The Characteristics and Outcomes of Patients Who Make an Emergency Department Visit for Hypertension After Use of a Home or Pharmacy Blood Pressure Device

Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients

Background

Hypertension (HTN) is common in discharged emergency department (ED) patients, yet the short-term outcomes of treating HTN at ED discharge are unclear. This study aimed to investigate whether emergency physician (EP) prescription of oral antihypertensive therapy at ED discharge for hypertensive patients is associated with a decreased 30-day risk of the severe adverse events (AEs), death, and revisits to the ED.

Methods

We conducted an observational cohort study assessing the 30-day outcomes of discharged ED patients with HTN, comparing outcomes based on whether antihypertensive therapy was prescribed. All discharged adult ED patients from an eight-hospital system with a diagnosis of HTN from January 2016 to February 2020 were screened, and consisted of a mix of suburban and urban patients with broad ethnic and socioeconomic backgrounds. Patients were categorized into the treatment group if they received a prescription for antihypertensive medication at ED discharge. The primary outcome was severe composite AEs from HTN (aortic catastrophe, heart failure, myocardial infarction, hemorrhagic and ischemic stroke, or hypertensive encephalopathy) within 30 days of ED discharge. The secondary outcomes were death or ED revisit over the same period.

Results

The study sample consisted of 93,512 ED visits; 57.5% were female, and mean age was 59.3 years. 4.7% of patients were prescribed antihypertensive treatment at ED discharge. Within 30 days, 0.7% of patients experienced an AE, 0.1% died, and 15.2% had an ED revisit. The treatment group had significantly lower odds of AE (adjusted odds ratio [aOR]: 0.224, 95%CI 0.106-0.416, p < 0.001), and ED revisits (aOR: 0.610, 95%CI 0.547-0.678, p < 0.001), adjusting for age, race, degree of HTN, ED treatment for elevated HTN, Elixhauser comorbidity index, and heart failure history. There was no difference in odds of death 30 days after discharge.

Conclusion and relevance

Prescription antihypertensive therapy for discharged ED patients is associated with a 30-day decrease in severe adverse events and ED revisit rate.

Elevated Blood Pressures Are Common in the Emergency Department but Are They Important? A Retrospective Cohort Study of 30,278 Adults

STUDY OBJECTIVE

We determine the frequency of elevated blood pressure (BP) readings in the emergency department (ED), the proportion of patients with prior or subsequent diagnosis of hypertension assigned in other settings, and the association between ED BP levels and cardiovascular outcomes after ED discharge.

METHODS

This was a retrospective cohort study using electronic medical records for all adults treated and released from a large-volume ED in 2016 that were linked to administrative records for all health care encounters in the province for 2 years before and after the index ED visit. The primary outcome measure was a composite of stroke or transient ischemic attack, acute coronary syndrome, new heart failure, or death.

RESULTS

Of 30,278 adults treated and released from the ED, 14,717 (48.6%) had elevated BP readings; 10,732 (72.9%) had no prior diagnosis of hypertension. Of the 3,480 patients with no prior diagnosis of hypertension but an ED BP greater than or equal to 160/100 mm Hg, 907 (26.1%) subsequently received a diagnosis of chronic hypertension or were prescribed antihypertensive therapy in other settings within 2 years. Among patients without a history of hypertension, those with an ED BP greater than or equal to 160/100 mm Hg were more likely to meet the composite outcome (stroke, transient ischemic attack, acute coronary syndrome, heart failure, or death) in the subsequent year (3.3% versus 2.5%) or 2 years (5.9% versus 3.8%) than those with ED BPs 120 to 139/80 to 89 mm Hg; however, after adjusting for age, sex, diabetes, atrial fibrillation, and prior cardiovascular disease, their risk was not elevated (adjusted hazard ratio 0.84; 95% confidence interval 0.71 to 1.004 during 2 years).

CONCLUSION

Elevated BP readings in the ED are common and are often the first time hypertension is detected; however, they were not associated with adverse cardiovascular outcomes within 2 years of the visit.

High blood pressure readings on in-store machines: a qualitative study of the perspective of pharmacy staff

OBJECTIVES

Emergency department (ED) visits for high blood pressure are on the rise. Yet the majority of these patients are discharged home after their ED evaluation, particularly those who present following an elevated reading on an in-store pharmacy machine. We aimed to gain insight on the practice and referral patterns of pharmacy staff who encounter a patient with an elevated in-store blood pressure (BP) reading.

METHODS

We conducted a qualitative study using semi-structured interviews with pharmacy staff (pharmacists and pharmacy technicians/assistants) from California, United States and Ontario, Canada. Interview questions were designed to examine the practice and referral patterns of pharmacy staff for patients with elevated in-store BP readings. Standard descriptive content analysis techniques were used to analyze the data and to develop themes for current practice and referral patterns.

RESULTS

Twenty-four interviews were completed: six with pharmacy technicians/assistants and 18 with pharmacists. Canadian pharmacy staff (83%) reported being approached frequently (defined as from weekly up to multiple times per day) by patients concerned about an elevated BP reading on an in-store machine, versus 50% reported by American participants. Participant definition of an elevated BP varied, with systolic values ranging from 120 to 150 mmHg and diastolic values from 60 to 90 mmHg. Participants emphasized the need to converse with and assess their patients prior to providing advice. The most frequently reported advice was to seek referral from an outside health care provider: ED, urgent care, or a primary care practitioner. Severity of the BP reading and symptomatology were reported as determining factors for referring patients to the ED. Pharmacists (92%) reported a lack of corporate and/or governing body policy for managing patients with in-store markedly elevated BP readings.

CONCLUSIONS

Managing patients with an elevated BP reading in the community pharmacy setting is complex and not standardized. Referral to an external health care provider, including the ED, was a common theme. The development of a pharmacy referral tool/algorithm may be helpful to refer in-store patients with elevated BP readings to the most appropriate healthcare resources.