- Email: [email protected]
Recognizing asymptomatic elevated blood pressure in ED patients: how good (bad) are we?
American Journal of Emergency Medicine (2007) 25, 313 – 317
www.elsevier.com/locate/ajem
Original Contribution
Recognizing asymptomatic elevated blood pressure in ED patients: how good (bad) are we? Keri Tilman MD, Mini DeLashaw MD, PhD, Sean Lowe MS-II, Sandy Springer BS, Susan Hundley, Francis L. Counselman MD* Department of Emergency Medicine, Eastern Virginia Medical School and Emergency Physicians of Tidewater, Norfolk, VA 23507, USA Received 19 July 2006; accepted 4 September 2006
Abstract Objective: This study was conducted to determine if emergency medicine (EM) physicians recognize emergency department (ED) patients with asymptomatic elevated blood pressure (AEBP) by diagnosis, treatment, or referral. The study also evaluated whether differences exist in identification of AEBP based on patient age, sex, race, or insurance status. Methods: A retrospective chart review of all adult patients presenting to a tertiary care teaching hospital ED between April 1, 2004, and June 30, 2004, was performed. Patients were included if documented blood pressure(s) were 140/90 mm Hg or higher. Exclusion criteria included age younger than 18 years or older than 89 years, history of hypertension, admission, condition clearly defined by a hypertensive state, or blood pressure lower than 140/90 mm Hg. Results: A total of 9805 charts were reviewed; 1574 (16%) patients met inclusion criteria. The average age of our study patient was 38 F 14 years; 51% were women and 71.8% were African American. Only 112 patients with AEBP (7%) received attention for their elevated blood pressure (ie, diagnosis, treatment, medication prescription, and/or referral). There was no statistically significant difference between patients identified with AEBP and those not recognized by ED physicians by patient age, sex, race, or insurance status. Conclusions: Emergency department physicians recognize, treat, and/or refer only a small percentage of ED patients with AEBP. No difference in identification, treatment, or referral exists based on patient age, sex, race, or insurance status. D 2007 Elsevier Inc. All rights reserved.
1. Introduction Elevated blood pressure is a serious and ubiquitous problem. It affects approximately 50 million people in the
* Corresponding author. Tel.: +1 757 388 3397; fax: +1 757 388 2885. E-mail address: [email protected] (F.L. Counselman). 0735-6757/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2006.09.007
United States and more than 1 billion individuals worldwide [1,2]. It is considered a modifiable risk factor for cardiovascular and renal disease, yet it has been estimated that 30% of those with hypertension are unaware of their disease [1]. Early identification and management of elevated blood pressure has been shown to reduce many of the long-term hypertension-related complications [3].
314 The May 2003 publication of the seventh report from the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 report) recommends strict guidelines for diagnosing hypertension. According to this report, a normal blood pressure is defined as lower than 120/80 mm Hg. An additional classification was made that defines systolic blood pressure (SBP) of 120 to 139 mm Hg and diastolic blood pressure (DBP) of 80 to 89 mm Hg as prehypertension. Hypertension is still classified by the JNC 7 report as an SBP of 140 mm Hg or higher and a DBP of 90 mm Hg or higher. These guidelines have clearly broadened the target population requiring blood pressure control. In a clinical policy released in March 2006 by the American College of Emergency Physicians (ACEP) Clinical Policies Subcommittee, the issue of management of emergency department (ED) patients with asymptomatic hypertension was addressed [2]. The committee recognized that emergency physicians evaluate ED patients with an incidental finding of asymptomatic hypertension on a daily basis. To compound this challenge, many ED patients do not have a primary care physician or access to primary care. This clinical policy was developed to help the clinician use the literature in addressing the problem [2]. In general, the ACEP recommendations emphasize the need for follow-up. Patients with persistently elevated blood pressures (ie, N140/90 mm Hg) should be referred for follow-up of possible hypertension and blood pressure management. The committee suggests that patients with a single elevated blood pressure reading in the ED may benefit from further screening for hypertension in the outpatient setting. Their review of the literature was not helpful regarding the need for the rapid lowering of elevated blood pressure in the ED. The committee stated that initiating treatment of asymptomatic hypertension in the ED is not necessary when patients have follow-up. Rapidly lowering blood pressure in asymptomatic patients in the ED is unnecessary and may be harmful in some patients. If ED treatment is initiated for these patients, blood pressure should be gradually lowered, and should not be expected to be normalized during the initial ED visit [2]. The key elements to this policy statement are emergency physician recognition of asymptomatic elevated blood pressure (AEBP) and follow-up. The purpose of our investigation was to determine if emergency physicians recognize ED patients with AEBP by diagnosis, treatment, and/or referral for follow-up care. We also attempted to determine if any differences exist to AEBP identification based on patient age, race, sex, or insurance status.
K. Tilman et al. primary training site for our fully accredited postgraduate year 1 through postgraduate year 3 emergency medicine (EM) residency program. All patients are seen by EM residents with EM faculty supervision, or by EM faculty alone. Patients were included in the study if their documented SBPs/DBPs at triage were 140/90 mm Hg or higher. Exclusion criteria for the study included the following conditions: patients younger than 18 years or older than 89 years of age, history of diagnosed hypertension, admission to the hospital, any condition clearly defined by a hypertensive state, and blood pressure lower than 140 mm Hg (systolic) and 90 mm Hg (diastolic). Conditions clearly defined by a hypertensive state for our study included cocaine use, alcohol withdrawal, preeclampsia or eclampsia, intracranial hemorrhage or ischemic stroke, dissecting thoracic aortic aneurysm, or acute coronary syndromes. A patient was considered to have a history of diagnosed hypertension if the patient self-reported a physician diagnosis of hypertension, documentation of hypertension in old records or previous ED visits, or documentation of commonly used blood pressure medication(s) in the medication profile for that ED visit. The Eastern Virginia Medial School Institutional Review Board approved this study. Information was gathered via a retrospective chart review using all charts scanned into a computer system from April 1, 2004, to June 30, 2004. Data were gathered from the online ED medical records by dedicated research associates who were not blinded to the study objectives. The research associates were trained in data collection for this particular study, human subject protection requirements, and good clinical research practices. If a patient visit qualified for inclusion in the study, the following patient information was abstracted from the ED chart: age, sex, triage blood pressure, repeat blood pressure (if available), insurance status, and race. In addition, data were collected regarding whether the emergency physician treated the elevated blood pressure in the ED or prescribed outpatient medications; whether the patient was discharged with a diagnosis of bhypertensionQ or belevated blood pressureQ; and/or whether the emergency physician recommended follow-up for the elevated blood pressure. Each of the actions described above was considered as an indication that the emergency physician recognized the elevated blood pressure. Data were analyzed using SAS 9.1.3 (Cary, NC). We used v 2 analyses to compare patient characteristics (sex, insurance status, and race). Continuous variables (age and blood pressure) were analyzed by using the Student t tests and 95% confidence intervals. A P value of less than .05 was considered statistically significant.
2. Methods We performed a retrospective chart review of all adult patients presenting to a tertiary care teaching hospital ED between April 1, 2004, and June 30, 2004. The ED is the
3. Results A total of 9805 charts were reviewed from the 3-month study period, of which 1574 (16%) met the inclusion
Recognizing asymptomatic elevated blood pressure in ED patients Table 1
315
Comparison of triage SBP and DBP in patients recognized with AEBP and those not identified
Mean SBP (mm Hg) Mean DBP (mm Hg)
AEBP identified (112)
AEBP not identified (1462)
P
173 (95% CI, 168-177) 98 (95% CI, 95-100)
158 (95% CI, 155-161) 88 (95% CI, 87-88)
b.0001 b.0001
CI indicates confidence interval.
criteria. The mean age of patients with AEBP was 38 F 14 years; 51% were women, 71.8% were African American, 24.9% were white, and 0.95% were Hispanic. A large percentage of patients (43.4%) had no medical insurance, 43% were insured, 9.4% had Medicare, and 4.1% reported having Medicaid. Among patients with AEBP, only 112 (7%) were recognized by the emergency physician. A discharge diagnosis of elevated blood pressure was noted in 5.9% (93) of patients, specific discharge instructions for follow-up of blood pressure were provided in 5.2% (82) of cases, antihypertensive treatment was initiated in the ED in 2.4% (38) of cases, and discharge with a prescription for antihypertensive medication(s) was documented in 2.1% (33) of cases. The sum of the number of patients for each of the categories cited above is greater than 112 because some patients were diagnosed, treated, and given specific follow-up instructions. Patients with repeat blood pressures lower than 140/ 90 mm Hg were excluded from the study. Of the 1574 patients who met inclusion criteria, only 636 (40%) had at least one repeat blood pressure measurement. Therefore, for approximately 60% of our study patients, only the initial triage blood pressure measurement was used to determine emergency physician recognition of AEBP. Patients identified to have AEBP (7%) had significantly greater mean triage systolic ( P b .0001) and diastolic ( P b .0001) blood pressures compared with patients whose elevated blood pressures were not identified by the emergency physician (Table 1). There was no statistically significant difference by sex ( P = .77), age ( P = .19), insurance status ( P = .83), or race Table 2
( P = .56) between patients whose elevated blood pressures were recognized and those who were not (Table 2).
4. Discussion Hypertension is a very common disease, affecting approximately 50 million people in the United States and more than 1 billion individuals worldwide [1,2]. It is the most common primary diagnosis reported by primary care physicians. The risks of untreated hypertension, including cardiovascular, cerebrovascular, kidney, and peripheral vascular disease, and retinopathy, are well documented [1,4 - 6]. Although public awareness has increased over the past several decades, it is estimated that 30% of individuals with hypertension do not know they have the condition [1]. Fortunately, early identification and treatment of hypertension have been demonstrated to reduce long-term complications such as myocardial infarction, stroke, and heart failure [7,8]. The purpose of our study was to determine if emergency physicians appropriately recognize asymptomatic ED patients with blood pressures of 140/90 mm Hg or higher. Data from previous investigations support that physicians can positively impact patient behavior by suggesting healthy lifestyle changes and encouraging follow-up [9,10]. Because ED visits are often the only medical contact some patients experience, these patient encounters become an invaluable opportunity to rapidly screen for hypertension, suggest lifestyle modifications, and encourage follow-up care. In our study, emergency physicians did a poor job of identifying patients with AEBP. Our findings are consistent
Comparison of patient characteristics
Sex Age (mean) Insurance status (no. of patients)
Race (no. of patients)
AEBP identified (112)
AEBP not identified (1462)
P
53 men (47%) 59 women (53%) 40 y 95% CI (37-43 y) Commercial 40% (45) Medicare 12% (13) Medicaid 4% (5) None 44% (49) African American 77% (86) White 21% (24) Hispanic 0% Asian 0% Not documented 2% (2)
718 men (49%) 744 women (51%) 38 y 95% CI (37-39 y) Commercial 43% (632) Medicare 9% (135) Medicaid 4% (60) None 44% (635) African American 71% (1045) White 25% (368) Hispanic 1% (15) Asian 1% (11) Not documented 2% (23)
.77 .19 .83
.56
316 with previously published reports regarding the recognition, treatment, and referral of patients with AEBP. Nerlinger and Jubanyik [11], in a study design similar to ours, found that only 3.6% of patients requiring referral for further blood pressure management received such instruction, and that no difference existed regarding patient age or sex and referral. Similarly, in a study of low-acuity ED patients, 27 (73%) of 37 patients with AEBP had no documentation of their blood pressure being rechecked or the patient being referred for follow-up [12]. In our study, emergency physicians were however more likely to identify AEBP in patients with higher SBPs and DBPs (Table 1). Other studies have demonstrated a similar correlation between physicians’ recognition (ie, treatment) of AEBP and the degree of blood pressure elevation [13]. Chiang and Jamashahi [13] found that 21% of patients with blood pressure exceeding 180/110 mm Hg (and without end-organ dysfunction) received antihypertensive treatment in the ED. Their treatment group had a significantly higher SBP and DBP than the nontreatment group. Of the patients whose AEBP was recognized in the ED, most received either a diagnosis of elevated BP or discharge instructions for follow-up, rather than antihypertensive treatment in the ED or a prescription for antihypertensive medication(s). This is consistent with the newly released ACEP clinical policy recommendations that states ensuring prompt follow-up for further evaluation of AEBP is more appropriate than initiating antihypertensive treatment in the ED [2,14,15]. Transient increases in blood pressure secondary to the day-to-day variability, inappropriate blood pressure measurement, environment, the bwhite coatQ phenomena, pain, and anxiety have been well documented and have led to some concern that ED blood pressure screening may result in a high false-positive rate [17-21]. Our goal was to minimize the inclusion of patients whose elevated blood pressure may not reflect their btrueQ baseline. Therefore, patients with repeat blood pressure(s) lower than 140/90 mm Hg were assumed to be normotensive and were excluded from our study. It should be noted, however, that repeat blood pressures were not available for 60% of our patients with elevated triage blood pressures. This low priority on reassessing elevated triage blood pressure has been noted by others. Lehrmann et al [22] surveyed ED registered nurses (RNs), EM residents, and EM attending physicians at 4 centers. They found that both physicians and nurses considered an elevated BP a low priority (physicians more so than RNs). They found that the physicians’ and RNs’ threshold for the need for blood pressure reassessment was a blood pressure of 161/95 mm Hg or higher [22]. The data on blood pressure trends in the ED are conflicting. Pitts and Adams [23] noted a spontaneous decline of blood pressure in their study of ED patients with AEBP. In contrast, other studies have demonstrated that blood pressure values remained elevated in most patients who underwent repeated measurements during the same ED
K. Tilman et al. visits [24,25] and on repeat visits to their primary care physician (PCP) [16,19]. Chernow et al [26], in a prospective study of 239 ED patients with BP N159/94 mm Hg, found 35% to be hypertensive, 33% with borderline hypertension, and the remaining 32% normotensive at follow-up. Although only 107 patients (45%) were actually followed up, the number of patients experiencing pain at the time of their initial ED visit (ie, from fracture, laceration, etc) was similar for all 3 groups [26]. In an interesting study of ED patients with a blood pressure higher than 160/100 mm Hg at triage, Dieterle et al [27] performed blood pressure measurements every 5 minutes for 2 hours to evaluate the natural time course of blood pressure and to define an optimal period for hypertension screening in ED patients with an elevated initial blood pressure [26]. They found that screening for hypertension in the ED is possible with high sensitivity and specificity. They found that blood pressure measurements between 60 and 80 minutes after initial presentation yielded the highest diagnostic value [27]. We also investigated whether emergency physician’s recognition, treatment, and referral practice were influenced by patient age, race, sex, or insurance status. Emergency physicians in our study were equally poor at identifying AEBP, regardless of these patient characteristics. This is similar to the finding of Nerlinger and Jubanyik [11] that neither sex nor age played a role in identification and referral. In our study, African Americans comprised the largest proportion (71.8%) of patients with elevated blood pressure. This finding is consistent with other studies conducted at urban hospitals and reflects the disproportionate incidence of hypertension in the African American population [24]. It is also, in all probability, a reflection of our predominately African American patient population. The beneficial impact of addressing even mildly elevated hypertension cannot be overstated. A 1990 study by Littenberg [28] provided evidence suggesting that the benefits gained from screening for mild hypertension outweigh any potential cost or risks. Screening is essentially free, considering that all ED patients should have at least an initial triage blood pressure measurement. Simple discharge instructions advising follow-up and lifestyle changes are easy, inexpensive, and rapidly provided. The most vulnerable patients include the uninsured (44% in our study), minorities (74% in our study), and those from lower socioeconomic classes. Many of these individuals receive their only medical and preventative care services in the ED setting. Although not ideal, the ED encounter may be the only chance to screen for medical conditions that cause preventable long-term illnesses such as hypertensive-related end organ damage [7,10]. There are several limitations to our study. First, this was a retrospective chart review at a single institution, with all of the problems inherent in such types of studies. However, during the period under study, a total of 24 residents and 43 attending faculty, or 67 unique physicians, were involved in the care of the study patients. The overall poor job of
Recognizing asymptomatic elevated blood pressure in ED patients AEBP identification cannot be attributed to the involvement of just a few physicians. Second, nearly 60% of our patients with an initially elevated blood pressure did not have a repeat blood pressure recorded in the ED chart. It is possible the BP returned to within the reference range for some of these patients, thereby falsely increasing our number of patients identified with AEBP. However, given our very low recognition rate, it is very doubtful this would have changed our overall conclusions. Next, we excluded patients from the study if their medication list included any antihypertensive class agents (ie, diuretics, b-blockers, calcium-channel blockers, etc). We recognize, however, that some patients may have been on one or more of these agents for reasons other than hypertension (ie, b-blocker for a post–myocardial infarction patient). By excluding these patients, however, we—if anything—potentially underestimated the problem of unrecognized AEBP. Finally, some patients may have been verbally informed by the physician and/or nurse of their elevated blood pressure and need for follow-up. However, given the importance of these types of instructions, they should have been documented in the chart (by either the physician or nurse) for both patient care and medicolegal reasons.
5. Conclusion In our study, emergency physicians were poor at recognizing elevated blood pressure(s) in asymptomatic ED patients, ultimately missing an opportunity for early intervention and disease prevention. Patient age, sex, race, and insurance status did not play a role in emergency physician recognition of AEBP. Emergency physicians should strive to be more vigilant in reassessing AEBP and referring patients for follow-up.
Acknowledgment We thank Yueqin Zhao, MS, from the Epidemiology and Biostatistics Core at Eastern Virginia Medical School (Va) for her invaluable assistance with statistical support.
References [1] Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC Report. JAMA 2003; 289:2560 - 72. [2] Decker WW, Godwin SA, Hess EP, Lenamond CC, Jagoda AS. Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department. Ann Emerg Med 2006;47:237 - 49. [3] Psaty BM, Smith NL, Siscovick DS, et al. Health outcomes associated with antihypertensive therapies used as first-line agents: a systematic review and meta-analysis. JAMA 1997;277:739 - 45. [4] Cherry DK, Woodwell DA. National ambulatory medical survey: 2000 summary. Adv Data 2002;328:1 - 32.
317
[5] Klag MJ, Whelton PK, Randall BL, et al. Blood pressure and endstage renal disease in men. N Engl J Med 1996;334:13 - 8. [6] Psaty BM, Furberg CD, Kuller LH, et al. Association between blood pressure level and the risk of myocardial infarction, stroke, and total mortality: the Cardiovascular Health Study. Arch Intern Med 2001; 161:1183 - 92. [7] Neal B, MacMahon S, Chapman N. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure–lowering drugs. Lancet 2000;256:1955 - 64. [8] Ogden LG, He J, Lydick E, Whelton PK. Long-term absolute benefit of lowering blood pressure in hypertensive patients according to the JNC VI risk stratification. Hypertension 2000;35:539 - 43. [9] Barrier PA, Li JT, Jensen NM. Two words to improve physicianpatient communication: what else? Mayo Clin Proc 2003;78:211 - 4. [10] Rhodes KV, Gordon JA, Lowe RA. Preventive care in the emergency department: Part I. Clinical preventative services—are they relevant to emergency medicine? Acad Emerg Med 2000;7:1036 - 41. [11] Nerlinger A, Jubanyik R. Quantifying the problem: undiagnosed hypertension in the emergency department and failure to refer for blood pressure recheck. (abstract)Acad Emerg Med 2006; 13(5, Suppl 1):S54. [12] Tanabe P, Steinmann R, Kippenham M, et al. Undiagnosed hypertension in the ED setting—an unrecognized opportunity by emergency nurses. J Emerg Nurs 2004;30(3):225 - 9. [13] Chiang WK, Jamshahi B. Asymptomatic hypertension in the ED. Am J Emerg Med 1997;16:701 - 4. [14] Thach AM, Schultz PJ. Nonemergent hypertension. New perspectives for the emergency medicine physician. Emerg Med Clin North Am 1995;13:1009 - 35. [15] Wachter RM. Symptomatic hypotension induced by nifedipine in the acute treatment of severe hypertension. Arch Intern Med 1987; 147:556 - 8. [16] Backer HD, Decker L, Ackerson L. Reproducibility of increased blood pressure during an emergency department or urgent care visit. Ann Emerg Med 2003;41:507 - 12. [17] Cienki JJ, DeLuca LA, Daniel N. The validity of emergency department triage blood pressure measurements. Acad Emerg Med 2004;11:237 - 43. [18] McAlister F, Straus SE. Measurement of blood pressure: an evidence based review. BMJ 2001;322:908 - 11. [19] Fleming J, Meredith C, Henry J. Detection of hypertension in the emergency department. Emerg Med J 2005;22:636 - 9. [20] Reeves RA. Does this patient have hypertension? How to measure pressure. JAMA 1995;273:1211 - 8. [21] Pickering TG. Blood pressure measurement and detection of hypertension. Lancet 1994;344:31 - 5. [22] Lehrmann JF, Baumann BM, Cienki JJ, et al. Physician and nurse self-reported blood pressure (BP) reassessment practices and perceptions of barriers to BP reassessment. (abstract)Acad Emerg Med 2006; 13(5, Suppl 1):S54 - 5. [23] Pitts SR, Adams RP. Emergency department hypertension and regression to the mean. Ann Emerg Med 1998;31(2):214 - 8. [24] Karras DJ, Ufberg JW, Heilpern KL, et al. Elevated blood pressure in urban emergency department patients. Acad Emerg Med 2005;12: 835 - 43. [25] Karras DJ, Kruus LK, Cienki JJ, et al. Evaluation and treatment of patients with severely elevated blood pressure in academic emergency departments: a multicenter study. Ann Emerg Med 2006; 47:230 - 6. [26] Chernow SM, Iserson KV, Criss E. Use of the emergency department for hypertension screening: a prospective study. Ann Emerg Med 1987;16:180 - 2. [27] Dieterle T, Schuurmans MM, Strobel W, et al. Moderate-to-severe blood pressure elevation at ED entry: hypertension or normotension? Am J Emerg Med 2005;23(4):474 - 9. [28] Littenberg B. A practice guideline revisited: screening for hypertension. Ann Intern Med 1995;122:937 - 9.
www.elsevier.com/locate/ajem
Original Contribution
Recognizing asymptomatic elevated blood pressure in ED patients: how good (bad) are we? Keri Tilman MD, Mini DeLashaw MD, PhD, Sean Lowe MS-II, Sandy Springer BS, Susan Hundley, Francis L. Counselman MD* Department of Emergency Medicine, Eastern Virginia Medical School and Emergency Physicians of Tidewater, Norfolk, VA 23507, USA Received 19 July 2006; accepted 4 September 2006
Abstract Objective: This study was conducted to determine if emergency medicine (EM) physicians recognize emergency department (ED) patients with asymptomatic elevated blood pressure (AEBP) by diagnosis, treatment, or referral. The study also evaluated whether differences exist in identification of AEBP based on patient age, sex, race, or insurance status. Methods: A retrospective chart review of all adult patients presenting to a tertiary care teaching hospital ED between April 1, 2004, and June 30, 2004, was performed. Patients were included if documented blood pressure(s) were 140/90 mm Hg or higher. Exclusion criteria included age younger than 18 years or older than 89 years, history of hypertension, admission, condition clearly defined by a hypertensive state, or blood pressure lower than 140/90 mm Hg. Results: A total of 9805 charts were reviewed; 1574 (16%) patients met inclusion criteria. The average age of our study patient was 38 F 14 years; 51% were women and 71.8% were African American. Only 112 patients with AEBP (7%) received attention for their elevated blood pressure (ie, diagnosis, treatment, medication prescription, and/or referral). There was no statistically significant difference between patients identified with AEBP and those not recognized by ED physicians by patient age, sex, race, or insurance status. Conclusions: Emergency department physicians recognize, treat, and/or refer only a small percentage of ED patients with AEBP. No difference in identification, treatment, or referral exists based on patient age, sex, race, or insurance status. D 2007 Elsevier Inc. All rights reserved.
1. Introduction Elevated blood pressure is a serious and ubiquitous problem. It affects approximately 50 million people in the
* Corresponding author. Tel.: +1 757 388 3397; fax: +1 757 388 2885. E-mail address: [email protected] (F.L. Counselman). 0735-6757/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2006.09.007
United States and more than 1 billion individuals worldwide [1,2]. It is considered a modifiable risk factor for cardiovascular and renal disease, yet it has been estimated that 30% of those with hypertension are unaware of their disease [1]. Early identification and management of elevated blood pressure has been shown to reduce many of the long-term hypertension-related complications [3].
314 The May 2003 publication of the seventh report from the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 report) recommends strict guidelines for diagnosing hypertension. According to this report, a normal blood pressure is defined as lower than 120/80 mm Hg. An additional classification was made that defines systolic blood pressure (SBP) of 120 to 139 mm Hg and diastolic blood pressure (DBP) of 80 to 89 mm Hg as prehypertension. Hypertension is still classified by the JNC 7 report as an SBP of 140 mm Hg or higher and a DBP of 90 mm Hg or higher. These guidelines have clearly broadened the target population requiring blood pressure control. In a clinical policy released in March 2006 by the American College of Emergency Physicians (ACEP) Clinical Policies Subcommittee, the issue of management of emergency department (ED) patients with asymptomatic hypertension was addressed [2]. The committee recognized that emergency physicians evaluate ED patients with an incidental finding of asymptomatic hypertension on a daily basis. To compound this challenge, many ED patients do not have a primary care physician or access to primary care. This clinical policy was developed to help the clinician use the literature in addressing the problem [2]. In general, the ACEP recommendations emphasize the need for follow-up. Patients with persistently elevated blood pressures (ie, N140/90 mm Hg) should be referred for follow-up of possible hypertension and blood pressure management. The committee suggests that patients with a single elevated blood pressure reading in the ED may benefit from further screening for hypertension in the outpatient setting. Their review of the literature was not helpful regarding the need for the rapid lowering of elevated blood pressure in the ED. The committee stated that initiating treatment of asymptomatic hypertension in the ED is not necessary when patients have follow-up. Rapidly lowering blood pressure in asymptomatic patients in the ED is unnecessary and may be harmful in some patients. If ED treatment is initiated for these patients, blood pressure should be gradually lowered, and should not be expected to be normalized during the initial ED visit [2]. The key elements to this policy statement are emergency physician recognition of asymptomatic elevated blood pressure (AEBP) and follow-up. The purpose of our investigation was to determine if emergency physicians recognize ED patients with AEBP by diagnosis, treatment, and/or referral for follow-up care. We also attempted to determine if any differences exist to AEBP identification based on patient age, race, sex, or insurance status.
K. Tilman et al. primary training site for our fully accredited postgraduate year 1 through postgraduate year 3 emergency medicine (EM) residency program. All patients are seen by EM residents with EM faculty supervision, or by EM faculty alone. Patients were included in the study if their documented SBPs/DBPs at triage were 140/90 mm Hg or higher. Exclusion criteria for the study included the following conditions: patients younger than 18 years or older than 89 years of age, history of diagnosed hypertension, admission to the hospital, any condition clearly defined by a hypertensive state, and blood pressure lower than 140 mm Hg (systolic) and 90 mm Hg (diastolic). Conditions clearly defined by a hypertensive state for our study included cocaine use, alcohol withdrawal, preeclampsia or eclampsia, intracranial hemorrhage or ischemic stroke, dissecting thoracic aortic aneurysm, or acute coronary syndromes. A patient was considered to have a history of diagnosed hypertension if the patient self-reported a physician diagnosis of hypertension, documentation of hypertension in old records or previous ED visits, or documentation of commonly used blood pressure medication(s) in the medication profile for that ED visit. The Eastern Virginia Medial School Institutional Review Board approved this study. Information was gathered via a retrospective chart review using all charts scanned into a computer system from April 1, 2004, to June 30, 2004. Data were gathered from the online ED medical records by dedicated research associates who were not blinded to the study objectives. The research associates were trained in data collection for this particular study, human subject protection requirements, and good clinical research practices. If a patient visit qualified for inclusion in the study, the following patient information was abstracted from the ED chart: age, sex, triage blood pressure, repeat blood pressure (if available), insurance status, and race. In addition, data were collected regarding whether the emergency physician treated the elevated blood pressure in the ED or prescribed outpatient medications; whether the patient was discharged with a diagnosis of bhypertensionQ or belevated blood pressureQ; and/or whether the emergency physician recommended follow-up for the elevated blood pressure. Each of the actions described above was considered as an indication that the emergency physician recognized the elevated blood pressure. Data were analyzed using SAS 9.1.3 (Cary, NC). We used v 2 analyses to compare patient characteristics (sex, insurance status, and race). Continuous variables (age and blood pressure) were analyzed by using the Student t tests and 95% confidence intervals. A P value of less than .05 was considered statistically significant.
2. Methods We performed a retrospective chart review of all adult patients presenting to a tertiary care teaching hospital ED between April 1, 2004, and June 30, 2004. The ED is the
3. Results A total of 9805 charts were reviewed from the 3-month study period, of which 1574 (16%) met the inclusion
Recognizing asymptomatic elevated blood pressure in ED patients Table 1
315
Comparison of triage SBP and DBP in patients recognized with AEBP and those not identified
Mean SBP (mm Hg) Mean DBP (mm Hg)
AEBP identified (112)
AEBP not identified (1462)
P
173 (95% CI, 168-177) 98 (95% CI, 95-100)
158 (95% CI, 155-161) 88 (95% CI, 87-88)
b.0001 b.0001
CI indicates confidence interval.
criteria. The mean age of patients with AEBP was 38 F 14 years; 51% were women, 71.8% were African American, 24.9% were white, and 0.95% were Hispanic. A large percentage of patients (43.4%) had no medical insurance, 43% were insured, 9.4% had Medicare, and 4.1% reported having Medicaid. Among patients with AEBP, only 112 (7%) were recognized by the emergency physician. A discharge diagnosis of elevated blood pressure was noted in 5.9% (93) of patients, specific discharge instructions for follow-up of blood pressure were provided in 5.2% (82) of cases, antihypertensive treatment was initiated in the ED in 2.4% (38) of cases, and discharge with a prescription for antihypertensive medication(s) was documented in 2.1% (33) of cases. The sum of the number of patients for each of the categories cited above is greater than 112 because some patients were diagnosed, treated, and given specific follow-up instructions. Patients with repeat blood pressures lower than 140/ 90 mm Hg were excluded from the study. Of the 1574 patients who met inclusion criteria, only 636 (40%) had at least one repeat blood pressure measurement. Therefore, for approximately 60% of our study patients, only the initial triage blood pressure measurement was used to determine emergency physician recognition of AEBP. Patients identified to have AEBP (7%) had significantly greater mean triage systolic ( P b .0001) and diastolic ( P b .0001) blood pressures compared with patients whose elevated blood pressures were not identified by the emergency physician (Table 1). There was no statistically significant difference by sex ( P = .77), age ( P = .19), insurance status ( P = .83), or race Table 2
( P = .56) between patients whose elevated blood pressures were recognized and those who were not (Table 2).
4. Discussion Hypertension is a very common disease, affecting approximately 50 million people in the United States and more than 1 billion individuals worldwide [1,2]. It is the most common primary diagnosis reported by primary care physicians. The risks of untreated hypertension, including cardiovascular, cerebrovascular, kidney, and peripheral vascular disease, and retinopathy, are well documented [1,4 - 6]. Although public awareness has increased over the past several decades, it is estimated that 30% of individuals with hypertension do not know they have the condition [1]. Fortunately, early identification and treatment of hypertension have been demonstrated to reduce long-term complications such as myocardial infarction, stroke, and heart failure [7,8]. The purpose of our study was to determine if emergency physicians appropriately recognize asymptomatic ED patients with blood pressures of 140/90 mm Hg or higher. Data from previous investigations support that physicians can positively impact patient behavior by suggesting healthy lifestyle changes and encouraging follow-up [9,10]. Because ED visits are often the only medical contact some patients experience, these patient encounters become an invaluable opportunity to rapidly screen for hypertension, suggest lifestyle modifications, and encourage follow-up care. In our study, emergency physicians did a poor job of identifying patients with AEBP. Our findings are consistent
Comparison of patient characteristics
Sex Age (mean) Insurance status (no. of patients)
Race (no. of patients)
AEBP identified (112)
AEBP not identified (1462)
P
53 men (47%) 59 women (53%) 40 y 95% CI (37-43 y) Commercial 40% (45) Medicare 12% (13) Medicaid 4% (5) None 44% (49) African American 77% (86) White 21% (24) Hispanic 0% Asian 0% Not documented 2% (2)
718 men (49%) 744 women (51%) 38 y 95% CI (37-39 y) Commercial 43% (632) Medicare 9% (135) Medicaid 4% (60) None 44% (635) African American 71% (1045) White 25% (368) Hispanic 1% (15) Asian 1% (11) Not documented 2% (23)
.77 .19 .83
.56
316 with previously published reports regarding the recognition, treatment, and referral of patients with AEBP. Nerlinger and Jubanyik [11], in a study design similar to ours, found that only 3.6% of patients requiring referral for further blood pressure management received such instruction, and that no difference existed regarding patient age or sex and referral. Similarly, in a study of low-acuity ED patients, 27 (73%) of 37 patients with AEBP had no documentation of their blood pressure being rechecked or the patient being referred for follow-up [12]. In our study, emergency physicians were however more likely to identify AEBP in patients with higher SBPs and DBPs (Table 1). Other studies have demonstrated a similar correlation between physicians’ recognition (ie, treatment) of AEBP and the degree of blood pressure elevation [13]. Chiang and Jamashahi [13] found that 21% of patients with blood pressure exceeding 180/110 mm Hg (and without end-organ dysfunction) received antihypertensive treatment in the ED. Their treatment group had a significantly higher SBP and DBP than the nontreatment group. Of the patients whose AEBP was recognized in the ED, most received either a diagnosis of elevated BP or discharge instructions for follow-up, rather than antihypertensive treatment in the ED or a prescription for antihypertensive medication(s). This is consistent with the newly released ACEP clinical policy recommendations that states ensuring prompt follow-up for further evaluation of AEBP is more appropriate than initiating antihypertensive treatment in the ED [2,14,15]. Transient increases in blood pressure secondary to the day-to-day variability, inappropriate blood pressure measurement, environment, the bwhite coatQ phenomena, pain, and anxiety have been well documented and have led to some concern that ED blood pressure screening may result in a high false-positive rate [17-21]. Our goal was to minimize the inclusion of patients whose elevated blood pressure may not reflect their btrueQ baseline. Therefore, patients with repeat blood pressure(s) lower than 140/90 mm Hg were assumed to be normotensive and were excluded from our study. It should be noted, however, that repeat blood pressures were not available for 60% of our patients with elevated triage blood pressures. This low priority on reassessing elevated triage blood pressure has been noted by others. Lehrmann et al [22] surveyed ED registered nurses (RNs), EM residents, and EM attending physicians at 4 centers. They found that both physicians and nurses considered an elevated BP a low priority (physicians more so than RNs). They found that the physicians’ and RNs’ threshold for the need for blood pressure reassessment was a blood pressure of 161/95 mm Hg or higher [22]. The data on blood pressure trends in the ED are conflicting. Pitts and Adams [23] noted a spontaneous decline of blood pressure in their study of ED patients with AEBP. In contrast, other studies have demonstrated that blood pressure values remained elevated in most patients who underwent repeated measurements during the same ED
K. Tilman et al. visits [24,25] and on repeat visits to their primary care physician (PCP) [16,19]. Chernow et al [26], in a prospective study of 239 ED patients with BP N159/94 mm Hg, found 35% to be hypertensive, 33% with borderline hypertension, and the remaining 32% normotensive at follow-up. Although only 107 patients (45%) were actually followed up, the number of patients experiencing pain at the time of their initial ED visit (ie, from fracture, laceration, etc) was similar for all 3 groups [26]. In an interesting study of ED patients with a blood pressure higher than 160/100 mm Hg at triage, Dieterle et al [27] performed blood pressure measurements every 5 minutes for 2 hours to evaluate the natural time course of blood pressure and to define an optimal period for hypertension screening in ED patients with an elevated initial blood pressure [26]. They found that screening for hypertension in the ED is possible with high sensitivity and specificity. They found that blood pressure measurements between 60 and 80 minutes after initial presentation yielded the highest diagnostic value [27]. We also investigated whether emergency physician’s recognition, treatment, and referral practice were influenced by patient age, race, sex, or insurance status. Emergency physicians in our study were equally poor at identifying AEBP, regardless of these patient characteristics. This is similar to the finding of Nerlinger and Jubanyik [11] that neither sex nor age played a role in identification and referral. In our study, African Americans comprised the largest proportion (71.8%) of patients with elevated blood pressure. This finding is consistent with other studies conducted at urban hospitals and reflects the disproportionate incidence of hypertension in the African American population [24]. It is also, in all probability, a reflection of our predominately African American patient population. The beneficial impact of addressing even mildly elevated hypertension cannot be overstated. A 1990 study by Littenberg [28] provided evidence suggesting that the benefits gained from screening for mild hypertension outweigh any potential cost or risks. Screening is essentially free, considering that all ED patients should have at least an initial triage blood pressure measurement. Simple discharge instructions advising follow-up and lifestyle changes are easy, inexpensive, and rapidly provided. The most vulnerable patients include the uninsured (44% in our study), minorities (74% in our study), and those from lower socioeconomic classes. Many of these individuals receive their only medical and preventative care services in the ED setting. Although not ideal, the ED encounter may be the only chance to screen for medical conditions that cause preventable long-term illnesses such as hypertensive-related end organ damage [7,10]. There are several limitations to our study. First, this was a retrospective chart review at a single institution, with all of the problems inherent in such types of studies. However, during the period under study, a total of 24 residents and 43 attending faculty, or 67 unique physicians, were involved in the care of the study patients. The overall poor job of
Recognizing asymptomatic elevated blood pressure in ED patients AEBP identification cannot be attributed to the involvement of just a few physicians. Second, nearly 60% of our patients with an initially elevated blood pressure did not have a repeat blood pressure recorded in the ED chart. It is possible the BP returned to within the reference range for some of these patients, thereby falsely increasing our number of patients identified with AEBP. However, given our very low recognition rate, it is very doubtful this would have changed our overall conclusions. Next, we excluded patients from the study if their medication list included any antihypertensive class agents (ie, diuretics, b-blockers, calcium-channel blockers, etc). We recognize, however, that some patients may have been on one or more of these agents for reasons other than hypertension (ie, b-blocker for a post–myocardial infarction patient). By excluding these patients, however, we—if anything—potentially underestimated the problem of unrecognized AEBP. Finally, some patients may have been verbally informed by the physician and/or nurse of their elevated blood pressure and need for follow-up. However, given the importance of these types of instructions, they should have been documented in the chart (by either the physician or nurse) for both patient care and medicolegal reasons.
5. Conclusion In our study, emergency physicians were poor at recognizing elevated blood pressure(s) in asymptomatic ED patients, ultimately missing an opportunity for early intervention and disease prevention. Patient age, sex, race, and insurance status did not play a role in emergency physician recognition of AEBP. Emergency physicians should strive to be more vigilant in reassessing AEBP and referring patients for follow-up.
Acknowledgment We thank Yueqin Zhao, MS, from the Epidemiology and Biostatistics Core at Eastern Virginia Medical School (Va) for her invaluable assistance with statistical support.
References [1] Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC Report. JAMA 2003; 289:2560 - 72. [2] Decker WW, Godwin SA, Hess EP, Lenamond CC, Jagoda AS. Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department. Ann Emerg Med 2006;47:237 - 49. [3] Psaty BM, Smith NL, Siscovick DS, et al. Health outcomes associated with antihypertensive therapies used as first-line agents: a systematic review and meta-analysis. JAMA 1997;277:739 - 45. [4] Cherry DK, Woodwell DA. National ambulatory medical survey: 2000 summary. Adv Data 2002;328:1 - 32.
317
[5] Klag MJ, Whelton PK, Randall BL, et al. Blood pressure and endstage renal disease in men. N Engl J Med 1996;334:13 - 8. [6] Psaty BM, Furberg CD, Kuller LH, et al. Association between blood pressure level and the risk of myocardial infarction, stroke, and total mortality: the Cardiovascular Health Study. Arch Intern Med 2001; 161:1183 - 92. [7] Neal B, MacMahon S, Chapman N. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure–lowering drugs. Lancet 2000;256:1955 - 64. [8] Ogden LG, He J, Lydick E, Whelton PK. Long-term absolute benefit of lowering blood pressure in hypertensive patients according to the JNC VI risk stratification. Hypertension 2000;35:539 - 43. [9] Barrier PA, Li JT, Jensen NM. Two words to improve physicianpatient communication: what else? Mayo Clin Proc 2003;78:211 - 4. [10] Rhodes KV, Gordon JA, Lowe RA. Preventive care in the emergency department: Part I. Clinical preventative services—are they relevant to emergency medicine? Acad Emerg Med 2000;7:1036 - 41. [11] Nerlinger A, Jubanyik R. Quantifying the problem: undiagnosed hypertension in the emergency department and failure to refer for blood pressure recheck. (abstract)Acad Emerg Med 2006; 13(5, Suppl 1):S54. [12] Tanabe P, Steinmann R, Kippenham M, et al. Undiagnosed hypertension in the ED setting—an unrecognized opportunity by emergency nurses. J Emerg Nurs 2004;30(3):225 - 9. [13] Chiang WK, Jamshahi B. Asymptomatic hypertension in the ED. Am J Emerg Med 1997;16:701 - 4. [14] Thach AM, Schultz PJ. Nonemergent hypertension. New perspectives for the emergency medicine physician. Emerg Med Clin North Am 1995;13:1009 - 35. [15] Wachter RM. Symptomatic hypotension induced by nifedipine in the acute treatment of severe hypertension. Arch Intern Med 1987; 147:556 - 8. [16] Backer HD, Decker L, Ackerson L. Reproducibility of increased blood pressure during an emergency department or urgent care visit. Ann Emerg Med 2003;41:507 - 12. [17] Cienki JJ, DeLuca LA, Daniel N. The validity of emergency department triage blood pressure measurements. Acad Emerg Med 2004;11:237 - 43. [18] McAlister F, Straus SE. Measurement of blood pressure: an evidence based review. BMJ 2001;322:908 - 11. [19] Fleming J, Meredith C, Henry J. Detection of hypertension in the emergency department. Emerg Med J 2005;22:636 - 9. [20] Reeves RA. Does this patient have hypertension? How to measure pressure. JAMA 1995;273:1211 - 8. [21] Pickering TG. Blood pressure measurement and detection of hypertension. Lancet 1994;344:31 - 5. [22] Lehrmann JF, Baumann BM, Cienki JJ, et al. Physician and nurse self-reported blood pressure (BP) reassessment practices and perceptions of barriers to BP reassessment. (abstract)Acad Emerg Med 2006; 13(5, Suppl 1):S54 - 5. [23] Pitts SR, Adams RP. Emergency department hypertension and regression to the mean. Ann Emerg Med 1998;31(2):214 - 8. [24] Karras DJ, Ufberg JW, Heilpern KL, et al. Elevated blood pressure in urban emergency department patients. Acad Emerg Med 2005;12: 835 - 43. [25] Karras DJ, Kruus LK, Cienki JJ, et al. Evaluation and treatment of patients with severely elevated blood pressure in academic emergency departments: a multicenter study. Ann Emerg Med 2006; 47:230 - 6. [26] Chernow SM, Iserson KV, Criss E. Use of the emergency department for hypertension screening: a prospective study. Ann Emerg Med 1987;16:180 - 2. [27] Dieterle T, Schuurmans MM, Strobel W, et al. Moderate-to-severe blood pressure elevation at ED entry: hypertension or normotension? Am J Emerg Med 2005;23(4):474 - 9. [28] Littenberg B. A practice guideline revisited: screening for hypertension. Ann Intern Med 1995;122:937 - 9.