Evaluation and treatment of patients with severely elevated blood pressure in academic emergency departments: a multicenter study.
OBJECTIVE
Current guidelines advise that emergency department (ED) patients with severely elevated blood pressure be evaluated for acute target organ damage, have their medical regimen adjusted, and be instructed to follow up promptly for reassessment. We examine factors associated with performance of recommended treatment of patients with severely elevated blood pressure.


METHODS
Observational study performed during 1 week at 4 urban, academic EDs. Severely elevated blood pressure was defined as systolic blood pressure greater than or equal to 180 mm Hg or diastolic blood pressure greater than or equal to 110 mm Hg on at least 1 measurement. ED staff were blinded to the study purpose. Demographics, presenting complaints, vital signs, tests ordered, medications administered, disposition, and discharge instructions were recorded, and associations were tested in bivariate analyses.


RESULTS
Severely elevated blood pressure was noted in 423 patients. Serum chemistry was obtained in 73% of patients, ECG in 53% of patients, chest radiograph in 46% of patients, urinalysis in 43% of patients, and funduscopy documented in 36% of patients. All studies were performed in 6% of patients and were associated with complaints of dyspnea (odds ratio [OR] 3.1; 95% confidence interval [CI] 1.1 to 8.7) and chest pain (OR 3.0; 95% CI 1.2 to 7.6). Oral antihypertensives were administered to 36% of patients and were associated with blood pressure-related complaints (OR 2.0 [1.2 to 3.3]), patient-suspected severely elevated blood pressure (OR 5.6, 95% CI 2.0 to 15.3), and being uninsured (OR 2.0; 95% CI 1.2 to 3.3). Intravenous antihypertensives were given to 4% of patients, associated only with chest pain (OR 3.2; 95% CI 1.1 to 9.5). Modification of antihypertensive regimen was documented in 19% of discharged patients and associated with patient-suspected severely elevated blood pressure (OR 5.5; 95% CI 2.5 to 12.2) and being uninsured (OR 1.8; 95% CI 1.1 to 2.9).


CONCLUSIONS
The majority of ED patients with severely elevated blood pressure do not receive the evaluation, medical regimen modification, and discharge instructions advised by current guidelines. Further study is necessary to determine whether these recommendations are appropriate in this setting.
Temple University School of Medicine, Philadelphia, PA 19140, USA. david.karras@temple.edu
David J
DJ
Karras
Linda K
LK
Kruus
John J
JJ
Cienki
Marlena M
MM
Wald
William K
WK
Chiang
Philip
P
Shayne
Jacob W
JW
Ufberg
Richard A
RA
Harrigan
David A
DA
Wald
Katherine L
KL
Heilpern
D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D000959:Antihypertensive Agents / Q000627:therapeutic use; D001774:Blood Chemical Analysis / Q000706:statistics & numerical data; D001795:Blood Pressure Determination / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D004562:Electrocardiography / Q000706:statistics & numerical data; D004635:Emergency Medicine / Q000592:standards* / Q000706:statistics & numerical data*; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D006973:Hypertension / Q000097:blood / Q000175:diagnosis* / Q000628:therapy* / Q000652:urine; D008875:Middle Aged; D009887:Ophthalmoscopy / Q000706:statistics & numerical data; D010043:Outcome and Process Assessment, Health Care; D010351:Patient Discharge / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D013902:Radiography, Thoracic / Q000706:statistics & numerical data; D016037:Single-Blind Method; D014481:United States; D016482:Urinalysis / Q000706:statistics & numerical data
D000959:Antihypertensive Agents