Original ContributionBlood pressure treatment and outcomes in hypertensive patients without acute target organ damage: a retrospective cohort
Introduction
Hypertension (HTN) is the most common risk factor for cardiovascular disease in the United States, affecting approximately 75 million individuals and, as such, is a frequently encountered condition among patients treated in the emergency department (ED) [1], [2]. Accordingly, emergency physicians evaluate and treat a variety of hypertensive patients ranging from those who have incidentally discovered elevations in their blood pressure (BP) to those who are critically ill with acute target organ damage (TOD) [3], [4]. Although there is relative uniformity in the approach to treatment of those with true hypertensive emergencies, a clear consensus on the management of patients with severely elevated BP in the ED who lack clinical evidence of acute TOD does not exist.
Significant confusion exists regarding how and when to intervene for patients with markedly elevated BP (ie, ≥ 180/100 mm Hg) but no symptoms of acute TOD, leading to widely divergent practice patterns [5], [6]. Much of this is driven by a scarcity of relevant outcome data, specifically as it pertains to the possible benefit or harm associated with acute BP reduction.
The goal of this investigation is to compare outcomes for ED patients with markedly elevated BP but no signs or symptoms of acute TOD based on whether they received antihypertensive therapy for BP reduction in the ED.
Section snippets
Study design and setting
This was an institutional review board–approved, retrospective cohort study of adult patients between the ages of 18 and 89 years who were discharged from the ED of an urban teaching hospital with a primary diagnosis of HTN between the dates of January 1, 2008, and December 31, 2008.
Study protocol
An initial search of ED billing company data yielded 1798 visits over the study period where HTN was the primary discharge diagnosis. For this analysis, we included only patients with an initial triage BP greater
Characteristics of study subjects
A total of 1016 patients met eligibility criteria, 435 (42.8%) of whom received treatment for elevated BP. As shown in Table 1, patients in both groups (treated vs not treated) were largely African American and relatively young with a mean (SD) age of 49.8 (11.6) vs 48.6 (11.9) years, respectively. Treated patients were more likely to have a history of HTN (93.1% vs 84.3%; difference of − 8.8; 95% CI, − 12.5 to − 4.9) and be on clonidine therapy at baseline (45.0% vs 7.5%; difference of − 36.9; 95%
Discussion
Despite strong sentiment that acute antihypertensive therapy is not necessary in the setting of HTN without acute TOD [3], [8], clinicians often feel inclined to do something when patients present with markedly elevated BP. However, as we demonstrate in this retrospective cohort study, acute BP reduction appears to provide no direct benefit to such patients. Moreover, the occurrence of adverse events was minimal, and death rates were low in both treated and not-treated patients signaling an
Limitations
By only including individuals who were discharged with a primary diagnosis of HTN, this study likely excluded a number of ED patients with marked BP elevation for whom HTN was either a secondary diagnosis or not diagnosed at all. Reviewing charts for consecutive patients may have allowed for greater capture of potentially eligible patients and reduced potential for selection bias. However, such an approach is labor intensive, and, given the low incidence of adverse events, it is unlikely that
Conclusions
In summary, in this single-center, retrospective cohort of predominantly African American ED patients with markedly elevated BP but no signs or symptoms of acute TOD, we found no evidence of benefit with treatment to acutely lower BP. That said, complications related to HTN were infrequent, and the all-cause mortality rate was low with no differences between groups providing a measure of reassurance to ED physicians who use either approach in the care of their acutely hypertensive patients.
References (21)
- et al.
Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department
Ann Emerg Med
(2006) - et al.
Severely increased blood pressure in the emergency department
Ann Emerg Med
(2003) - et al.
Initiation of therapy for asymptomatic hypertension in the emergency department
Ann Emerg Med
(2009) Against routine initiation of antihypertensive therapy in the emergency department
Ann Emerg Med
(2009)Hypertensive urgencies: treating the mercury?
Ann Emerg Med
(2003)- et al.
Asymptomatic hypertension in the ED
Am J Emerg Med
(1998) - et al.
Recognizing asymptomatic elevated blood pressure in ED patients: how good (bad) are we?
Am J Emerg Med
(2007) - et al.
Emergency department hypertension and regression to the mean
Ann Emerg Med
(1998) - et al.
Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure
Ann Emerg Med
(2013) - et al.
Asymptomatic hypertension in the emergency department: a matter of critical public health importance
Acad Emerg Med
(2009)
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