A 50 year-old woman, who presented to the ENT clinic for followup check of a facial fracture, has a blood pressure of 210/100. She is asymptomatic and in no pain. She gets referred immediately to the ED for care.
Now you see her in your ED. What next?
There is a lot of controversy whether you should treat or not treat asymptomatic hypertension in the ED. The ACEP Clinical Policy says that there is no need to immediately reduce an asymptomatic patient's blood pressure. With "close followup", they can be referred to their primary care physician.
With so many patients being uninsured or unable to access their primary care physician on short notice, many emergency physicians like myself are slowly moving towards starting antihypertensive medications for them.
If you do decide to start an antihypertensive, which medication do you choose? This Paucis Verbis card is based on a 2009 Cochrane Review, and summarized in American Family Physician in 2010. The blue numbers denote a Risk Ratio (RR) which cross 1, meaning that there is no benefit. The red numbers denote a RR < 1, meaning that there IS a benefit.
Bottom line:
A low-dose thiazide, such as hydrochlorothiazide 12.5-25 mg po daily, is a safe and effective choice.
References
Quynh B. Cochrane for clinicians. First-line treatment for hypertension. Amer Fam Phys. 2010, 81(11), 1333-5.
Mensah G, Bakris G. Treatment and Control of High Blood Pressure in Adults. Cardiology Clinics. 2010, 28(4), 609-22.
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If you do decide to start an antihypertensive, which medication do you choose? This Paucis Verbis card is based on a 2009 Cochrane Review, and summarized in American Family Physician in 2010. The blue numbers denote a Risk Ratio (RR) which cross 1, meaning that there is no benefit. The red numbers denote a RR < 1, meaning that there IS a benefit.
Bottom line:
A low-dose thiazide, such as hydrochlorothiazide 12.5-25 mg po daily, is a safe and effective choice.
Feel free to download this card and print on a 4'' x 6'' index card.
Quynh B. Cochrane for clinicians. First-line treatment for hypertension. Amer Fam Phys. 2010, 81(11), 1333-5.
Mensah G, Bakris G. Treatment and Control of High Blood Pressure in Adults. Cardiology Clinics. 2010, 28(4), 609-22.
. .
I'll be the devil's advocate and argue that generally we cannot make a diagnosis of asymptomatic hypertension in the emergency dept. Most available primary care guidelines require multiple visits and multiple readings before a HTN diagnosis is made (though mostly this is grade D evidence) unless the patient has hypertensive emergency or urgency.
ReplyDeleteNow I do not disagree that the obese patient presenting with a foot infection, a high glucose, and a BP of 160/95 is most likely hypertensive, but the fact is that with the best available guidelines for hypertension that patient requires a follow-up visit before his hypertension is diagnosed.
I personally think that before we take on (more) basic primary care in the ED we should look for evidence that the intervention of putting a patient thought to be hypertensive on a medication in the emerg offers some benefit, and those studies do not exist as of yet. Until I see such a study I will remain a skeptic on this issue.
Can't argue with you on any of your points. I think I personally feel more obligated in our medical system where they often have a 1-2 month wait before being able to see a new primary care doctor. In a patient with SBP over 200, I have a hard time letting them go home without intervention. In patients without pain or signs of distress, I assume that the HTN is real. For patients with SBP<200, I do indeed leave them to see their own physician.
ReplyDeleteThe piece of information that has helped pushed me more towards prescribing HCTZ is that serial BP measurements in the ED may be reflective of what their BP is in the outpatient setting. Patients with an ED BP consistently > 160/105 over 80 minutes indeed had HTN. There's a great pros/cons discussion article in Annals Dec 2009 by Kinsella, Baraff, Shayne.