emDOCs Videocast: EBM Update – Initiating Therapy for Asymptomatic Hypertension

Article #1: Todd BR, Xing Y, Zhao L, et al. Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients. J Am Coll Emerg Physicians Open. 2024 Mar 30;5(2):e13138.

Clinical Question: 

• In ED patients with HTN, is a prescription for oral anti-HTN therapy associated with a decreased 30-day risk of severe adverse events, death, and ED revisits?

Design: 

• Multicenter, observational cohort study.
• Included discharged patients > 18 years from the ED with a primary or secondary diagnosis of HTN and not previously receiving therapy for HTN.
• Exclude patients prescribed antihypertensive treatment 18 months prior to the ED visit.
• HTN classified as 140/90 to 179/119 and > 180/120 mm Hg.
• Intervention: Antihypertensive prescription at ED discharge.

Outcomes:

• Primary: Composite of adverse events from HTN (aortic catastrophe, heart failure, myocardial infarction, hemorrhagic and ischemic stroke, or hypertensive encephalopathy) within 30 days of ED discharge.
• Secondary: Death or ED revisit over the same period.

Results:

• 93,512 ED visits; 57.5% were female, and mean age was 59.3 years.
• 2% between 140/90 and 179/119 mm Hg; 16.8% > 180/120 mm Hg.
• 7% (4435) received anti-HTN prescription from ED; 4.8% (4458) from another clinician within 30 days of discharge.
• Those receiving prescription were more likely to be younger, Black, male, higher BP, received anti-HTN treatment in ED, less comorbidities, less likely to have heart failure.
• Within 30 days, 0.7% of patients experienced an AE, 0.1% died, and 15.2% had an ED revisit.
• Treatment group had significantly lower odds of adverse events (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.

• No difference in odds of death 30 days after discharge.

Considerations:

• Study asks important question and outcome.
• Single healthcare system, but included a socioeconomically diverse population with large sample size.
• Limited by retrospective nature and patient selection through the review of the EMR and data query; may introduce selection bias and limits ability to assess causality.
• Generalizability limited by the exclusion of patients already prescribed antihypertensive treatment or who may not be taking outpatient antihypertensive therapy as prescribed.
• Patients presenting to different hospital system not captured in query.
• Deaths obtained from regional database, which could underestimate total number.
• No evaluation of which antihypertensive medications were prescribed.
• No data on filling of the discharge prescriptions or patient compliance with the discharge prescriptions.
• Authors unable to discern the clinical thought process of treating physicians or the socioeconomic factors that may influence these treatment decisions.

Article #2: Akhetuamhen A, Bibbins-Domingo K, Fahimi J, et al. Missed Opportunities to Diagnose and Treat Asymptomatic Hypertension in Emergency Departments in the United States, 2016-2019. J Emerg Med. 2024 May;66(5):e562-e570.

Clinical Question: 

• What is the prevalence and management of asymptomatic hypertension in U.S. EDs?

Design: 

• Authors retrospectively examined the 2016-2019 National Hospital Ambulatory Medical Care Surveys for estimates of asymptomatic HTN visits in U.S. EDs.
• Asymptomatic HTN defined as adult patients with blood pressure ≥ 160/100 mm Hg at triage and discharge without trauma or signs of end organ damage.
• Stratified asymptomatic HTN into a 160-179/100-109 mm Hg subgroup and > 180/110 mm Hg subgroup.
• Authors examined diagnosis of HTN and treatment outcomes.

Results: 

• 9% of total visits between 2016 and 2019 met the definition for asymptomatic HTN; 74% of patients were discharged home (estimated 26.5 million visits).
• For those discharged home, emergency physicians diagnosed 13% (95% CI 10.6-15.8%) and treated asymptomatic HTN in 3.9% (95% CI 2.8-5.5%) of patients in the higher HTN subgroup.
• In the lower HTN subgroup, diagnosis and treatment were 3.1% (95% CI 2.4-4.1%) and 1.2% (95% CI 0.7-2.0%), respectively.

Article #3: Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM; American College of Emergency Physicians Clinical Policies Committee. 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 Jul;62(1):59-68.

Update:

• https://www.acep.org/patient-care/clinical-policies/outpatient-management-asymptomatic-elevated-blood-pressure

Medications:

The Bottom Line:

• Literature suggests we are poor at diagnosing and treating asymptomatic HTN in discharged ED patients.
• Studies suggest providing a prescription for patients with asymptotic HTN is safe and reduces adverse events.
• Consider prescribing an anti-HTN agent in asymptomatic HTN (especially in patients with poor follow-up). Refer patients for follow up.