Recognizing asymptomatic elevated blood pressure in ED patients: how good (bad) are we?

Tilman, Keri; DeLashaw, Mini; Lowe, Sean E.; Springer, Sandy; Hundley, Susan; Counselman, Francis L.

doi:10.1016/j.ajem.2006.09.007

Cited by 40 publications

(47 citation statements)

References 26 publications

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“…21 However, that study included all-comers to the ED and did not assess average BP values or patient comorbidities. Another study that screened all ED patients for hypertension reported that 8.5% of patients were offered an antihypertensive prescription if their BP was 160 systolic or 100 diastolic mm Hg, 22 a finding similar to our study where 5% of participants offered an antihypertensive prescription at 160/100 mm Hg.…”

Section: Discussionmentioning

confidence: 99%

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: 99%

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

Cho

Austin

Atzema

2015

CJEM

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“…For instance, several studies have established thresholds and referral practices for elevated blood pressure and its correlation with outpatient diagnosis of hypertension, [23][24][25] which has led to incorporation of this ''passive'' screening into national guidelines for emergency medicine. 26 Such recommendations must be weighed against competing concerns, including ED crowding, understaffing, unavailability of primary care follow-up, and medical-legal liability from new diagnosis without follow-up, which may limit the feasibility of even passive screening.…”

Section: Discussionmentioning

confidence: 99%

Point‐of‐care Glucose and Hemoglobin A1c in Emergency Department Patients without Known Diabetes: Implications for Opportunistic Screening

Ginde

Cagliero

Nathan

et al. 2008

Academic Emergency Medicine

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Objectives: The objectives were to evaluate the correlation between random glucose and hemoglobin A1c (HbA1c) in emergency department (ED) patients without known diabetes and to determine the ability of diabetes screening in the ED to predict outpatient diabetes.Methods: This was a cross-sectional study at an urban academic ED. The authors enrolled consecutive adult patients without known diabetes during eight 24-hour periods. Point-of-care (POC) random capillary glucose and HbA1c levels were tested, as well as laboratory HbA1c in a subset of patients. Participants with HbA1c ‡ 6.1% were scheduled for oral glucose tolerance test (OGTT). Results:The 265 enrolled patients were 47% female and 80% white, with a median age of 42 years. Median glucose and HbA1c levels were 93 mg ⁄ dL (interquartile range [IQR] = 82-108) and 5.8% (IQR = 5.5-6.2), respectively. The correlation between POC and laboratory HbA1c was r = 0.96, with mean difference 0.33% (95% confidence interval [CI] = 0.27% to 0.39%). Glucose threshold ‡ 120 mg ⁄ dL had 89% specificity and 26% sensitivity for predicting the 76 (29%) patients with abnormal HbA1c; ‡ 140 mg ⁄ dL had 98% specificity and 14% sensitivity. The correlation between random glucose and HbA1c was moderate (r = 0.60) and was affected by age, gender, prandial status, corticosteroid use, and current injury. Only 38% of participants with abnormal HbA1c returned for OGTTs; 38% had diabetes, 34% had impaired fasting glucose ⁄ impaired glucose tolerance, and 28% had normal glucose tolerance.Conclusions: ED patients have a high prevalence of undiagnosed diabetes. Although screening with POC random glucose and HbA1c is promising, improvement in follow-up with confirmatory testing and initiation of treatment is needed before opportunistic ED screening can be recommended.

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“…To our knowledge, this investigation is the first prospective investigation that required three BP assessments as a criterion for the determination of an elevated BP in ED patients. 9,[12][13][14][15][16][21][22][23][24][25] Although three measurements were used, the prevalence of ED patients with elevated BP in our study remained high. This population may represent a unique opportunity for an ED-based referral for further BP assessments in patients with no prior history of HTN and for improved treatment of suboptimally controlled hypertensive patients.…”

Section: Discussionmentioning

confidence: 99%

“…The implementation of screening and referral of hypertensive ED patients appears a natural extension of emergency-based health care. [9][10][11] Yet scientific evidence supporting such screening measures is limited at best. Prevalence estimates of uncontrolled blood pressure (BP) (systolic blood pressure [sBP] of R140 mm Hg or diastolic blood pressure [dBP] of R90 mm Hg) in ED patients range from 3% to 45%.…”

mentioning

confidence: 99%

“…[6][7][8] Given the significant costs associated with uncontrolled HTN and its increased prevalence and morbidity in minorities and the economically disadvantaged, emergency departments (EDs) are now considered potential sites for the screening and referral of such patients. 9 The ED often serves as a proxy for the primary care physician and, in addition, functions as the health care safety net for many communities. The implementation of screening and referral of hypertensive ED patients appears a natural extension of emergency-based health care.…”

mentioning

confidence: 99%

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Characteristics and Referral of Emergency Department Patients with Elevated Blood Pressure

Baumann¹,

Abate

Cowan

et al. 2007

Academic Emergency Medicine

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Objectives: To assess the prevalence, characteristics, and referral to health care of emergency department (ED) patients with elevated blood pressure (BP) and to compare those without a history of hypertension (HTN) with suboptimally controlled, known-hypertensive patients.Methods: A prospective, observational study was conducted in non-critically ill adults with a triage systolic blood pressure (sBP) of R140 or with a diastolic blood pressure (dBP) of R90 mmHg. Two additional measurements were obtained, and a standardized questionnaire recorded demographics, medical history, and ED staff referrals.Results: Of 1,719 nonpregnant adults, 991 agreed to participate, of whom 455 had elevated triage BP values. Using the mean of three measurements, 305 (67%) had an sBP of R140 or a dBP of R90 mm Hg (mean sBP = 157 and mean dBP = 89 mm Hg). Subjects with no prior history of HTN (n = 105) were predominantly male, younger, and more likely to smoke and consume alcohol than were known-hypertensive patients (n = 200). Three quarters of all subjects had access to primary health care; however, time elapsed since the last BP assessment was greater (155 vs. 53 d, p = 0.03) in subjects with no previous history. These subjects were also less likely to be informed of their elevated BP (33% vs. 50%, p = 0.02) or to be instructed by ED staff to obtain a repeat measurement (13% vs. 31%, p = 0.001).Conclusions: Of ED patients with elevated BP, one third had no prior history, and the remainder were suboptimally controlled hypertensive patients. Both groups were inadequately informed of their elevated BPs, and the group with no prior history of HTN, the population likely to obtain the greatest health benefit, had the lowest referral rate.ACADEMIC EMERGENCY MEDICINE 2007; 14:779-784 ª

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Recognizing asymptomatic elevated blood pressure in ED patients: how good (bad) are we?

Cited by 40 publications

References 26 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

Point‐of‐care Glucose and Hemoglobin A1c in Emergency Department Patients without Known Diabetes: Implications for Opportunistic Screening

Characteristics and Referral of Emergency Department Patients with Elevated Blood Pressure

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