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Tran KC, Mak M, Kuyper LM, Bittman J, Mangat B, Lindsay H, Kim Sing C, Xu L, Wong H, Dawes M, Khan N, Ho K. Home Blood Pressure Telemonitoring Technology for Patients With Asymptomatic Elevated Blood Pressure Discharged From the Emergency Department: Pilot Study. JMIR Form Res 2024; 8:e49592. [PMID: 38111177 PMCID: PMC10865197 DOI: 10.2196/49592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/17/2023] [Accepted: 12/19/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Hypertension affects 1 in 5 Canadians and is the leading cause of morbidity and mortality globally. Hypertension control is declining due to multiple factors including lack of access to primary care. Consequently, patients with hypertension frequently visit the emergency department (ED) due to high blood pressure (BP). Telehealth for Emergency-Community Continuity of Care Connectivity via Home-Telemonitoring Blood Pressure is a pilot project that implements and evaluates a comprehensive home blood pressure telemonitoring (HBPT) and physician case management protocol designed as a postdischarge management strategy to support patients with asymptomatic elevated BP as they transition from the ED to home. OBJECTIVE Our objective was to conduct a feasibility study of an HBPT program for patients with asymptomatic elevated BP discharged from the ED. METHODS Patients discharged from an urban, tertiary care hospital ED with asymptomatic elevated BP were recruited in Vancouver, British Columbia, Canada, and provided with HBPT technology for 3 months of monitoring post discharge and referred to specialist hypertension clinics. Participants monitored their BP twice in the morning and evenings and tele-transmitted readings via Bluetooth Sensor each day using an app. A monitoring clinician received these data and monitored the patient's condition daily and adjusted antihypertensive medications. Feasibility outcomes included eligibility, recruitment, adherence to monitoring, and retention rates. Secondary outcomes included proportion of those who were defined as having hypertension post-ED visits, changes in mean BP, overall BP control, medication adherence, changes to antihypertensive medications, quality of life, and end user experience at 3 months. RESULTS A total of 46 multiethnic patients (mean age 63, SD 17 years, 69%, n=32 women) found to have severe hypertension (mean 191, SD 23/mean 100, SD 14 mm Hg) in the ED were recruited, initiated on HBPT with hypertension specialist physician referral and followed up for 3 months. Eligibility and recruitment rates were 40% (56/139) and 88% (49/56), respectively. The proportion of participants that completed ≥80% of home BP measurements at 1 and 3 months were 67% (31/46) and 41% (19/46), respectively. The proportion of individuals who achieved home systolic BP and diastolic BP control at 3 months was 71.4% (30/42) and 85.7% (36/42) respectively. Mean home systolic and diastolic BP improved by -13/-5 mm Hg after initiation of HBPT to the end of the study. Patients were prescribed 1 additional antihypertensive medication. No differences in medication adherence from enrollment to 3 months were noted. Most patients (76%, 25/33) were highly satisfied with the HBPT program and 76% (25/33) found digital health tools easy to use. CONCLUSIONS HBPT intervention is a feasible postdischarge management strategy and can be beneficial in supporting patients with asymptomatic elevated BP from the ED. A randomized trial is underway to evaluate the efficacy of this intervention on BP control.
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Affiliation(s)
- Karen C Tran
- Division of General Internal Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Meagan Mak
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Laura M Kuyper
- Division of General Internal Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jesse Bittman
- Division of General Internal Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Birinder Mangat
- Division of General Internal Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Heather Lindsay
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chad Kim Sing
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Liang Xu
- Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Hubert Wong
- Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Martin Dawes
- Division of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nadia Khan
- Division of General Internal Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Kendall Ho
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Ali N, Aftab U, Soomar SM, Tareen H, Khan UR, Khan BA, Razzak JA. Clinical utility of routine investigations and risk factors of end-organ damage in asymptomatic severe hypertension. Intern Emerg Med 2023; 18:2037-2043. [PMID: 37668749 DOI: 10.1007/s11739-023-03403-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/18/2023] [Indexed: 09/06/2023]
Abstract
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.
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Affiliation(s)
- Noman Ali
- Department of Emergency Medicine, Aga Khan University Stadium Road, Karachi, 74800, Pakistan.
| | - Umaira Aftab
- Department of Emergency Medicine, Aga Khan University Stadium Road, Karachi, 74800, Pakistan
| | - Salman Muhammad Soomar
- Department of Emergency Medicine, Aga Khan University Stadium Road, Karachi, 74800, Pakistan
| | - Hafsa Tareen
- Department of Emergency Medicine, Aga Khan University Stadium Road, Karachi, 74800, Pakistan
| | - Uzma Rahim Khan
- Department of Emergency Medicine, Aga Khan University Stadium Road, Karachi, 74800, Pakistan
| | - Badar Afzal Khan
- Department of Emergency Medicine, Aga Khan University Stadium Road, Karachi, 74800, Pakistan
| | - Junaid Abdul Razzak
- Department of Emergency Medicine, Aga Khan University Stadium Road, Karachi, 74800, Pakistan
- Weill Cornell Medicine,, New York, USA
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The Management of Hypertensive Emergencies-Is There a "Magical" Prescription for All? J Clin Med 2022; 11:jcm11113138. [PMID: 35683521 PMCID: PMC9181665 DOI: 10.3390/jcm11113138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 12/04/2022] Open
Abstract
Hypertensive emergencies (HE) represent high cardiovascular risk situations defined by a severe increase in blood pressure (BP) associated with acute, hypertension mediated organ damage (A-HMOD) to the heart, brain, retina, kidneys, and large arteries. Blood pressure values alone do not accurately predict the presence of HE; therefore, the search for A-HMOD should be the first step in the management of acute severe hypertension. A rapid therapeutic intervention is mandatory in order to limit and promote regression of end-organ damage, minimize the risk of complications, and improve patient outcomes. Drug therapy for HE, target BP, and the speed of BP decrease are all dictated by the type of A-HMOD, specific drug pharmacokinetics, adverse drug effects, and comorbidities. Therefore, a tailored approach is warranted. However, there is currently a lack of solid evidence for the appropriate treatment strategies for most HE. This article reviews current pharmacological strategies while providing a stepwise, evidence based approach for the management of HE.
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Vitto CM, Lykins V JD, Wiles-Lafayette H, Aurora TK. Blood Pressure Assessment and Treatment in the Observation Unit. Curr Hypertens Rep 2022; 24:311-323. [PMID: 35596047 DOI: 10.1007/s11906-022-01196-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW To review the pathophysiology, diagnosis, and the management of hypertension. Given the paucity of literature regarding the role of the observation unit in the management of hypertension, we will provide our recommendations based on our experience working in an observation unit. RECENT FINDINGS Many patients have limited access to primary care, and hypertension diagnosis often relies on office-based measurements. We will describe situations where that is not necessary to make the diagnosis. We will discuss the current non-pharmacologic treatment guidelines, the education of which should be provided to patients both in the emergency department and observation units. We will provide the current recommendations on what anti-hypertension medications can be initiated in the emergency department and observation units. Hypertension is a leading cause of morbidity and mortality in the USA. The utility of an observation unit in the diagnosis and management of patients with hypertension is beneficial particularly for those with risk factors for atherosclerotic disease. An observation unit stay provides the opportunity to diagnosis hypertension, initiate lifestyle education and pharmacologic treatment if indicated, and help to arrange appropriate follow-up for ongoing management and treatment in individuals with limited access to care.
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Nijskens CM, Veldkamp SR, Van Der Werf DJ, Boonstra AH, Ten Wolde M. Funduscopy: Yes or no? Hypertensive emergencies and retinopathy in the emergency care setting; a retrospective cohort study. J Clin Hypertens (Greenwich) 2020; 23:166-171. [PMID: 33017517 PMCID: PMC8029924 DOI: 10.1111/jch.14064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/08/2020] [Accepted: 07/28/2020] [Indexed: 12/04/2022]
Abstract
According to international guidelines, patients with a suspected hypertensive emergency (HE) admitted to the emergency department (ED) should undergo comprehensive evaluation including funduscopic examination. However, funduscopy is not always readily available and little is known about the prevalence of retinopathy among these patients in the ED setting. In order to characterize patients who should undergo funduscopy, we studied the prevalence, characteristics and clinical outcome in patients with a suspected HE and retinopathy grade III/IV. We conducted a retrospective cohort study of consecutive patients with severe elevation of blood pressure (BP) admitted to the ED between 2012 and 2015. Patients with a systolic blood pressure (SBP) ≥180 mm Hg or diastolic blood pressure (DBP) ≥120 mm Hg at time of presentation were included. A total of 271 patients were included, of whom 18 (6.6%; 95%CI 3.9‐10.5) had a HE. In 121 patients (44.6%; 95%CI 37.1‐53.3), funduscopy was performed, of whom 17 (14.0%; 95%CI 8.2‐22.5) had retinopathy grade III/IV. Mean SBP and DBP were significantly higher in patients with retinopathy (P < .001). However, retinopathy was also seen in patients with lower BP (SBP < 200 mm Hg and DBP < 120 mm Hg). No differences in other clinical characteristics, including visual disturbances, were found. One patient with retinopathy suffered an ischemic stroke after taking oral medication. The prevalence of retinopathy is high among examined patients. Except for higher BP, no clinical signs or symptoms are associated with the presence of retinopathy grade III/IV. We therefore conclude that funduscopic examination should be performed in every patient with a suspected HE.
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Affiliation(s)
| | - Saskia R Veldkamp
- Department of Internal Medicine, Flevohospital, Almere, The Netherlands
| | | | - Arnold H Boonstra
- Department of Internal Medicine, Flevohospital, Almere, The Netherlands
| | - Marije Ten Wolde
- Department of Internal Medicine, Flevohospital, Almere, The Netherlands
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Drug nonadherence is a common but often overlooked cause of hypertensive urgency and emergency at the emergency department. J Hypertens 2020; 37:1048-1057. [PMID: 30480568 DOI: 10.1097/hjh.0000000000002005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Over 70% of patients who visit the emergency department with a hypertensive emergency or a hypertensive urgency have previously been diagnosed with hypertension. Drug nonadherence is assumed to play an important role in development of hypertensive urgency and hypertensive emergency, but exact numbers are lacking. We aimed to retrospectively compare characteristics of patients with hypertensive urgency and hypertensive emergency and to prospectively quantify the attribution of drug nonadherence. METHODS We retrospectively analysed clinical data including information on nonadherence obtained by treating physicians of patients with SBP at least 180 mmHg and DBP at least 110 mmHg visiting the emergency department between 2012 and 2015. We prospectively studied drug adherence among patients admitted to the emergency department with severely elevated BP by measuring plasma drug levels using liquid chromatography tandem mass spectrometry from September 2016 to March 2017. RESULTS Of the 1163 patients retrospectively analysed, 257 (22.0%) met the criteria for hypertensive urgency and 356 (30.6%) for hypertensive emergency. Mean SBP (SD) was 203 (19) mmHg and mean DBP 121 (12) mmHg. Mean age was 60.1 (14.6) years; 55.1% were men. In 6.3% of patients with hypertensive urgency or hypertensive emergency, nonadherence was recorded as an attributing factor. Of the 59 patients prospectively analysed, 18 (30.5%) were nonadherent for at least one of the prescribed antihypertensive drugs. CONCLUSION Hypertensive urgency and hypertensive emergency are common health problems resulting in frequent emergency department admissions. Workup of patients with a hypertensive urgency or hypertensive emergency should include an assessment of drug adherence to optimize treatment strategy.
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Abstract
OBJECTIVES Acute severe hypertension is a common problem among inner-city ethnic minority populations. Nevertheless, the effects of currently employed treatment regimens on blood pressure have not been determined in a clinical practice setting. We determined the SBP responses to acute antihypertensive drug protocols and the 2-year natural history of patients presenting with severe hypertension. METHODS Retrospective cohort investigation in consecutive patients with SBP at least 220 mmHg and/or DBP at least 120 mmHg during 3-month enrollment in 2014 with 2-year follow-up. Primary outcomes were SBP versus time for the first 5 h of emergency treatment and 2-year follow-up including repeat visits, target organ events, and hospitalizations. RESULTS One hundred and fifty-six unique patients met criteria with 69% Black; 34% Hispanic; 56% had previous visits for severe hypertension; 31% had preexisting target injury. Acute management: Acute antihypertensive regimens resulted in grossly unpredictable and often exaggerated effects on SBP. Treatment acutely reduced SBP to less than 140 mmHg in 30 of 159 patients. Clonidine reduced SBP to less than 140 mmHg in 19/61. Two-year follow-up: We observed 389 repeat visits for severe hypertension, 99 new target events, and 76 hospitalizations accounting for 620 hospital days. CONCLUSION Acute treatment of severe hypertension produced unpredictable and potentially dangerous responses in SBP. Two-year follow-up demonstrated extraordinary rates of recurrent visits, target organ events, and hospitalizations. Our findings indicate a need to develop effective management strategies to lower blood pressure safely and to prevent long-term consequences. Our findings may apply to other hospitals caring for ethnic minority populations.
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Affiliation(s)
- Aldo J Peixoto
- From the Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, and the Hypertension Program, Yale New Haven Hospital Heart and Vascular Center, New Haven, CT
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Goldberg EM, Wilson T, Jambhekar B, Marks SJ, Boyajian M, Merchant RC. Emergency Department-Provided Home Blood Pressure Devices Can Help Detect Undiagnosed Hypertension. High Blood Press Cardiovasc Prev 2019; 26:45-53. [PMID: 30659517 DOI: 10.1007/s40292-019-00300-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/09/2019] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Emergency departments (EDs) are critical sites for hypertension (HTN) screening. Home blood pressure (BP) monitoring (HBPM) is used routinely in outpatient settings, yet its utility after the ED visit for those with elevated BP in the ED is unclear. AIM In this pilot study, we assessed if HBPM could detect HTN in patients with elevated in-ED BP. METHODS From September 2014 to July 2017, we recruited adult patients at an urban, academic ED with a triage BP ≥ 120/80 mmHg and no history of HTN into this prospective cohort observational study. After their ED visit, participants obtained BP measurements for two weeks using a validated HBPM. HTN was considered probable if the average HBPM BP was ≥ 135/85 mmHg. We calculated the proportion of participants whose ED BP measurement accurately predicted HTN using HBPM after discharge. RESULTS Of 136 participants enrolled, 93 (68%) returned the HBPM with at least four home BP measurements [mean number of measurements obtained: 29 (SD: 17, range 4-59)]. Participants' median age was 40 years-old (IQR 34-48); 55% were female, 19% were black, and 58% were white. Forty-six percent of participants with elevated in-ED BP had HTN in follow-up. CONCLUSIONS For patients with elevated BP in the ED, HBPM could be valuable for determining which patients have HTN and require expedient follow-up.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Emergency Medicine, Brown University, 55 Claverick Street, Providence, RI, 02903, USA. .,Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Taneisha Wilson
- Department of Emergency Medicine, Brown University, 55 Claverick Street, Providence, RI, 02903, USA
| | | | - Sarah J Marks
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Roland C Merchant
- Department of Emergency Medicine, Brown University, 55 Claverick Street, Providence, RI, 02903, USA.,Alpert Medical School of Brown University, Providence, RI, USA
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Goldberg EM, Marks SJ, Merchant RC. National trends in the emergency department management of adult patients with elevated blood pressure from 2005 to 2015. JOURNAL OF THE AMERICAN SOCIETY OF HYPERTENSION : JASH 2018; 12:858-866. [PMID: 30396852 PMCID: PMC6226022 DOI: 10.1016/j.jash.2018.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/11/2018] [Accepted: 09/29/2018] [Indexed: 02/02/2023]
Abstract
Emergency department (ED)-based screening and referral of patients with elevated blood pressure (BP) are recommended by 2006 and 2013 American College of Emergency Physicians guidelines; however, it is unknown if these recommendations or disparities in care impact clinical practice. The objectives of the study were to assess temporal trends in antihypertensive prescriptions, outpatient follow-up referrals, and diagnosis of hypertension (HTN)/elevated BP and to identify potential disparities by patient characteristics. Using the 2005-2015 National Hospital Ambulatory Medical Care Survey, we examined the frequency and trends over time of antihypertensive prescriptions, outpatient follow-up referrals, and BP diagnoses for US ED visits by adult patients with an elevated triage BP and identified potential disparities in management by patient demography and socioeconomic status. Of the 594 million eligible ED visits by patients from 2005 to 2015, 1.2% (1.0%-1.4%) received antihypertensive prescriptions at discharge, 82.3% (80.0%-83.6%) outpatient follow-up referrals, and 2.1% (1.9%-2.4%) an HTN/elevated BP diagnosis. There were small annual increases over time in the odds of antihypertensive prescriptions at discharge (adjusted odds ratio [aOR] 1.05 [1.00-1.10]), follow-up referrals (aOR 1.04 [1.01-1.07]), and HTN/elevated BP diagnosis (aOR 1.05 [1.02-1.08]). For BPs ≥160/100 mm Hg, prescriptions were more common for Blacks (aOR 2.36 [1.93, 2.88]) and uninsured patients (aOR 1.81 [1.38, 2.38]), and diagnoses were more common for Blacks (aOR 1.95 [1.70, 2.24]) and uninsured patients (aOR 1.30 [1.09, 1.55]). These data suggest little change in and the need for improvement in the management of ED patients with elevated BP, despite the American College of Emergency Physicians guidelines, and raise concern about patient care disparities.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Emergency Medicine, Brown University, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University, Providence, RI, USA.
| | - Sarah J Marks
- Department of Emergency Medicine, Brown University, Providence, RI, USA
| | - Roland C Merchant
- Departments of Emergency Medicine & Epidemiology, Brown University, Providence, RI, USA
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Atzema CL, Wong A, Masood S, Zia A, Al-bulushi S, Sohail QZ, Cherry A, Chan FS. 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; 72:534-543. [DOI: 10.1016/j.annemergmed.2018.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/22/2018] [Accepted: 05/31/2018] [Indexed: 10/28/2022]
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Therapeutic Approach to Hypertension Urgencies and Emergencies in the Emergency Room. High Blood Press Cardiovasc Prev 2018; 25:177-189. [DOI: 10.1007/s40292-018-0261-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/05/2018] [Indexed: 12/15/2022] Open
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Asymptomatic Hypertension in the Emergency Department. PHYSICIAN ASSISTANT CLINICS 2017. [DOI: 10.1016/j.cpha.2017.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Nakprasert P, Musikatavorn K, Rojanasarntikul D, Narajeenron K, Puttaphaisan P, Lumlertgul S. Effect of predischarge blood pressure on follow-up outcomes in patients with severe hypertension in the ED. Am J Emerg Med 2016; 34:834-9. [DOI: 10.1016/j.ajem.2016.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/18/2016] [Accepted: 01/19/2016] [Indexed: 11/27/2022] Open
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Abstract
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.
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Affiliation(s)
- Stewart Siu-Wa Chan
- A&E Department, Prince of Wales Hospital, Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong.
| | - Colin A Graham
- A&E Department, Prince of Wales Hospital, Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong
| | - T H Rainer
- A&E Department, Prince of Wales Hospital, Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong.,Emergency Medicine, Cardiff University, Cardiff and Vale UHB. NHS Wales, Cardiff, UK
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Risk of Intracerebral Hemorrhage after Emergency Department Discharges for Hypertension. J Stroke Cerebrovasc Dis 2016; 25:1683-1687. [PMID: 27068776 DOI: 10.1016/j.jstrokecerebrovasdis.2016.03.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 03/22/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Recent literature suggests that acute rises in blood pressure may precede intracerebral hemorrhage. We therefore hypothesized that patients discharged from the emergency department with hypertension face an increased risk of intracerebral hemorrhage in subsequent weeks. METHODS Using administrative claims data from California, New York, and Florida, we identified all patients discharged from the emergency department from 2005 to 2011 with a primary diagnosis of hypertension (ICD-9-CM codes 401-405). We excluded patients if they were hospitalized from the emergency department or had prior histories of cerebrovascular disease at the index visit with hypertension. We used the Mantel-Haenszel estimator for matched data to compare each patient's odds of intracerebral hemorrhage during days 8-38 after emergency department discharge to the same patient's odds during days 373-403 after discharge. This cohort-crossover design with a 1-week washout period enabled individual patients to serve as their own controls, thereby minimizing confounding bias. RESULTS Among the 552,569 patients discharged from the emergency department with a primary diagnosis of hypertension, 93 (.017%) were diagnosed with intracerebral hemorrhage during days 8-38 after discharge compared to 70 (.013%) during days 373-403 (odds ratio 1.33, 95% confidence interval .96-1.84). The odds of intracerebral hemorrhage were increased in certain subgroups of patients (≥60 years of age and those with secondary discharge diagnoses besides hypertension), but absolute risks were low in all subgroups. CONCLUSIONS Patients with emergency department discharges for hypertension do not face a substantially increased short-term risk of intracerebral hemorrhage after discharge.
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Olives TD, Patel RG, Thompson HM, Joing S, Miner JR. Seventy-two-hour antibiotic retrieval from the ED: a randomized controlled trial of discharge instructional modality. Am J Emerg Med 2016; 34:999-1005. [PMID: 26969079 DOI: 10.1016/j.ajem.2016.02.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/15/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Limited health literacy is a risk factor for poor outcomes in numerous health care settings. Little is known about the impact of instructional modality and health literacy on adherence to emergency department (ED) discharge instructions. PURPOSE To examine the impact of instructional modality on 72-hour antibiotic retrieval among ED patients prescribed outpatient antibiotics for infections. METHODS English-speaking ED patients diagnosed as having acute infections and prescribed outpatient antibiotics were randomized to standard discharge instructions, standard instructions plus text-messaged instructions, or standard instructions plus voicemailed instructions targeting ED prescriptions. Health literacy was determined by validated instrument. Seventy-two-hour antibiotic retrieval, 30-day report of prescription completion, and discharge instructional modality preference were assessed. RESULTS Nearly one-quarter of the 2521 participants demonstrated low health literacy. Low health literacy predicted decreased 72-hour antibiotic retrieval (χ(2) = 9.56, P=.008). No significant association with antibiotic retrieval was noted across the 3 treatment groups (χ(2) = 5.112, P=.078). However, patients randomized to the text message group retrieved antibiotic prescriptions within 72 hours more frequently than did those randomized to the voicemail treatment group (χ(2) = 4.345, P=.037), and patients with low health literacy randomized to voicemailed instructions retrieved their antibiotic prescriptions less frequently than did those randomized to standard of care instructions (χ(2) = 5.526, P=.019). Reported instructional modality preferences were inconsistent with the primary findings of the study. CONCLUSIONS Discharge instructional modality impacts antibiotic retrieval in patients with low health literacy. Preference for discharge instructional modality varies by degree of health literacy, but does not predict which modality will optimize 72-hour antibiotic retrieval.
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Affiliation(s)
- Travis D Olives
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
| | - Roma G Patel
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN; University of Minnesota-Twin Cities, Minneapolis, MN
| | - Hannah M Thompson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN; University of Minnesota-Twin Cities, Minneapolis, MN
| | - Scott Joing
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - James R Miner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
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Emergency department patients with acute severe hypertension: a comparison of those admitted versus discharged in studying the treatment of acute hypertension registry. Crit Pathw Cardiol 2015; 13:66-72. [PMID: 24827883 DOI: 10.1097/hpc.0000000000000014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare the characteristics, treatments, and outcomes for emergency department (ED) patients with severe hypertension by disposition (admitted versus discharged home). METHODS Studying the Treatment of Acute hyperTension (STAT) is a multicenter registry of 1566 patients with blood pressure ≥180/110 mm Hg who were treated with intravenous antihypertensive medications in an ED or intensive care unit. Presenting and in-hospital variables, and postdischarge outcomes for the 1053 patients in the ED subset were compared by disposition. RESULTS In the multivariable analysis, ED patients were less likely to be discharged if >75 years of age (odds ratio [OR] = 0.3, 95% confidence interval [CI] = 0.1-0.9) or if they had shortness of breath (OR = 0.4, 95% CI = 0.2-0.8) or alteration of mental status (OR = 0.1, 95% CI = 0.02-0.9) on arrival. Nondialysis patients with an admission creatinine concentration >1.5 mg/dL were 80% less likely to be discharged than those ≤1.5 mg/dL (OR = 0.2, 95% CI = 0.08-0.5). In the bivariate analysis, patients with a decrease in systolic blood pressure of <10% 2 hours after medication administration were more likely to be admitted than those discharged (57% vs. 44%; P = 0.041). Disposition did not correlate with 90-day or 6-month mortality or 30-day readmission. However, admitted patients had a higher 90-day readmission rate (38% vs. 24%; P = 0.038). CONCLUSIONS ED patients with severe hypertension were more likely to be admitted to the hospital if they were >75 years of age, presented with shortness of breath or altered mental status, or had a creatinine >1.5 mg/dL and were not on hemodialysis.
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Mahn JJ, Dubey E, Brody A, Welch R, Zalenski R, Flack JM, Ference B, Levy PD. Test characteristics of electrocardiography for detection of left ventricular hypertrophy in asymptomatic emergency department patients with hypertension. Acad Emerg Med 2014; 21:996-1002. [PMID: 25269580 DOI: 10.1111/acem.12462] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 04/19/2014] [Accepted: 04/20/2014] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The objective was to evaluate the diagnostic test characteristics of three validated electrocardiographic (ECG) criteria for the diagnosis of left ventricular hypertrophy (LVH) in undifferentiated, asymptomatic emergency department (ED) patients with hypertension (HTN). METHODS This was a prospective cohort study of ED patients with asymptomatic HTN at a single tertiary care facility. Patients 35 years of age or older with systolic blood pressure (sBP) ≥ 140 mm Hg or diastolic blood pressure (dBP) ≥ 90 mm Hg on two separate readings (at least 1 hour apart) were eligible for inclusion. At enrollment, ECGs were obtained for all patients. Presence of LVH on ECG was defined using Cornell voltage, Cornell product, and Minnesota Code 3.1/3.2 criteria. Echocardiography was then performed, with LVH defined by the presence of one or more of the following validated criteria: interventricular septal or posterior wall thickness ≥ 1.3 cm, LV mass ≥ 225 g (male) or ≥ 163 g (female), or LV mass indexed to height raised to the power of 2.7 ≥ 48 g/m(2.7) (male) or ≥ 45 g/m(2.7) (female). Descriptive statistics and diagnostic characteristics (i.e., sensitivity and specificity) with corresponding 95% confidence intervals (CIs) for each of the three ECG criteria were derived for both the composite and the individual echocardiographic determinants of LVH. Logistic regression was also used to model LVH before and after subsequent inclusion of clinically relevant variables. RESULTS A total of 161 patients (93.8% African American; mean [±SD] age = 49.8 [±8.3] years) were enrolled, and LVH was present in 89 patients (55.2%, 95% CI = 47.6% to 62.8%). On ECG analysis, mean Cornell voltage (21.5 mV vs. 28.7 mV; difference = -7.2 mV, 95% CI = -3.8 to -10.7 mV) and Cornell product (1868.4 msec × mV vs. 2616.4 msec × mV; difference = -748.0 msec × mV, 95% CI = -401.2 to -1094.8 msec × mV) were significantly lower among those without LVH on echocardiography. Subjects without LVH on echocardiography were less likely to meet Cornell voltage (30.5% vs. 48.3%; difference = -17.8%, 95% CI = -2.5% to -31.7%) or Cornell product (26.4% vs. 49.4%; difference = -23.0%, 95% CI = -8.0% to -36.5%) criteria for LVH. The diagnosis of LVH by Minnesota Code was less common (18.1% vs. 25.8%; difference = -7.7%, 95% CI = -20.1% to 5.3%) with no difference by group. Sensitivity and specificity were as follows: for the Cornell voltage, sensitivity 25.4% (95% CI = 15.3% to 37.9%), specificity 50.0% (95% CI = 67.6% to 93.2%); for the Cornell product, sensitivity 25.4% (95% CI = 15.3% to 37.9%), specificity 75.0% (95% CI = 19.4% to 99.4%); and for the Minnesota code, sensitivity 26.9% (95% CI = 16.6% to 39.7%), specificity 75.0% (95% CI = 19.4% to 99.4%). On logistic regression, the c-statistics for Cornell voltage and Cornell product were equivalent (0.67), with only marginal improvement after the addition of body mass index (BMI; 0.69 and 0.70, respectively), B-type natriuretic peptide (BNP; 0.68 and 0.69, respectively), or both (0.71 and 0.72, respectively) to the models. CONCLUSIONS In this cohort of predominately African American ED patients with asymptomatic HTN, sensitivity and specificity of standard ECG criteria were relatively poor for the diagnosis of LVH on echocardiography. Thus, ECG is of limited use for LVH risk stratification in asymptomatic ED patients with elevated blood pressure, with additional clinical information only modestly strengthening its predictive value.
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Affiliation(s)
- James J. Mahn
- The Wayne State University School of Medicine; Wayne State University; Detroit MI
- The Department of Emergency Medicine; Wayne State University; Detroit MI
| | - Elizabeth Dubey
- The Department of Emergency Medicine; Wayne State University; Detroit MI
| | - Aaron Brody
- The Department of Emergency Medicine; Wayne State University; Detroit MI
| | - Robert Welch
- The Department of Emergency Medicine; Wayne State University; Detroit MI
| | - Robert Zalenski
- The Department of Emergency Medicine; Wayne State University; Detroit MI
| | - John M. Flack
- The Department of Internal Medicine; Wayne State University; Detroit MI
- The Cardiovascular Research Institute; Wayne State University; Detroit MI
| | - Brian Ference
- The Department of Internal Medicine; Wayne State University; Detroit MI
- The Division of Cardiology; Wayne State University; Detroit MI
| | - Phillip D. Levy
- The Department of Emergency Medicine; Wayne State University; Detroit MI
- The Cardiovascular Research Institute; Wayne State University; Detroit MI
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McNaughton CD, Self WH, Levy PD, Barrett TW. High-Risk Patients with Hypertension: Clinical Management Options. CLINICAL MEDICINE REVIEWS IN VASCULAR HEALTH 2013; 2012:65-71. [PMID: 23888121 DOI: 10.4137/cmrvh.s8109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Hypertension, one of the most common human diseases worldwide, affects nearly 1 billion individuals. Complaints related to hypertension are commonly evaluated and treated in the acute care settings such as emergency departments and acute care medical clinics. The evaluation, treatment, and disposition of these patients require thorough knowledge of potential complications and treatment options. This manuscript details a structured approach to evaluating high-risk patients with acute hypertension-related complaints and provides recommendations for treatment and disposition.
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Affiliation(s)
- Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Frei SP, Burmeister DB, Coil JF. Frequency of Serious Outcomes in Patients With Hypertension as a Chief Complaint in the Emergency Department. J Osteopath Med 2013; 113:664-8. [DOI: 10.7556/jaoa.2013.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
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.
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Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM. 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; 62:59-68. [PMID: 23842053 DOI: 10.1016/j.annemergmed.2013.05.012] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Cannon CM, Levy P, Baumann BM, Borczuk P, Chandra A, Cline DM, Diercks DB, Hiestand B, Hsu A, Jois P, Kaminski B, Nowak RM, Schrock JW, Varon J, Peacock WF. Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial. BMJ Open 2013; 3:e002338. [PMID: 23535700 PMCID: PMC3612758 DOI: 10.1136/bmjopen-2012-002338] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 02/16/2013] [Accepted: 02/22/2013] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare the efficacy of Food and Drug Administration recommended dosing of nicardipine versus labetalol for the management of hypertensive patients with signs and/or symptoms (S/S) suggestive of end-organ damage (EOD). DESIGN Secondary analysis of the multicentre prospective, randomised CLUE trial. SETTING 13 academic emergency departments in the USA. PARTICIPANTS Eligible patients had two systolic blood pressure (SBP) measures ≥180 mm Hg at least 10 min apart, no contraindications to nicardipine or labetalol and predefined S/S suggestive of EOD on arrival. INTERVENTIONS Medications were administered by continuous infusion (nicardipine) or repeat intravenous bolus (labetalol) for a study period of 30 min or until a specified target SBP ±20 mm Hg was achieved. PRIMARY OUTCOME MEASURE Percentage of participants achieving a predefined target SBP range (TR) defined as an SBP within ±20 mm Hg as established by the treating physician. RESULTS Of the 141 eligible patients, 49.6% received nicardipine, 51.7% were women and 81.6% were black. Mean age was 52.2±13.9 years. Median initial SBP did not differ in the nicardipine (210.5 (IQR 197-226) mm Hg) and labetalol (210 (200-226) mm Hg) groups (p=0.862). Nicardipine patients were more likely to have a history of diabetes (41.4% vs 25.7%, p=0.05) but there were no other historical, demographic or laboratory differences between groups. Within 30 min, nicardipine patients more often reached the target SBP range than those receiving labetalol (91.4% vs 76.1%, difference=15.3% (95% CI 3.5% to 27.3%); p=0.01). On multivariable modelling with adjustment for gender and clinical site, nicardipine patients were more likely to be in TR by 30 min than patients receiving labetalol (OR 3.65, 95% CI 1.31 to 10.18, C statistic=0.72). CONCLUSIONS In the setting of hypertension with suspected EOD, patients treated with nicardipine are more likely to reach prespecified SBP targets within 30 min than patients receiving labetalol. CLINICAL TRIAL REGISTRATION NCT00765648, clinicaltrials.gov.
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Affiliation(s)
- Chad M Cannon
- Department of Emergency Medicine, University of Kansas Hospital, Kansas City, Kansas, USA
| | - Phillip Levy
- Department of Emergency Medicine, Wayne State University, Detroit, Michigan, USA
- Cardiovascular Research Institute, Wayne State University, Detroit, Michigan, USA
| | - Brigitte M Baumann
- Division of Clinical Research, Cooper University Hospital, Camden, New Jersey, USA
- Department of Emergency Medicine, Cooper University Hospital, Camden, New Jersey, USA
| | - Pierre Borczuk
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Abhinav Chandra
- Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - David M Cline
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Deborah B Diercks
- Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento, California, USA
| | - Brian Hiestand
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Amy Hsu
- Cardiovascular Medicine, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Preeti Jois
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Richard M Nowak
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jon W Schrock
- Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Joseph Varon
- Department of Medicine and Acute and Continuing Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- The University of Texas Medical Branch at Galveston, Houston, Texas, USA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
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Levy P, Ye H, Compton S, Zalenski R, Byrnes T, Flack JM, Welch R. Subclinical Hypertensive Heart Disease in Black Patients With Elevated Blood Pressure in an Inner-City Emergency Department. Ann Emerg Med 2012; 60:467-74.e1. [DOI: 10.1016/j.annemergmed.2012.03.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 03/17/2012] [Accepted: 03/30/2012] [Indexed: 01/13/2023]
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Emergency department hypertension: time for a reassessment. Ann Emerg Med 2012; 60:475-7. [PMID: 22699016 DOI: 10.1016/j.annemergmed.2012.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 05/14/2012] [Accepted: 05/14/2012] [Indexed: 11/23/2022]
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Elevated Blood Pressure in ED Patients: Best Evidence on the Importance of Assessment, Recognition, and Referral. J Emerg Nurs 2012; 38:245-50. [DOI: 10.1016/j.jen.2010.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 12/18/2010] [Accepted: 12/20/2010] [Indexed: 11/20/2022]
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Shorr AF, Zilberberg MD, Sun X, Johannes RS, Gupta V, Tabak YP. Severe acute hypertension among inpatients admitted from the emergency department. J Hosp Med 2012; 7:203-10. [PMID: 22038891 DOI: 10.1002/jhm.969] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 07/13/2011] [Accepted: 07/25/2011] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hospitalists often treat patients with severe acute hypertension (AH) presenting to the hospital. Little is known about the epidemiology of this syndrome. OBJECTIVE To examine the prevalence of severe AH in patients admitted through the emergency department (ED) and its associated outcomes. DESIGN A cohort study using retrospectively collected vital signs and other clinical data. PATIENTS A total of 1,290,804 adults admitted between 2005 and 2007. SETTING One hundred fourteen acute-care hospitals. MEASUREMENTS Severe AH was defined as at least 1 systolic blood pressure (SBP) >180 mmHg. We used multivariable regression to estimate AH-attributable in-hospital mortality, need for mechanical ventilation (MV), and length of stay (LOS). RESULTS Severe AH occurred in 178,131 (13.8%) patients. Disease categories with the highest prevalence were nervous (29.0%), circulatory (16.0%), endocrine (14.7%), and kidney/urinary (13.5%). The overall in-hospital mortality was 3.6%. The relationship between severe AH strata and mortality was graded for nervous system diseases; mortality rates for each 10 mmHg increase in SBP from 180 to >220 mmHg were 6.5%, 8.1%, 9.9%, 12.0%, and 19.7%, respectively (P < 0.0001). The relationship between severe AH strata and need for MV was graded in the most pronounced way in respiratory and circulatory conditions (P < 0.0001). The relationship between severe AH strata and LOS was graded in most disease categories (P < 0.0001). CONCLUSIONS Severe AH appears common and its prevalence varies by underlying clinical condition. Severe AH is associated with excess in-hospital mortality for patients with nervous system diseases and, for most disease categories, prolongs hospitalization.
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Affiliation(s)
- Andrew F Shorr
- Pulmonary and Critical Care Medicine Service, Washington Hospital Center, Washington, DC 20010, USA.
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Koonce TY, Giuse NB, Storrow AB. A pilot study to evaluate learning style-tailored information prescriptions for hypertensive emergency department patients. J Med Libr Assoc 2011; 99:280-9. [PMID: 22022222 PMCID: PMC3193368 DOI: 10.3163/1536-5050.99.4.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE This pilot study explored whether learning style-tailored education materials, "information prescriptions," are effective in increasing hypertension knowledge in emergency room patients. METHODS In a randomized trial, hypertensive emergency medicine patients received either standard care discharge instructions or discharge instructions in combination with an information prescription individualized to each patient's learning-style preference. Two weeks post-visit, the study team assessed changes in hypertension knowledge via a survey. RESULTS No significant difference was observed for changes in quiz scores on the hypertension knowledge assessment, though patients receiving the tailored information prescriptions reported higher levels of satisfaction with intervention materials. CONCLUSION The study demonstrated the workflow feasibility of implementing a learning-style approach to patient education in the emergency department setting. Further research is needed to develop more robust measures of high blood pressure knowledge among the emergency department patient population. This work will contribute to establishing a framework for developing customized information prescriptions that can be broadly adapted for use in varied settings and with varied health care conditions.
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Peacock WF, Hilleman DE, Levy PD, Rhoney DH, Varon J. A systematic review of nicardipine vs labetalol for the management of hypertensive crises. Am J Emerg Med 2011; 30:981-93. [PMID: 21908132 DOI: 10.1016/j.ajem.2011.06.040] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 05/27/2011] [Accepted: 06/30/2011] [Indexed: 11/16/2022] Open
Abstract
Hypertensive emergencies are acute elevations in blood pressure (BP) that occur in the presence of progressive end-organ damage. Hypertensive urgencies, defined as elevated BP without acute end-organ damage, can often be treated with oral agents, whereas hypertensive emergencies are best treated with intravenous titratable agents. However, a lack of head-to-head studies has made it difficult to establish which intravenous drug is most effective in treating hypertensive crises. This systematic review presents a synthesis of published studies that compare the antihypertensive agents nicardipine and labetalol in patients experiencing acute hypertensive crises. A MEDLINE search was conducted using the term "labetalol AND nicardipine AND hypertension." Conference abstracts were searched manually. Ultimately, 10 studies were included, encompassing patients with hypertensive crises across an array of indications and practice environments (stroke, the emergency department, critical care, surgery, pediatrics, and pregnancy). The results of this systematic review show comparable efficacy and safety for nicardipine and labetalol, although nicardipine appears to provide more predictable and consistent BP control than labetalol.
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Affiliation(s)
- W Frank Peacock
- Department of Emergency Medicine E19, The Cleveland Clinic, Cleveland, OH 44195, USA.
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Baumann BM, Cline DM, Pimenta E. Treatment of hypertension in the emergency department. ACTA ACUST UNITED AC 2011; 5:366-77. [DOI: 10.1016/j.jash.2011.05.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 04/22/2011] [Accepted: 05/06/2011] [Indexed: 12/18/2022]
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Abstract
Hypertension is a common chronic medical condition affecting over 65 million Americans. Uncontrolled hypertension can progress to a hypertensive crisis defined as a systolic blood pressure >180 mm Hg or a diastolic blood pressure >120 mm Hg. Hypertensive crisis can be further classified as a hypertensive urgency or hypertensive emergency depending on end-organ involvement including cardiac, renal, and neurologic injury. The prompt recognition of a hypertensive emergency with the appropriate diagnostic tests and triage will lead to the adequate reduction of blood pressure, ameliorating the incidence of fatal outcomes. Severely hypertensive patients with acute end-organ damage (hypertensive emergencies) warrant admission to an intensive care unit for immediate reduction of blood pressure with a short-acting titratable intravenous antihypertensive medication. Hypertensive urgencies (severe hypertension with no or minimal end-organ damage) may in general be treated with oral antihypertensives as an outpatient. Rapid and short-lived intravenous medications commonly used are labetalol, esmolol, fenoldopam, nicardipine, sodium nitroprusside, and clevidipine. Medications such as hydralazine, immediate release nifedipine, and nitroglycerin should be avoided. Sodium nitroprusside should be used with caution because of its toxicity. The risk factors and prognosticators of a hypertensive crisis are still under recognized. Physicians should perform complete evaluations in patients who present with a hypertensive crisis to effectively reverse, intervene, and correct the underlying trigger, as well as improve long-term outcomes after the episode.
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Severely elevated blood pressure: when is it an emergency? J Cardiovasc Nurs 2011; 26:519-23. [PMID: 21372732 DOI: 10.1097/jcn.0b013e31820db112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
High blood pressure is one of the most common chronic medical conditions in this country, occurring in about 1 of every 3 adults. It is not uncommon for nurses to see individuals in the emergency room, hospital, home, or other settings who have severely elevated blood pressure readings. Extremely elevated readings generally evoke considerable concern among healthcare staff. They are faced with deciding whether the individual requires immediate treatment and a higher level of care, such as transport to an emergency department. Severely elevated blood pressure can be a true medical emergency, may require urgent care, or may in fact be a nonemergency. The purpose of this article is to assist nurses in recognizing those situations in which severely elevated blood pressure requires immediate intervention. Current research and best evidence regarding severely elevated blood pressure are presented.
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[High blood pressure in the emergency department: epidemiology and evaluation of a dedicated consultation]. Presse Med 2011; 40:e139-44. [PMID: 21196099 DOI: 10.1016/j.lpm.2010.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Revised: 09/09/2010] [Accepted: 10/15/2010] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The Arterial High blood pressure represents a consultation on 5 in general medicine. The main objective of our study was to estimate patients' proportion appearing at emergency department (ED) with a high Blood pressure and to demonstrate that it is possible to detect the patients at risk of essential and secondary hypertension as well as their cardiovascular risk there. METHODS Non-interventional forward-looking Study led over 6 weeks. After measure of the vital parameters in the reception of ED, the patients were included if the Systolic Blood Pressure (SBP) was ≥ 140 mmHg and\or Diastolic Blood Pressure (DBP) ≥ 90 mmHg. A control of Blood Pressure (BP) was made at least 40 minutes after the inclusion. If the Arterial High blood pressure persisted (BP ≥ 140/90 mmHg and age < 30 years or BP ≥ 180/110 mmHg after 30 years), the patients had to see again a cardiologist of the hospital in 7 days because they were considered as at high cardiovascular risk. RESULTS A high initial BP was discovered to 582 (8,7 %) 6685 patients having consulted in ED during the period of the study. 64 % of them (n = 372) had a persistent Arterial High Blood pressure after 40 minutes. 27 patients, defined at high cardiovascular risk had a proposition of consultation of cardiology, appeared 11 to it. 4 secondary hypertension was discovered. CONCLUSION During the period of study, 582 patients presented a High BP. To 64 % of those who had a control of BP this imbalance was confirmed. The patients (n=27) presenting a high cardiovascular risk had a proposition of fast consultation. This one allowed discovering 4 secondary hypertension. There is thus a utility to estimate the BP in a systematic way at Emergency Department.
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Devlin JW, Dasta JF, Kleinschmidt K, Roberts RJ, Lapointe M, Varon J, Anderson FA, Wyman A, Granger CB. Patterns of Antihypertensive Treatment in Patients with Acute Severe Hypertension from a Nonneurologic Cause: Studying the Treatment of Acute Hypertension (STAT) Registry. Pharmacotherapy 2010; 30:1087-96. [DOI: 10.1592/phco.30.11.1087] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Nishijima DK, Paladino L, Sinert R. Routine testing in patients with asymptomatic elevated blood pressure in the ED. Am J Emerg Med 2010; 28:235-42. [DOI: 10.1016/j.ajem.2008.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Revised: 11/11/2008] [Accepted: 11/12/2008] [Indexed: 10/19/2022] Open
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Evaluation, management, and referral of elderly emergency department patients with elevated blood pressure. Blood Press Monit 2009; 14:251-6. [DOI: 10.1097/mbp.0b013e328332fd40] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Levy PD, Cline D. Asymptomatic hypertension in the emergency department: a matter of critical public health importance. Acad Emerg Med 2009; 16:1251-7. [PMID: 19845553 DOI: 10.1111/j.1553-2712.2009.00512.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Asymptomatic hypertension (HTN) is commonly encountered in the emergency department (ED), but in most circumstances little is done about it. While many factors may contribute to this, the failure to recognize asymptomatic HTN as a public health problem is particularly important. Given the established long-term consequences of elevated blood pressure (BP), a reconsideration of methods that could enhance surveillance and intervention in the ED is needed. In this article, we discuss the relevant epidemiology of asymptomatic HTN and present a novel approach using a modified version of the Haddon's matrix to systematically address the challenges that contribute to ineffective screening and suboptimal outcomes.
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Affiliation(s)
- Phillip D Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA.
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Practice patterns, outcomes, and end-organ dysfunction for patients with acute severe hypertension: the Studying the Treatment of Acute hyperTension (STAT) registry. Am Heart J 2009; 158:599-606.e1. [PMID: 19781420 DOI: 10.1016/j.ahj.2009.07.020] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Accepted: 07/13/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND Limited data are available on the care of patients with acute severe hypertension requiring hospitalization. We characterized contemporary practice patterns and outcomes for this population. METHODS STAT is a 25-institution, US registry of consecutive patients with acute severe hypertension (>180 mm Hg systolic and/or >110 mm Hg diastolic; >140 and/or >90 for subarachnoid hemorrhage) treated with intravenous therapy in a critical care setting. RESULTS One thousand five hundred eighty-eight patients were enrolled (January 2007 to April 2008). Median age was 58 years (interquartile range 49-70 years), 779 (49%) were women, and 892 (56%) were African American; 27% (n = 425) had a prior admission for acute hypertension and 486 (31%) had chronic kidney disease. Median qualifying blood pressure (BP) was 200 (186, 220) systolic and 110 (93, 123) mm Hg diastolic. Initial intravenous antihypertensive therapies used to control BP varied, with 1,009 (64%) patients requiring multiple drugs. Median time to achieve a systolic BP <160 mm Hg (<140 mm Hg for subarachnoid hemorrhage) was 4.0 (0.8, 12) hours; 893 (60%) had reelevation to >180 (>140 for subarachnoid hemorrhage) after initial control; and 63 (4.0%) developed iatrogenic hypotension. Hospital mortality was 6.9% (n = 109) with an aggregate 90-day mortality rate of 11% (174/1,588); 59% (n = 943) had acute/worsening end-organ dysfunction during hospitalization. The 90-day readmission rate was 37% (523/1,415), of which one quarter (132/523) was due to recurrent acute severe hypertension. CONCLUSION This study highlights heterogeneity in care, BP control, and outcomes of patients hospitalized with acute severe hypertension.
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Ginde AA, Cagliero E, Nathan DM, Camargo CA. Point-of-care glucose and hemoglobin A1c in emergency department patients without known diabetes: implications for opportunistic screening. Acad Emerg Med 2008; 15:1241-7. [PMID: 18785943 DOI: 10.1111/j.1553-2712.2008.00240.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objectives were to evaluate the correlation between random glucose and hemoglobin A1c (HbA1c) in emergency department (ED) patients without known diabetes and to determine the ability of diabetes screening in the ED to predict outpatient diabetes. METHODS This was a cross-sectional study at an urban academic ED. The authors enrolled consecutive adult patients without known diabetes during eight 24-hour periods. Point-of-care (POC) random capillary glucose and HbA1c levels were tested, as well as laboratory HbA1c in a subset of patients. Participants with HbA1c > or = 6.1% were scheduled for oral glucose tolerance test (OGTT). RESULTS The 265 enrolled patients were 47% female and 80% white, with a median age of 42 years. Median glucose and HbA1c levels were 93 mg/dL (interquartile range [IQR] = 82-108) and 5.8% (IQR = 5.5-6.2), respectively. The correlation between POC and laboratory HbA1c was r = 0.96, with mean difference 0.33% (95% confidence interval [CI] = 0.27% to 0.39%). Glucose threshold > or = 120 mg/dL had 89% specificity and 26% sensitivity for predicting the 76 (29%) patients with abnormal HbA1c; > or = 140 mg/dL had 98% specificity and 14% sensitivity. The correlation between random glucose and HbA1c was moderate (r = 0.60) and was affected by age, gender, prandial status, corticosteroid use, and current injury. Only 38% of participants with abnormal HbA1c returned for OGTTs; 38% had diabetes, 34% had impaired fasting glucose/impaired glucose tolerance, and 28% had normal glucose tolerance. CONCLUSIONS ED patients have a high prevalence of undiagnosed diabetes. Although screening with POC random glucose and HbA1c is promising, improvement in follow-up with confirmatory testing and initiation of treatment is needed before opportunistic ED screening can be recommended.
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Affiliation(s)
- Adit A Ginde
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, CO, USA.
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Abstract
The key points of this article are: (1) A hypertensive crisis is present when markedly elevated blood pressure is accompanied by progressive or impending acute target organ damage. (2) Most instances of very elevated blood pressure encountered in the office setting will not be crises and will not require acute reduction of blood pressure. (3) Hypertensive crises are largely preventable and often result from inadequate management of hypertension or poor adherence to therapy. (4) Effective triage of patients into categories of severe hypertension, hypertensive urgency, and hypertensive emergency through an expeditious history, examination, and testing should guide therapy. (5) Hypertensive urgency is managed with oral medications and usually on an outpatient basis; a hypertensive emergency warrants intensive care unit admission and parenteral therapy. (6) Ensuring adequate follow-up after treatment of very elevated blood pressure is a critical step that is often mishandled.
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Affiliation(s)
- Christopher J Hebert
- Department of Nephrology and Hypertension, Cleveland Clinic, Suite A51, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Initial combination therapy for rapid and effective control of moderate and severe hypertension. J Hum Hypertens 2008; 23:4-11. [PMID: 18615100 DOI: 10.1038/jhh.2008.72] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Moderate (grade 2) and severe (grade 3) hypertension are important public health problems associated with high cardiovascular risk. Blood pressure (BP) control becomes more difficult to achieve as hypertension progresses. Therefore, early and effective treatment is essential to prevent hypertensive urgencies and emergencies and reduce cardiovascular risk. Currently, less than 50% of patients being treated for moderate or severe hypertension in the United States achieve their BP goal as recommended by treatment guidelines. This review examines the cardiovascular risk and physician inertia associated with moderate and severe hypertension, and concludes that increased use of initial combination therapy can overcome many of the barriers to effective BP control. Furthermore, initial combination therapy with a renin-angiotensin system (RAS) inhibitor and diuretic has the potential to rapidly and effectively reduce BP across a range of baseline BPs, with a comparable adverse event profile to monotherapy.
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Umscheid CA, Maguire MG, Pines JM, Everett WW, Baren JM, Townsend RR, Mines D, Szyld D, Gross R. Untreated hypertension and the emergency department: a chance to intervene? Acad Emerg Med 2008; 15:529-36. [PMID: 18616438 DOI: 10.1111/j.1553-2712.2008.00132.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Untreated hypertension (HTN) is a major public health problem. Screening for untreated HTN in the emergency department (ED) may lead to appropriate treatment of more patients. The authors investigated the accuracy of identifying HTN in the ED, the proportion of ED patients with untreated HTN, patient characteristics predicting untreated HTN, and provider documentation of untreated HTN. METHODS The authors performed a retrospective cross-sectional study on a random sample of 2,061 adults treated at an urban academic ED. The validity of six candidate definitions of HTN in the ED was assessed in a subsample using outpatient clinic records as the reference standard. "Untreated HTN" was HTN without a HTN medication listed in the ED history. "Documentation of untreated HTN was documentation of HTN as a visit problem, specific referral for HTN, or ED discharge with a HTN" information sheet or a HTN medication. Multivariable logistic regression was used to determine associations. RESULTS The preferred definition of HTN in the ED had sensitivity of 86% (95% confidence interval [CI] = 80% to 90%), specificity of 78% (95% CI = 69% to 85%), and accuracy of 83% (95% CI = 78% to 87%). Of the 42% (95% CI = 40% to 44%) of ED patients with HTN, 43% (95% CI = 39% to 46%) had untreated HTN. Patients who were younger and male, without primary care physicians, with fewer prior ED visits, and without cardiovascular comorbidities, had higher odds of untreated HTN. Of those with untreated HTN, 8% (95% CI = 5% to 11%) had their untreated HTN documented. CONCLUSIONS Untreated HTN was common in the ED but rarely documented. Providers can use ED blood pressures along with patient characteristics to identify those with untreated HTN for referral to primary care.
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Affiliation(s)
- Craig A Umscheid
- Center for Clinical Epidemiology and Biostatistics, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Karras DJ, Kruus LK, Cienki JJ, Wald MM, Ufberg JW, Shayne P, Wald DA, Heilpern KL. Utility of Routine Testing for Patients With Asymptomatic Severe Blood Pressure Elevation in the Emergency Department. Ann Emerg Med 2008; 51:231-9. [PMID: 17499391 DOI: 10.1016/j.annemergmed.2007.03.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Revised: 03/15/2007] [Accepted: 03/26/2007] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE Recommendations for the treatment of emergency department (ED) patients with asymptomatic severely elevated blood pressure advise assessment for occult, acute hypertensive target-organ damage. This study determines the prevalence of unanticipated, clinically meaningful test abnormalities in ED patients with asymptomatic severely elevated blood pressure. METHODS This was a prospective observational study at 3 urban academic EDs. Consecutive patients with systolic blood pressure greater than or equal to 180 mm Hg or diastolic blood pressure greater than or equal to 110 mm Hg on 2 measurements were enrolled if they denied symptoms of hypertensive emergency. A basic metabolic panel, urinalysis, ECG, CBC count, and chest radiograph were obtained. Treating physicians were interviewed about the indication for each test and whether an abnormal result was anticipated according to clinical findings. When test results were available, physicians were asked whether abnormal findings were clinically meaningful, defined as leading to unanticipated hospitalization, medication modification, or further immediate evaluation. The primary outcome was the prevalence of unanticipated clinically meaningful test abnormalities. RESULTS One hundred nine patients with asymptomatic severely elevated blood pressure were enrolled. Unanticipated abnormal test results were noted in 57 (52%) patients. Clinically meaningful unanticipated test abnormalities were found in 7 (6%) patients: basic metabolic panel in 2 (2%), CBC count in 3 (3%), urinalysis in 3 (4%), ECG in 2 (2%), and chest radiograph in 1 (1%). Five patients (5%) had abnormalities assessed as possible manifestations of acute hypertensive target-organ injury; none had abnormalities clearly related to severely elevated blood pressure. CONCLUSION Screening tests of urban ED patients with asymptomatic severely elevated blood pressure infrequently detect unanticipated hypertension-related abnormalities that alter ED management.
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Affiliation(s)
- David J Karras
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA 19140, USA.
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Pretest risk assessment in suspected acute pulmonary embolism. Acad Radiol 2008; 15:3-14. [PMID: 18078902 DOI: 10.1016/j.acra.2007.07.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Revised: 06/27/2007] [Accepted: 07/13/2007] [Indexed: 11/24/2022]
Abstract
RATIONALE AND OBJECTIVES To assess the pretest practices of US clinicians who treat patients with acute pulmonary embolism (PE). MATERIALS AND METHODS We surveyed 855 practicing physicians selected randomly from three professional organizations. We asked participants to estimate how often and by what method they determine the likelihood of PE before they request confirmatory studies. Participants reported their awareness of four published clinical practice guidelines dealing with acute PE and selected options for further diagnostic testing after reviewing clinical data from three hypothetical patients presenting with low, intermediate, and high probability of acute PE. RESULTS We received completed surveys from 240 physicians practicing in 44 states. Although most (98.3%) report that they assess pretest probability of PE before testing, slightly more than half do so routinely. A total of 72.5% prefer an unstructured approach to pretest assessment, whereas 22.9% use published prediction rules. Most (93.0%) are aware of at least one published guideline for assessing acute PE, but only 44.2% report using one or more in daily practice. Respondents who use published prediction rules, estimate pretest probability routinely, or use at least one practice guideline were more likely to request additional testing when reviewing a low probability clinical scenario. No differences in testing frequency or preferences were observed for intermediate or high probability clinical scenarios. CONCLUSIONS The majority of clinicians we surveyed use an unstructured approach when estimating the pretest probability of acute PE. With the exception of low probability scenario, clinicians agreed on testing choices in suspected acute PE, regardless of the method or frequency of pre-test assessment.
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Baumann BM, Abate NL, Cowan RM, Chansky ME, Rosa K, Boudreaux ED. Characteristics and Referral of Emergency Department Patients with Elevated Blood Pressure. Acad Emerg Med 2007. [DOI: 10.1111/j.1553-2712.2007.tb02351.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tilman K, DeLashaw M, Lowe S, Springer S, Hundley S, Counselman FL. Recognizing asymptomatic elevated blood pressure in ED patients: how good (bad) are we? Am J Emerg Med 2007; 25:313-7. [PMID: 17349906 DOI: 10.1016/j.ajem.2006.09.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Accepted: 09/04/2006] [Indexed: 11/30/2022] Open
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 +/- 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.
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Affiliation(s)
- Keri Tilman
- Department of Emergency Medicine, Eastern Virginia Medical School and Emergency Physicians of Tidewater, Norfolk, VA 23507, USA
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