The next patient in the rack was sent by WebMD after their new iHealth Wireless Wrist Blood Pressure Monitor told them to come to the ED because their blood pressure was at “stroke level.”
While indeed, this patient has a blood pressure on initial evaluation of 205/115, but they have not had any chest pain. They are clearly not altered on eval, and they deny any vision changes or headaches and have a non-focal neurological exam. When asked why they even checked their blood pressure, it was because all their friends who have doctors were told to check their blood pressure at home.
So what does this patient need?
If the patient offers some vague complaints that were persistent, I guess you could argue for electrolytes, maybe an EKG / troponin (if dyspneic, diaphoretic, or nausea after exertion then perhaps go the ACS workup route). If the patient is completely asymptomatic or with fleeting vague symptoms, the first step – if any (after an H&P) – should be a urinalysis. In June 2010, AJEM published an important study on this. They screened 5,416 patients just like the ones above. Essentially, if the patient has neither hematuria nor proteinuria, there is a 98.3% chance that they will not have a serum creatinine above 2.0. For Creatinine above 1.3 and 1.5, the lack of both proteinuria and hematuria has a negative predictive value of 92.4% and 95.3% respectively.
What does ACEP say? ACEP recommends, with a level C recommendation, that screening for acute end-organ injury is not required. As long as the patient is not altered, has a normal neurological exam, no vision changes, and no crushing chest pain, you essentially already screened them without doing a single test! A UA will do a great job at ruling out AKI. If a UA is positive for either hematuria or proteinuria, then send a serum creatinine – if at that point you have an elevated creatinine >25% from baseline, then consider admission. With a benign history and exam, the patient does not need electrolytes, troponins, a BNP, an EKG, Chest XRay, and certainly not a brain CT. Here is the data ACEP provides on this:
“A Class III study, the VA Cooperative Trial of 1967, was a randomized placebo-controlled trial of 143 male patients with diastolic blood pressure of 115 mm Hg to 130 mm Hg. No adverse outcomes in either group were demonstrated during the initial 3 months of enrollment. Four of 70 patients in the placebo group (6%; 95% CI 2% to 14%) versus 0 of 73 patients in the treatment group (0%; 95% CI 0% to 5%) developed significant complications within 4 months of enrollment, including sudden death, ruptured aortic aneurysm and death, severely elevated blood urea nitrogen level, and congestive heart failure. However, within 20 months, 27 of 70 patients (39%; 95% CI 27% to 51%) treated with placebo and 2 of 73 patients (3%; 95% CI 0.3% to 9.5%) treated with antihypertensive drugs experienced adverse events (absolute risk reduction 36%; number needed to treat = 3.″
So at 3 months, no worries. At 4 months, trouble may start. At 20 months, big trouble. So what are we supposed to do about it in the ED? For the patient who has no symptoms, a normal UA, and isolated hypertension treat based on the locale you’re in. If follow up is easy, leave it alone. If getting into clinic is impossible, consider starting an oral medication in the ED.
Now, what does the legal side of this look like? Well, I attempted to peruse Google Scholar, using the terms “Emergency Department” “malpractice” and “hypertension.” I’m far from good at browsing the medico-legal literature, but of the 97 results, I can not find a single case of an asymptomatic hypertensive that was sent home and the provider was later sued. Of the vaguely pertinent cases where the patient presented with significantly elevated blood pressure (email or tweet me for links), all the patients had some other symptoms that were alarming- “cold symptoms” – ie, misdiagnosed CHF; chest pain and weakness that was given Ramipril, Bisoprolol / HCTZ that later stroked; syncopal elderly patient that fell twice in the ED and was usually ambulatory; “slow, unsteady, hot & sweat with double vision,” ; severe headache, off balance, blurred vision, dizziness. Bottom line, you’ve got time to work with outside the ED walls, so there is no need to “buff the chart” and give IV hydralazine prior to discharge. As ACEP policy notes, you are more likely to do harm than good.