Hypertension in the Emergency Department: Should We be Concerned?
Hypertension in the Emergency Department: Should We be Concerned?
Abstract & Commentary
By Joseph Varon, MD, FACP, FCCP, FCCM, Clinical Professor of Internal Medicine, University of Texas Health Science Center, Houston; Adjunct Professor of Medicine, University Texas Medical Branch, Galveston. Dr. Varon reports no financial relationship to this field of study.
Synopsis: Patients that present with elevated blood pressure (BP) to the emergency department (ED) frequently have elevated BP measurements at home, independent of pain and anxiety. Clinicians must provide close follow up for these patients.
Source: Tanabe P, et al: Ann Emerg Med 2008; 51: 221-229.
This prospective cohort study was aimed at evaluating those patients without a prior history of hypertension that presented to a single urban ED and were found to have BP of at least 140/90 mm Hg. These patients were then provided with automatic BP monitors and instructed to take their BP at least twice a week for a period of one week. The data obtained in the ED and at home was correlated with the Spielberg State Anxiety State (SSAS) scale and a 10-point pain scale. The change in BP upon discharge from the ED was also recorded and used for the analysis.
Two hundred sixty-one patients met study criteria characteristics and were offered enrollment in this study. Of them, 189 were enrolled (mean age was 47 ± 13 years). Fifty percent were 50% women, 35% African Americans, 60% Caucasians and 7% Hispanic. Of the patients enrolled, 83% (n=156) returned the monitor and completed a minimum of 4 BP readings. The mean number of BP readings was 14.
Of the 156 patients who returned the monitor and completed BP recordings, 51% had increased mean home BP readings. Of these patients with elevated BP, 71% had increased systolic and 88% had increased diastolic BP. The mean BP difference from ED to home was 19.5 mm Hg systolic and 3.6 mm Hg diastolic. Interestingly in this cohort, a high proportion of patients reported having commercial insurance.
Those patients with increased home BP readings tended to be older, were more likely to be women, and more likely to be African American and had significantly higher ED systolic BP measurements. The mean pain score for the cohort was 4.1 and the mean anxiety score was 37.8. Anxiety was not correlated with a change in either systolic or diastolic BP. No association was found either with the presence of pain in the ED in those patients with persistently elevated BP readings at home.
Commentary
It is estimated that there are more than 70 million adults in the United States with hypertension.1 Roughly 1 out of 100 patients with essential hypertension will experience a hypertensive crisis at some point during their lifetime, and these hypertensive emergencies and urgencies account for more than 27% of all acute medical problems presenting to EDs in the United States.2 What it is not known, is the relevance of isolated BP elevations in the ED for those patients with prior history of hypertension.
The study by Tanabe and associates is interesting because it shows that patients with elevated BP in the ED in more than 50% of the cases continued to have elevated BP at home.3 Moreover, this persistent elevation in BP was independent of pain or anxiety. This may be a good indicator for hypertension and clinicians working in EDs should arrange for adequate follow up of these patients.
References
1. Varon J. Drugs. 2008;68(3):283-297.
2. Marik P, Varon J. Chest. 2007;131:1949-1962.
3. Tanabe P, et al. Ann Emerg Med. 2008;51:221-229.
Patients that present with elevated blood pressure (BP) to the emergency department (ED) frequently have elevated BP measurements at home, independent of pain and anxiety. Clinicians must provide close follow up for these patients.Subscribe Now for Access
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