Screening for hypertension in the emergency department

Engaging, empowering and educating the waiting patient

While emergency departments are open to anyone without appointment, the need for prioritisation results in periods of waiting that are both wasteful and frustrating. However, value can be added to patient care by (1) engaging the waiting patient, (2) empowering the waiting patient and (3) educating the waiting patient. If these principles are implemented, they will benefit both the patient and the healthcare system.

The prognostic value of emergency department measured hypertension: A systematic review and meta-analysis

OBJECTIVES

The objective was to assess the prognostic value of hypertension detected in the emergency department (ED).

METHODS

The ED presents a unique opportunity to predict long-term cardiovascular disease (CVD) outcomes with its potential for high-footfall, and large-scale routine data collection applied to underserved patient populations. A systematic review and meta-analyses were conducted to assess the prognostic performance and feasibility of ED-measured hypertension as a risk factor for long-term CVD outcomes. We searched MEDLINE and Embase databases and gray literature sources. The target populations were undifferentiated ED patients. The prognostic factor of interest was hypertension. Feasibility outcomes included prevalence, reliability, and follow-up attendance. Meta-analyses were performed for feasibility using a random effect and exact likelihood.

RESULTS

The searches identified 1072 studies after title and abstract review, 53 studies had their full text assessed for eligibility, and 26 studies were included. Significant heterogeneity was identified, likely due to the international populations and differing study design. The meta-analyses estimate of prevalence for ED-measured hypertension was 0.31 (95% confidence interval  0.25-0.37). ED hypertension was persistent outside the ED (FE estimate of 0.50). The proportion of patients attending follow-up was low with an exact likelihood estimate of 0.41. Three studies examined the prognostic performance of hypertension and demonstrated an increased risk of long-term CVD outcomes.

CONCLUSION

Hypertension can be measured feasibly in the ED and consequently used in a long-term cardiovascular risk prediction model. There is an opportunity to intervene in targeted individuals, using routinely collected data.

Screening for hypertension: an elevated office blood pressure measurement is valuable, adding an automated one is even better

BACKGROUND

Previous studies have examined the relevance of hypertension (HTN) screening in walk-in clinics. So far, no valid algorithm has been proposed on how to integrate HTN screening in this context. The aim of our study was to assess, in a walk-in clinic setting, the HTN screening strategy for performing an automated office blood pressure (AOBP) measurement following an initially high office blood pressure (OBP) measurement.

PATIENTS AND METHODS

Included participants were adults with nonemergent medical conditions and an initial walk-in clinic OBP between systolic 140 and/or diastolic 90 mmHg and systolic 180 and/or diastolic 110 mmHg. AOBP was performed with patients unattended. The 24-h ambulatory blood pressure measurement (ABPM) was used as the diagnostic threshold.

RESULTS

Fifty participants were included in the study. The overall HTN prevalence as confirmed by the 24-h ABPM was 46% [95% confidence interval (CI): 32.19-59.81]. After an elevated OBP, AOBP over diagnostic thresholds occurred in 32 patients and were confirmed by ABPM in 20 participants, leading to a 62.5% positive predictive value (95% CI: 51.5-72.3%). Measurements under the AOBP diagnostic threshold occurred in 18 patients and were confirmed by ABPM in 15 participants, leading to a negative predictive value of 83.3% (95% CI: 62.3-93.8%).

CONCLUSION

In a walk-in clinic, an elevated OBP is a useful screening tool due its ability to recognize nearly one in two patients as actually hypertensive. Adding an AOBP makes it possible to specify what course of action to take. This ultimately results in better targeting of patients for an ABPM referral.

Hypertension in the Emergency Department

Hypertension is the leading risk factor for the global burden of disease, yet more than 20% of adults with hypertension are unaware of their condition. Underlying hypertension affects over 25% emergency department attendees, and the condition is more commonly encountered in emergency departments than in primary care settings. Emergency departments are strategically well placed to fulfill the important public health goal of screening for hypertension, yet less than 30% of patients with mild to severe hypertension are referred for follow up. In predominantly African American populations, subclinical hypertensive disease is highly prevalent in ED attendees with asymptomatic elevated blood pressure. Although medical intervention is not usually required, in select patient populations, it may be beneficial for antihypertensive medications to be started or adjusted in the emergency department, aiming for optimizing blood pressure control earlier while waiting for continuing care.

Feasibility of referral of patients with elevated blood pressure from the Emergency Department

Recent studies suggest that patients' elevated blood pressure (BP) readings in the Emergency Department (ED) may be due to hypertension (HTN) rather than pain and anxiety. Identifying BP patterns suggestive of HTN in the ED presents an opportunity for referral. The purpose of this prospective cohort study was to assess the feasibility of referral of ED patients with elevated BP readings suggestive of HTN. Adults with elevated BP suggestive of HTN and no history of HTN were tracked as to referral status using an actively monitored ED referral system. Patients referred to a community clinic network were tracked regarding clinic visits, subsequent BP, and diagnosis of HTN. Of 662 patients with elevated BP in the ED at triage, 197 (29.8%) had a pattern of blood pressure readings that were suggestive of HTN. Of these, 63 (32.0%) were referred to in-network clinics, 5 (2.5%) were referred out of network, and 129 (65.5%) were not referred. Of the 63 referred to network clinics, 17 (27.0%) kept their appointments and of those, 5 (29.4%) were diagnosed with HTN. Elevated BP was not mentioned in any ED physician referral notes as a reason for referral and the number of appointments kept among patients who were referred was low. Referral to outpatient clinics based on BP levels suggestive of HTN may not be feasible despite active referral systems.

Asymptomatic hypertension in the emergency department: a matter of critical public health importance

Asymptomatic hypertension (HTN) is commonly encountered in the emergency department (ED), but in most circumstances little is done about it. While many factors may contribute to this, the failure to recognize asymptomatic HTN as a public health problem is particularly important. Given the established long-term consequences of elevated blood pressure (BP), a reconsideration of methods that could enhance surveillance and intervention in the ED is needed. In this article, we discuss the relevant epidemiology of asymptomatic HTN and present a novel approach using a modified version of the Haddon's matrix to systematically address the challenges that contribute to ineffective screening and suboptimal outcomes.