomatic elevated BP presenting to the ED, engaging community health workers, implementing specific care pathways, and providing referral strategies, including harnessing alternative care models to facilitate primary care follow-up and ongoing BP management, are critical to ensuring appropriate and equitable management after ED discharge. 34–40…”

Manejo de Crisis Hipertensiva en la Atención Primaria de Salud

“…Entre las condiciones que entran en la categoría de emergencia hipertensiva se encuentran problemas cardiacos y cerebrovasculares, como el aneurisma disecante de la aorta, el edema agudo de pulmón, enfermedad coronaria aguda (incluidos infarto agudo de miocardio y angina inestable), insuficiencia ventricular izquierda aguda, encefalopatía hipertensiva, accidente cerebrovascular hemorrágico, accidente cerebrovascular isquémico con presión arterial diastólica superior a 120 mmHg, presión arterial sistólica superior a 210 mmHg o necesidad de trombo, y la Necesidad de trombo. accidente cerebrovascular debido a un exceso de catecolaminas circulantes, como en una crisis de feocromocitoma inmediatamente (13).…”

“…Para el diagnóstico es importante excluir adecuadamente el daño agudo de órgano diana, mediante la realización de tres pasos fundamentales que son: anamnesis e historia clínica, examen físico y los exámenes complementarios, este último generalmente se realiza ante un episodio de emergencia hipertensiva como, hemograma, química sanguínea, elemental de orina, electrocardiograma de 12 desviaciones, radiografías y en un nivel de mayor complejidad se puede realizar exámenes de imagen específicos como son tomografía y resonancia magnética dependiendo del caso y la clínica del paciente. Por tanto, la historia clínica debe ser rápida, integral y dirigida, para que el médico pueda realizar un abordaje terapéutico de la forma más rápida y eficaz posible (10,13).…”