It’s a busy Monday afternoon. Patients are packed into the department like sardines. You have bruises on your shins from trying to wade through the stretchers to discharge a few people, but now you’re back at the computer ready to pick up some new ones. You click on the next person waiting to be seen, hoping for a nice satisfying shoulder reduction, and read the chief complaint: high blood pressure, denies other complaints.
We’ve all been there. As emergency physicians, we know that asymptomatic hypertension does not need acute treatment in the emergency department, yet people come in all the time with concerns about the readings they obtained at home.
Why does this keep happening? Beginning in the early 2000s, guidelines began recommending patients monitor their BP at home in order to help primary care physicians obtain more accurate data for titrating BP meds. But patients (and doctors) can sometimes get fixated on numbers, and this resulted in an increase in ED visits for asymptomatic hypertension.
A paper published in Annals of Emergency Medicine in July 2018 (see reference below) conducted a retrospective study of 1508 patients who self-referred to the emergency department with asymptomatic hypertension. (20% of those patients came by ambulance, but that is a topic for another day!) 3% of the study patients had true hypertensive emergencies and were admitted. Mortality at 2 years in the study population was comparable to what would be expected in age matched patients with similar comorbidities. I’m sure it’s no surprise that the majority of patients with asymptomatic hypertension can be treated safely in the outpatient setting, but data to back that up is always helpful.
Symptoms of hypertensive emergency include: chest pain, shortness of breath, altered mental status, severe HA, blurry vision, and signs of volume overload or heart failure. Clearly, these patients should be admitted. Know what to watch out for and educate your patients so they can triage themselves to the right setting for their blood pressure treatment. Take a little extra time when giving discharge instructions to reassure them. No one wants to wait 5+ hours only to be told they don’t need us to do anything today.
Additional things to click on:
Only have time to read one thing? PICK THIS!!!! (Teaser: my favorite part is the end, when you find out checking blood pressure at home causes cancer!)
Hypertension and the Emergency Physician, by Reuben Strayer
Want to brush up on hypertensive emergencies? Go here:
EMCrit Podcast 190 – Emergencies with a side of hypertension
Overachiever? This is not exactly high yield for our purposes, but if you need some data, here is a link to the AHA 2017 Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults:
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.