Evaluation and Treatment of Asymptomatic Hypertension
May 2019
Vignette
You are working an evening shift in The Deuce when your next patient is roomed—a 53-year-old African American woman whose chief complaint is elevated blood pressure. She tells you that she was at CVS shopping for some Herbal Essences shampoo and
conditioner when she was unable to find her favorite variety, Passion Flower and Rice
Milk. Dejected, she decided to soothe her sorrows by taking a ride on the blood pressure machine. Much to her horror, the machine spits out a result of 205/110. She says she called her doctor’s exchange in a panic and was advised, “For the love of God, woman, go immediately to the nearest Emergency Department or you gon’ die!”
She immediately left the store, drove to the hospital, and waited the 4 hours in the waiting room to see you. She reports no other symptoms beyond the disappointment of the local CVS not carrying her favorite hair products—no chest pain, shortness of breath, headache, dizziness, weakness, or change in urinary habits. Her blood pressure in the room is 185/95. You offer your condolences regarding her smelling like a truck stop bathroom instead of sweet, sweet passion flower and rice milk, and walk back to the computer to place orders for “screening labs” and to type your note.
However, before you even click the mouse you begin to wonder—is there utility in
ordering tests? Should I try to lower her blood pressure now? Should I write a
prescription for her to take at home? Should I do nothing and just have her follow up with her primary doctor? You find a previous Wash U Journal Club synopsis, but the included studies are almost 10 years old now and you wonder what has been published on the topic since then, prompting your own literature search.
PICO Question
Population: Patients presenting to the emergency department (ED) with severely elevated BP and no signs or symptoms concerning for end-organ damage
Intervention: Laboratory testing, electrocardiogram (ECG), chest x-ray, rapid reduction blood pressure, initiation of antihypertensive agents upon discharge
Comparison: Outpatient referral for evaluation and initiation of antihypertensive therapy
Outcome: Sroke, MI, renal failure, dialysis, death
Search Strategy
PudMed was searched for articles publised between 1/1/2010 to 3/13/2019 (i.e. since the previous journal club) using the terms (hypertens* OR elevated blood pressure) AND “emergency department”. (https://tinyurl.com/y4d3nmlj). This strategy yielded articles from which the four most relevant articles were chosen.
Articles
Article 1: Levy P, Ye H, Compton S, Zalenski R, Byrnes T, Flack JM, Welch R.
Subclinical hypertensive heart disease in black patients with elevated blood
pressure in an inner-city emergency department. Ann Emerg Med. 2012 Oct;60(4):
467-74. ANSWER KEY
Article 2: Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM; American College of
Emergency Physicians Clinical Policies Committee. Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013 Jul;62(1):59-68. ANSWER KEY
Article 3: Masood S, Austin PC, Atzema CL. A Population-Based Analysis of
Outcomes in Patients With a Primary Diagnosis of Hypertension in the Emergency
Department. Ann Emerg Med. 2016 Sep;68(3):258-267. ANSWER KEY
Article 4: Patel KK, Young L, Howell EH, Hu B, Rutecki G, Thomas G, Rothberg MB.
Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in
the Ofhice Setting. JAMA Intern Med. 2016 Jul 1;176(7):981-8. ANSWER KEY
Bottom Line
Hypertension, which affects nearly one in three Americans, represents not only a
significant public health burden, but also places a significant burden on emergency
departments. In the US, the number of ED visits for hypertension doubled between
2006 and 2013, rising from 170,340 visits (1820 per million adult ED visits overall)
to 496,894 visits (4610 per million), with hypertensive emergency representing just
over a third of these visits.
The risks of hypertension, both treated and untreated, include long-term and acute
damage to various organs. One study conducted at Detroit Receiving Hospital found
that in a cohort of predominantly African-American patients presenting to the ED
with asymptomatic elevated blood pressure, the prevalence of subclinical
hypertensive heart disease is very high (90.7%; 95% CI 85.2% to 94.3%). While this
finding is striking, the study does not suggest how these results can be used, and
more specifically does not suggest that the ED bears the burden of diagnosing
subclinical heart disease, or that these results need influence ED management.
While hypertensive emergency, in which hypertension has led to acute end-organ
damage, is certainly in the purview of the emergency physician, much less
straightforward is the management of patients with elevated blood pressure but no
signs or symptoms of end-organ damage. In 2013, a Clinical Policy published by the
American College of Emergency Physicians asked two questions related to this issue:
1) Does screening for target organ injury reduce rates of adverse outcomes?
2) Does emergency department medical intervention reduce rates of adverse outcomes?
For the first question, the authors’ conclusion was that while routine screening was
not required, screening for an elevated creatinine may affect patient disposition in
select patients (i.e. those with poor follow-up). These recommendation were Level C;
in other words, they were based on poor evidence (case series or reports) or panel
consensus alone. For the second question, the authors concluded that routine
medical intervention in the ED was not required, but that in patients with poor
access to follow-up, physicians may initiate therapy for long-term blood pressure
control. This recommendation was also level C, suggesting a lack of quality evidence.
In Ontario, Canada, it was found that 0.55% of ED visits involved a primary diagnosis
of hypertension. Out of these visits, 7.8% resulted in hospital admission. Mortality
among these patients was low (0.17% at 7 days and 0.43% at 30 days), as was need
for subsequent hospitalization for a potential complication of hypertension (0.35%
at 7 days, 0.73% at 30 days). These results suggest that patients discharged from the
ED, despite a primary diagnosis of hypertension, tended to have a low risk of short-term
adverse outcomes.
Further research has looked at the outcomes of patients seen in an outpatient clinic
setting (Cleveland Clinic Healthcare System) with significantly elevated blood
pressure (systolic blood pressure [SBP] ≥180 mmHg or diastolic blood pressure
[DBP] ≥ 110 mmHg) but without symptoms. In this study, out of over 58,000
patients seen in clinic with significantly elevated blood pressure, only 0.7% were
referred to the hospital (ED or hospital admission). Patients sent to the hospital, not
surprisingly, had higher rates of hospital admission at 7 days and at 8 to 30 days;
they also had higher rates of major adverse cardiac events (MACE) at 7 days, but not
at 8 to 30 days or 1 to 6 months. Following propensity matching to attempt to
balance the groups, patients referred to the hospital were still more likely to be
admitted at 7 days and 8 to 30 days, but there was no difference in MACE at any
timeframe.
While the most recent ACEP Clinical Policy is based on low quality evidence, review
of further evidence suggests a low incidence of adverse outcomes among patients
with asymptomatic hypertension, and further suggests that referral to the hospital
or ED does not reduce the risks of major adverse cardiac events (though does
increase the probability of hospital admission in the short term). As noted in the
clinical policy, special consideration should be given to patients with poor access to
follow-up, and brief screening for renal failure and initiation of long-term antihypertensive therapy may be considered in such cases. Acute lowering of blood pressure should be avoided, however, and primary care follow-up for long-term blood pressure management should be the primary goal in the vast majority of cases.