Practical Evidence 013 – ACEP Management of Asymptomatic Blood Pressure 2013

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We discuss the management of asymptomatic markedly elevated blood pressure as evaluated by the ACEP Clinical Policies Committee in Sept 2013.

The Policy

ACEP Management of Asymptomatic HTN 2013

The Questions and the Recs

In ED patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce rates of adverse outcomes?

Patient Management Recommendations

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations.

  1. In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required.
  2. In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission).

 

In patients with asymptomatic markedly elevated blood pressure, does ED medical intervention reduce rates of adverse outcomes?

Patient Management Recommendations

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations.

  1. In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required.
  2. In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control. [Consensus recommendation]
  3. Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation]

What is EMCrit Drinking?

LilBPorter

Now on to the Podcast…

 

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Comments

  1. Aaron Brody says:

    Scott,

    Great Podcast as usual!

    A few comments:
    1. Regarding the utility of obtaining serum Cre for pts with poor follow up – one point is that once a pt has ESRD, they magically get on Medicare, so there may be some benefit to testing and admitting those pts.
    2. Regarding initiation of treatment in the ED – I am actually a research fellow, and this is my big project – keep an eye out – I might have an answer for you in a couple of years!

    Aaron

  2. Roger Helmers says:

    Fist of all, I’m a huge fan. I absolutely love driving to work now, listening to your podcasts – and the ones by Jeffrey Guy. I am a veterinarian and specialize in emergency and critical care and I have learned so much already listening to your podcasts. I would to comment on the one about asymptomatic hypertension. I was a bit taken back by the fact that there is a lack of recommendation to treat asymptomatic hypertension. If someone has a pressure of 260/110, aren’t you just waiting for disaster to strike if you don’t treat? In cats we also see asymptomatic hypertension but I would have a serious problem with someone not treating it because you can prevent some serious, often irreversible complications from this if you treat right away. Cats often get hypertensive retinopathy, including retinal bleed and retinal detachment, which can lead to irreversible blindness. If I detect hypertension, even without any apparent effects of it, you bet that I will treat it immediately. If that cat came back to me (or another doctor) with sudden blindness after not having its hypertension treated, I would be devastated.

    • Thanks Roger. Hypertension absolutely needs treatment, just not emergent treatment. In fact the only way to screw up an asymptomatic patient is to bring their bp down too quickly. If they are sitting comfortably at 260/110 it means they’ve been there for a long time. Acute lowering leads to ischemia. This was discovered when folks thought it clever to break open nifedipine capsules to use sublingually. Strokes resulted.

      • Roger Helmers says:

        Hi Scott,

        thanks for the reply. It totally makes sense what you said and I actually would not admit them for treatment, either. The only drug we usually have for this is nitroprusside and I would not use it in an asymptomatic cat, either. I would just script out some amlodipine (our treatment of choice for hypertension in cats) and this is generally safe and well tolerated.

  3. I think this problem will increase as we see more iPhone apps and such capable of measuring BP. It makes me think: What is the cutoff for having a symptom? In my experience some patients say “I feel a little strange” and are not able to narrow it down. I try to convey to the students that this warrants treatment, observation and Cr as well as the clinical examination. I worry that innocent appearing symptoms, that are poorly quantified by the patient is interpreted as no symptoms.

    • Symptoms in this regard are not subtle. In hypertensive emergency the patient looks like crap. When the studies have looked at ?s like can elevated BP cause headache or other vague symptoms, the answer turns out to be that the headache was much more likely to have caused the BP elevation than vice versa.

      • Alex Kobzik says:

        I have been looking into this recently and have not found good data regarding the vague symptoms. Do you have any pubmed links handy?

        Alex
        EM/IM resident

  4. Robb Bassett says:

    Hey Scott,
    Let me start with the obligatory sunshine blow: I love your stuff and thanks to the unaware masses not catching on to the impact of amazingly current and high-yield FOAM (especially EmCrit) I look a little smarter each day.
    Now on to the practical question. As a committed, albeit junior, academician I struggle with balancing EBM, efficiency, and medico-legal issues on a daily basis. Your review of the Management of Asymptomatic HTN nicely epitomizes one of those challenges. I think there are many from the “recently trained” community who recognize the party-line statement that we should resist the temptation and not treat asymptotic HTN. I often reference the same analogy that you used above that it is more likely that headache caused high blood pressure than the the elevated BP causing the headache. That being said, I think Paul’s comment from above highlights a big knowledge gap for many of us which is “How do you define asymptomatic?” Certainly, no one is going to miss the symptom of crushing chest pain that occurs with “end organ failure of the heart”, the symptom of tearing back pain that occurs with “end organ failure of the aorta”, the symptom of encephalopathy that occurs with “end organ failure of the squash (PRES)”, the symptom of peaked t waves the occurs with “end organ failure of the beans”, etc. However, apart from the chief complaint of: Med Refill, rarely is it the case that someone is sitting in an ED with absolutely no symptoms…let’s face it, they’re in the ED for something. When we do have those patients with “severely uncontrolled blood pressure” (what ever that means) and they have vague complaints that are not obviously associated with the catastrophic collapse of one of their organs, it does give me a little agita that I may be too dogmatic about my understanding of what “asymptomatic” really means. On behalf of the EM community who wants to balance aggressive life saving with an appropriate dose of “don’t just do something, stand there!” can you bring to bear the full resources of EmCrit, Practical Evidence, and your hypertrophied brain to please tell us how to REALLY define “asymptomatic”?

    Your humble disciple,

    Robb

    #CraftbrewdrinkingEMspecialistsunite

  5. Solid podcast – like the addition of the practical evidence (and beer) to the emcrit feed. Love everything evil twin does – they’re actually a “gypsy brewer” from Denmark that sets up shop in other breweries and puts out collaboration beers, they used to be with Westbrook brewing back home in charleston, sc … would love for them to follow me to residency in chi-town!

  6. Mike Jasumback says:

    Hey Scott,
    In your hypertensive emergencies discussion I hope you touch on what type/degree of renal impairment should mandate admission/intervention.

    Example, Pt rolls in with the usual drug store hypertension and really does have a BP of 220/140, asymptomatic, repeatedly elevated in the ED. Hasn’t seen a primary doc in a few years. Creatinine 1.8 or 2.4 or 3.8 or 5? I’m never sure what to do with this, especially if arranging follow up is not easily obtainable.

    Look forward to hearing the Htnsive episode

    Mike.

    • Mike, I think it is dealer’s choice on these guys. If you want to admit or can’t get them f/u locked in within a short time (3-5 days), admit. If you can get them f/u (in an office that has the ability to get them all the tests they need–renal uts, rapid return blood tests, etc.). In my county trauma center, we would admit all of these guys and we’d get paid for it.

  7. Great summary of this paper Scott. While the literature doesn’t support universal screening for asymptomatic hypertension, most of these patients will rule in for essential hypertension in the outpatient setting, and many of these patients will have significant renal dysfunction, so getting a quick Creatinine I think is reasonable. If the patient follows up as an outpaitent armed with an elevated Creatinine they will be more likely to be treated appropriately. Just like we have a responsibility for screening for abuse, we have a responsibility for screening for kidney dz in patients with markedly elevated BP in the ED. We’ll be discussing this and much more on everything to do with hypertension in the ED in the February EM Cases episode with Joel Yaphe & Clare Atzema.

    • I don’t disagree, but the ? pit docs want to know is can they get the pt out right away, and the answer is yes. They’ve prob. been sitting in the dpet for some repeat measurements by the time the doc picks up their chart and they can get d/ced within minutes after that in the right circumstance.

  8. What if you send a asymptomatic patient home with BP of 250/110 without treatment and next day his BP goes further up and then he comes back with brian bleed or MI or aortic dissection ? Bomb will blast if pressure keeps on going up. Everyone knows that BP should not be corrected quickly in these set of patients but I am not sure discharging these people completely untreated is a good idea. If things can go wrong they will go wrong on occasions.

  9. Hey Scott,

    Great podcast, great refresher. You wondered about why 3 months as the cutoff for adverse outcomes (~7:30 in podcast): From the ACEP rec:

    “A Class III study, the VA Cooperative Trial of 1967, was a randomized placebo-controlled trial of 143 male patients with diastolic blood pressure of 115 mm Hg to 130 mm Hg. No adverse outcomes in either group were demonstrated during the initial 3 months of enrollment. Four of 70 patients in the placebo group (6%; 95% CI 2% to 14%) versus 0 of 73 patients in the treatment group (0%; 95% CI 0% to 5%) developed significant complications within 4 months of enrollment, including sudden death, ruptured aortic aneurysm and death, severely elevated blood urea nitrogen level, and congestive heart failure. However, within 20 months, 27 of 70 patients (39%; 95% CI 27% to 51%) treated with placebo and 2 of 73 patients (3%; 95% CI 0.3% to 9.5%) treated with antihypertensive drugs experienced adverse events (absolute risk reduction 36%; number needed to treat = 3″

    So at 3 months, no worries. At 4 months, trouble may start. At 20 months, big trouble. Definitely agree, treat based on the locale you’re in – if follow up easy, leave it alone, if getting into clinic impossible, consider starting on something or admitting.

    Beer rec: Third Shift.

Trackbacks

  1. […] has just released a policy based on the available evidence on the topic that was reviewed recently by Scott Weingart on emcrit. There are some key recommendations that provides excellent and simple guidance for the clinician […]

  2. […] Here’s a link to Scott’s emcrit post: Weingarts’s podcast on asymptomatic hypertension […]

  3. […] Scott Weingart’s Take: http://emcrit.org/practicalevidence/2013-acep-management-of-asymptomatic-htn/ […]

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