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Should We Diagnose and Start Hypertension Treatment in the Emergency Department?

July 4, 2024

Written by Chris Thom

Spoon Feed
This was an analysis of the 2016-2019 National Hospital Ambulatory Medical Care Survey (NHAMCS) of patients presenting to the ED with asymptomatic hypertension. ED physicians infrequently diagnosed hypertension in this cohort and rarely initiated outpatient antihypertensive prescriptions.

No need to emergently treat, but consider diagnosis and outpatient management
This analysis of NHAMCS data identified 4,498 ED visits with asymptomatic hypertension (aHTN) out of 75,948 analyzed ED visits (5.9%). NHAMCS uses a “patient visit weight” variable to estimate the total number of national ED visits based on the number of reporting hospitals. Using this ‘weighted’ variable, there were an estimated 33,348,858 ED visits for aHTN during the four survey years analyzed. The authors defined aHTN as blood pressure > 160/100 mm Hg at both triage and discharge, along with no evidence of acute end organ injury, pregnancy, or other emergent conditions that cause elevated blood pressure.

Two subgroups were analyzed, patients with HTN 160-179/100-109 and patients with HTN > 180/110. Among visits with HTN > 180/110, 13% (95%CI 10.6-15.8) were given a diagnosis of HTN, while 3.1% (95%CI 2.4-4.1) received this diagnosis in the milder HTN group. The more severe HTN subgroup received outpatient antihypertensive prescriptions 8.4% (95%CI 5.8-12) of the time, while 5.84% (95%CI 4.6-7.4) of the milder HTN group did so.

How will this change my practice?
We know that aHTN does not need to be emergently treated in the ED. However, our patients still benefit from diagnosis of hypertension, outpatient referral, and consideration of outpatient prescription management, dependent on patient-specific factors. We do well to recall that HTN > 160/100 in the ED is associated with a definitive diagnosis of HTN at follow-up (1,2). This study serves as a reminder that we can often identify these patients and encourage appropriate outpatient follow up and management.

Another Spoonful
If the BP is high now, it’s probably going to high later per these articles.

Missed Opportunities to Diagnose and Treat Asymptomatic Hypertension in Emergency Departments in the United States, 2016-2019. The Journal of emergency medicine vol. 66,5 (2024): e562-e570.

What are your thoughts?