Written by Clay Smith
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Self-referral to the ED for elevated blood pressure after using a home or pharmacy cuff led to a very low admission rate of 3%.
Why does this matter?
Guidelines recommended checking BP at home starting in the early 2000s, which corresponded with an increase in ED visits for elevated blood pressure. But does it benefit patients for them to come to the ED?
Stuff the cuff
This was a retrospective study of 1508 patients presenting to the ED with hypertension (HTN) as the primary reason for the visit. Of these, the largest percentage, 41%, were self-referred because of an elevated reading on a home cuff. About 20% of these came by ambulance. Only 3% of these patients were admitted, which means very few were identified as having end-organ damage from BP elevation. Many of them had symptoms that may have been, but were not necessarily associated with hypertension: headache (39%), dizziness (31%), chest pain (14%), nausea (10%), and malaise/fatigue/weakness (10%). Mortality at two years was 5.4% for the home BP-cuff group, which was near that expected for patients with a median age of 63 with comorbid conditions. In the overwhelming majority of cases, patients with HTN on a home or pharmacy cuff did not have an emergency and were safe to follow up with primary care. If you work in urgent care, retail medicine, or primary care, carefully consider the added benefit of ED referral. If no signs or symptoms of end-organ damage, they don’t need to go. That’s not my opinion; that’s from the AHA. By all means, refer to the ED if HTN is accompanied by chest pain, shortness of breath, volume overload, heart failure, altered mental status, coma, severe headache, or blurry vision. This caveat – HTN is often associated with headache but is rarely the cause of it.
Source
The Characteristics and Outcomes of Patients Who Make an Emergency Department Visit for Hypertension After Use of a Home or Pharmacy Blood Pressure Device. Ann Emerg Med. 2018 Jul 18. pii: S0196-0644(18)30497-9. doi: 10.1016/j.annemergmed.2018.06.002. [Epub ahead of print]
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Another Spoonful
EM Lit of Note has a very funny and thoughtful writeup on this article.
Reviewed by Thomas Davis
The home cuff isn’t the problem though, it’s the response to the readings. Patients need to be educated that if the machine reads high, they should record the number and go see their primary care doctor about it. And nothing else.
The home BP readings are actually valuable for long-term management of this chronic condition. I agree with everything in this writeup except the misleading title. : )
Probably right. Sometimes we feel like they would stuff the cuff…plus it rhymes.