Skip to main content Accessibility help
×
Home

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

  • Dennis D. Cho (a1), Peter C. Austin (a2) and Clare L. Atzema (a1) (a2) (a3)

Abstract

Introduction

Many patients are seen in the emergency department (ED) for hypertension, and the numbers will likely increase in the future. Given limited evidence to guide the management of such patients, the practice of one’s peers provides a de facto standard.

Methods

A survey was distributed to emergency physicians during academic rounds at three community and four tertiary EDs. The primary outcome measure was the proportion of participants who had a blood pressure (BP) threshold at which they would offer a new antihypertensive prescription to patients they were sending home from the ED. Secondary outcomes included patient- and provider-level factors associated with initiating an antihypertensive based on clinical vignettes of a 69-year-old man with two levels of hypertension (160/100 vs 200/110 mm Hg), as well as the recommended number of days after which to follow up with a primary care provider following ED discharge.

Results

All 81 surveys were completed (100%). Half (51.9%; 95% CI 40.5-63.1) of participants indicated that they had a systolic BP threshold for initiating an antihypertensive, and 55.6% (95% CI 44.1-66.6) had a diastolic threshold: mean systolic threshold was 199 mm Hg (SD 19) while diastolic was 111 mm Hg (SD 8). A higher BP (OR 12.9; 95% CI 7.5-22.2) and more patient comorbidities (OR 3.0; 95% CI 2.1-4.3) were associated with offering an antihypertensive prescription, while physician years of practice, certification type, and hospital type were not. Participants recommended follow-up care within a median 7.0 and 3.0 days for the patient with lower and higher BP levels, respectively.

Conclusions

Half of surveyed emergency physicians report having a BP threshold to start an antihypertensive; BP levels and number of patient comorbidities were associated with a modification of the decision, while physician characteristics were not. Most physicians recommended follow-up care within seven days of ED discharge.

Introduction

Beaucoup de patients sont examinés au service des urgences (SU) pour de l’hypertension, et leur nombre augmentera probablement au cours des prochaines années. Compte tenu du peu de données probantes sur le traitement et le suivi de ces patients, la pratique des pairs constitue une sorte de norme de fait.

Méthode

Un questionnaire d’enquête a été remis à des médecins d’urgence durant des tournées de formation théorique dans trois SU d’hôpitaux communautaires et dans quatre SU d’hôpitaux de soins tertiaires. Le principal critère d’évaluation était la proportion de participants qui appliquaient un seuil de pression artérielle (PA) à partir duquel ils étaient prêts à offrir une nouvelle prescription d’antihypertenseurs aux patients avant de les retourner à domicile. Les critères d’évaluation secondaires comprenaient des facteurs liés aux patients ou aux fournisseurs de soins, et associés à l’instauration d’un traitement antihypertenseur dans le contexte de scénarios cliniques décrivant un homme de 69 ans, atteint d’hypertension (deux degrés: 160/100 ou 200/110 mm Hg), ainsi que le nombre de jours recommandé pour assurer le suivi par un fournisseur de soins primaires après le congé du SU.

Résultats

Tous les sondés, soit 81, ont répondu au questionnaire (100 %). La moitié des participants (51,9 %; IC à 95 %: 40,5-63,1) ont indiqué appliquer un seuil de pression systolique (PS) pour entreprendre un traitement antihypertenseur, et 55,6 % (IC à 95 %: 44,1-66,6) ont indiqué appliquer un seuil de pression diastolique (PD); le seuil moyen de PS était de 199 mm Hg (écart-type: 19) et le seuil moyen de PD, de 111 mm Hg (écart-type: 8). Des valeurs élevées de PA (risque relatif approché [RRA]: 12,9; IC à 95 %: 7,5-22,2) et la présence de maladies concomitantes (RRA: 3,0; IC à 95 %: 2,1-4,3) ont été associées à l’offre d’un traitement antihypertenseur, tandis que le nombre d’années de pratique des médecins, le type de certificat et le type d’hôpital ne l’étaient pas. Les participants ont recommandé un délai médian de 7,0 jours et de 3,0 jours, respectivement, pour le suivi des patients ayant une PA plus basse et une PA plus haute.

Conclusions

La moitié des médecins d’urgence qui ont participé à l’enquête ont indiqué appliquer un seuil de PA pour l’amorce d’un traitement antihypertenseur; les valeurs de PA ainsi que le nombre de maladies concomitantes ont été associées à une modification de la décision, tandis que les caractéristiques des médecins, elles, ne l’étaient pas. La plupart des médecins ont recommandé un suivi dans les sept jours après le congé du SU.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study
      Available formats
      ×

Copyright

Corresponding author

Correspondence to: Clare Atzema MD, MSc, Institute of Clinical Evaluative Sciences, 2075 Bayview Avenue, Rm G157, Toronto, ON M4N 3M5; Email: clare.atzema@ices.on.ca

References

Hide All
1. World Health Organization. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks. 1st ed. Geneva: WHO Publications; 2009.
2. Robitaille, C, Dai, S, Waters, C, et al. Diagnosed hypertension in Canada: incidence, prevalence and associated mortality. CMAJ 2012;184(1):e49-e56.
3. Chobanian, AV, Bakris, GL, Black, HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289(19):2560-2572.
4. Levy, PD, Cline, D. Asymptomatic hypertension in the emergency department: a matter of critical public health importance. Acad Emerg Med 2009;16(11):1251-1257.
5. Nawar, EW, Niska, RW, Xu, J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data 2007;386:1-32.
6. Fields, LEL, Burt, VLV, Cutler, JAJ, et al. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension 2004;44:398-404.
7. Mancia, G, Fagard, RH, Narkiewicz, K, et al. 2013 ESH/ESC Guidelines for the Management of Arterial Hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Blood Press 2013;22(4):193-278.
8. Wolf, SJ, Lo, B, Shih, RD, et al. 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(1):59-68.
9. Hackam, DG, Quinn, RR, Ravani, P, et al. The 2013 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2013;29(5):528-542.
10. Decker, WW, Godwin, SA, Hess, EP, et al. Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department. Ann Emerg Med 2006;47(3):237-249.
11. Statistics Canada. Immigration and Ethnocultural Diversity. Available at: http://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-010-x/99-010-x2011001-eng.pdf (accessed March 11, 2014).
12. Hollowell, CM, Patel, RV, Bales, GT, et al. Internet and postal survey of endourologic practice patterns among American urologists. J Urol 2000;163(6):1779-1782.
13. VanDenKerkhof, EG, Parlow, JL, Goldstein, DH, et al. In Canada, anesthesiologists are less likely to respond to an electronic, compared to a paper questionnaire. Can J Anaesth 2004;51(5):449-454.
14. Health Quality Ontario. Quality Monitor - Health Quality Ontario. 2011. Available at: http://www.hqontario.ca/portals/0/Documents/pr/qmonitor-full-report-2011-en.pdf (accessed March 20, 2014).
15. Gilbert, EH, Lowenstein, SR, Koziol-McLain, J, et al. Chart reviews in emergency medicine research: Where are the methods? Ann Emerg Med 1996;27(3):305-308.
16. James, PA, Oparil, S, Carter, BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2013;311(5):507-520.
17. VA Cooperative Study Group on Antihypertensive Agents. Effects of treatment on morbidity in hypertension: Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAM A 1967;202(11):1028-1034.
18. Preston, RA, Baltodano, NM, Cienki, J, et al. Clinical presentation and management of patients with uncontrolled, severe hypertension: results from a public teaching hospital. J Hum Hypertens 1999;13(4):249-255.
19. Grassi, DD, O'Flaherty, MM, Pellizzari, MM, et al. Hypertensive urgencies in the emergency department: evaluating blood pressure response to rest and to antihypertensive drugs with different profiles. J Clin Hypertens (Greenwich) 2008;10(9):662-667.
20. Frei, S, Burmeister, D, Coil, J. Frequency of serious outcomes in patients with hypertension as a chief complaint in the emergency department. JAOA 2013;113(9):664-668.
21. Tilman, K, DeLashaw, M, Lowe, S, et al. Recognizing asymptomatic elevated blood pressure in ED patients: how good (bad) are we? Am J Emerg Med 2007;25(3):313-317.
22. Baumann, BM, Cline, DM, Cienki, JJ, et al. Provider self-report and practice: reassessment and referral of emergency department patients with elevated blood pressure. Am J Hypertens 2009;22(6):604-610.
23. Rosen, MP, Davis, RB, Lesky, LG. Utilization of outpatient diagnostic imaging. J Gen Intern Med 1997;12(7):407-411.
24. Stiell, IG, Clement, CM, Brison, RJ, et al. Variation in management of recent-onset atrial fibrillation and flutter among academic hospital emergency departments. Ann Emerg Med 2011;57(1):13-21.
25. Tu, JV, Austin, PC, Chan, BT. Relationship between annual volume of patients treated by admitting physician and mortality after acute myocardial infarction. JAMA 2001;285(24):3116-3122.
26. Rathore, SS, Chen, J, Wang, Y, et al. Sex differences in cardiac catheterization: the role of physician gender. JAMA 2001;286(22):2849-2856.
27. Berthold, HK, Gouni-Berthold, I, Bestehorn, KP, et al. Physician gender is associated with the quality of type 2 diabetes care. J Int Med 2008;264(4):340-350.

Keywords

Related content

Powered by UNSILO

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

  • Dennis D. Cho (a1), Peter C. Austin (a2) and Clare L. Atzema (a1) (a2) (a3)

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.