Routine testing in patients with asymptomatic elevated blood pressure in the ED

Clinical utility of routine investigations and risk factors of end-organ damage in asymptomatic severe hypertension

Asymptomatic severe hypertension is defined as systolic blood pressure of ≥ 180 mmHg or diastolic blood pressure of ≥ 120 mmHg without signs and symptoms of end-organ damage or dysfunction. Literature shows that around 5% of the patients with severe asymptomatic hypertension had acute hypertension-related end-organ damage. This study aimed to determine the clinical utility of routine investigations and risk factors of end-organ damage in patients presented to the emergency department with  asymptomatic severe hypertension. This single-center, cross-sectional study was conducted at the emergency department of the Aga Khan University Hospital, Karachi, Pakistan, from January 2018 to December 2020. All adult patients (age ≥ 18 years) presented to the emergency department with a systolic blood pressure of ≥ 180 or diastolic blood pressure of ≥ 120 mmHg without any signs and symptoms of end-organ damage (e.g., chest pain, unilateral limb or facial weakness, or hemiplegia, altered mental status, shortness of breath, decreased urine output, and sudden-onset of severe headache) were included. Routine investigations were analyzed to detect end-organ damage, including complete blood count, basic metabolic panel, urine detailed report, electrocardiogram, and troponin-I. Multivariable binary logistic regression was applied to identify the risk factors of end-organ damage considering the significant p value of ≤ 0.05. A total of 180 patients were presented to the emergency department with asymptomatic severe hypertension during the study period. Among the total patients, 60 patients (33.3%) had abnormal investigation findings; out of them, new-onset end-organ damage was diagnosed in 15 patients (8.3%). The most common end-organ damage was the kidney (73.3%) followed by the heart (26.6%). The multivariable binary logistic regression showed that age of more than 60 years, past medical history of diabetes, ischemic heart disease, and cerebrovascular accident were significantly associated with a higher risk of end-organ damage (p < 0.05). The study identified a higher prevalence of abnormal routine investigations and acute end-organ damage in emergency department patients with asymptomatic severe hypertension compared to high-income countries and suggested a lower threshold for end-organ damage screening in these patients. The current recommendations of foregoing further workup in patients with asymptomatic severe hypertension may need modification for emergency departments in low-middle-income countries if similar associations are replicated in other settings.

Hypertension in the Emergency Department

Hypertension is the leading risk factor for the global burden of disease, yet more than 20% of adults with hypertension are unaware of their condition. Underlying hypertension affects over 25% emergency department attendees, and the condition is more commonly encountered in emergency departments than in primary care settings. Emergency departments are strategically well placed to fulfill the important public health goal of screening for hypertension, yet less than 30% of patients with mild to severe hypertension are referred for follow up. In predominantly African American populations, subclinical hypertensive disease is highly prevalent in ED attendees with asymptomatic elevated blood pressure. Although medical intervention is not usually required, in select patient populations, it may be beneficial for antihypertensive medications to be started or adjusted in the emergency department, aiming for optimizing blood pressure control earlier while waiting for continuing care.

Frequency of Serious Outcomes in Patients With Hypertension as a Chief Complaint in the Emergency Department

Context: Hypertension is a common incidental finding in the emergency department (ED). However, the authors noticed a segment of patients who present to the ED specifically because their blood pressure is found to be elevated outside of the hospital. Emergency medicine physicians are often unsure of the level of intervention that is required for these patients.

Objective: To determine if these patients have serious outcomes (ie, final diagnosis of myocardial infarction, angina, coronary syndrome, congestive heart failure, pulmonary edema, hypertensive encephalopathy, malignant hypertension, stroke, transient ischemic attack, subarachnoid hemorrhage, loss of vision, kidney failure, or aortic dissection) within 7 days of the initial ED visit.

Methods: The authors retrospectively reviewed ED medical records from 2008 with a chief complaint of high blood pressure or hypertension in the physician or nursing notes. Age, sex, blood pressure, history of hypertension, associated symptoms, tests, medications, admission or discharge information, final diagnoses, and return visits within 7 days were recorded.

Results: Of the 316 medical records that were reviewed, 149 met the study criteria and were included in analysis. Patient age range was 19 to 94 years (mean, 59.8 years; median, 61 years). Sixty patients (40%) were men and 89 (60%) were women. Of the 149 patients, 121 (81%) had a previous diagnosis of hypertension and 28 (19%) did not. Five patients (3%) had a normal initial blood pressure in the ED. Sixteen patients (11%) did not undergo diagnostic tests, and 77 patients (52%) received medication in the ED. Twenty-six patients (17%) were admitted to the hospital, and 123 (83%) were discharged or eloped. Four patients (2.7%; 95% confidence interval, 0.7-6.7) had a serious outcome noted within 7 days of initial presentation to the ED.

Conclusion: Among patients presenting to the ED with a chief complaint of hypertension or high blood pressure and no serious associated complaint, the risk of serious outcome within 7 days is low.