Cardiology, Cardiology, Improving Throughput, Mythbusting

Surprise! You still do not need to treat asymptomatic hypertension in the ED!

Surprise! We have yet another paper, in addition to the ones mentioned here that demonstrates acutely managing hypertension without end organ damage is unnecessary.

 

This multicenter study retrospectively looks at 1,016 patients, age 18 years or older, with an initial blood pressure greater than or equal to 180/100, with no evidence of target organ damage, that were discharged with a primary diagnosis of hypertension.  435 patients (42.8%) received antihypertensive therapy (88.5% received clonidine!), while the rest did not receive antihypertensive treatment in the ED.   Those who received antihypertensives often had a higher mean initial systolic and diastolic BP (systolic 202 vs 185, and diastolic 115 vs 106). Otherwise, all other measures were similar & not statistically significant- this includes repeat ED visits within 24 hours (4.4% vs 2.4% antihypertensives vs none), repeat visit within 30 days (18.9% vs 15.2%), mortality at 30 days (0.2% for both groups), as well as mortality at one year (2.1% vs 1.6%).

Unfortunately, this is a retrospective study, so perhaps they are not catching the patients with a chief complaint of hypertension, and perhaps ultimately diagnosed as a bleed.  It is reassuring to see that 30 day and mortality and 1 year mortality are similar.  However, with 94.5% of the total patient population being African American, these results may not necessarily be broadly applicable to all ED patients.  It would have been nice to see them analyze all patients over a 12 month period who presented with a triage BP > 180/100, and blind reviewers to disposition and outcomes.  With only ~500 patients in each arm, I am not certain this adequately screens for rare events, but I still think that this is one of the better attempts to date to back up ACEP policy on asymptomatic hypertension

(1) Initiating treatment for asymptomatic hypertension in the ED is not necessary when patients have follow-up; (2) Rapidly lowering blood pressure in asymptomatic patients in the ED is unnecessary and may be harmful in some patients; (3) When ED treatment for asymptomatic hypertension is initiated, blood pressure management should attempt to gradually lower blood pressure and should not be expected to be normalized during the initial ED visit.

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