Advertisement

Institutional Pathways to Improve Care of Patients with Elevated Blood Pressure in the Emergency Department

  • Aaron M. Brody
  • Joseph Miller
  • Rimma Polevoy
  • Asaad Nakhle
  • Phillip D. Levy
Hypertension and Emergency Medicine (T Rainer and P Levy, Section Editors)
  • 149 Downloads
Part of the following topical collections:
  1. Topical Collection on Hypertension and Emergency Medicine

Abstract

Purpose of Review

Hypertension (HTN) is the most prevalent cardiovascular disease and poses a major population level risk to long-term health outcomes. Despite this critical importance, and the widespread availability of effective and affordable medications, blood pressure (BP) remains uncontrolled in up to 50% of the diagnosed patients. This problem is exacerbated in communities with limited access to primary care, who often utilize hospital emergency departments (EDs) as their primary healthcare resource. Despite the ubiquity of patients presenting to EDs with severely elevated BP, a unified, evidence-based approach is not yet widely implemented, and both under- and overtreatment are common. The purpose of this review is to describe an approach towards institutional policy regarding asymptomatic HTN, in which we will translate the accepted principles of appropriate outpatient BP management to ED and inpatient settings.

Recent Findings

Results from the recent SPRINT trial, and the subsequent publication of the American Heart Association updated guidelines for the treatment of HTN, significantly lower both the diagnostic threshold and the treatment goals for hypertensive patients. This change will drastically increase the proportion of patients presenting to EDs with newly diagnosed and uncontrolled HTN. Several recent studies emphasize the safety in outpatient management of patients with severely elevated BP in the absence of acute end-organ damage and, conversely, the long- and intermediate-term risk associated with these patients. System-based approaches, particularly those led by non-physicians, have shown the greatest promise in reducing population level uncontrolled HTN.

Summary

Evidence-based approaches, such as those described in emergency medicine and cardiology society guidelines, can guide appropriate management of ED and inpatient BP elevations. Translating these patient oriented guidelines into institutional policy, and maintaining provider adherence, is a challenge across healthcare institutions. We present here several examples of successful policies developed and implemented by the authors. While brief inpatient and ED encounters cannot replace long-term outpatient care, they have the potential to serve as a crucial inlet to health care and an opportunity to optimize care.

Keywords

Hypertension Severely elevated blood pressure Hypertensive urgency Hypertensive emergency Institutional policy Emergency department Antihypertensive therapy 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Mills KT, Bundy JD, Kelly TN, et al. Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries. Circulation. 2016;134:441–50.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Brody A, Murphy E, Flack J, Levy P. Primary care in the emergency department—an untapped resource for public health research and innovation. West Indian Med J. 2014;63(3);234-7.Google Scholar
  3. 3.
    Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017;135:e146–603.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Niska RW. Blood pressure measurements at emergency department visits by adults: United States, 2007–2008. NCHS Data Brief. 2011;72;1–8.Google Scholar
  5. 5.
    Janke AT, McNaughton CD, Brody AM, Welch RD, Levy PD. Trends in the incidence of hypertensive emergencies in US emergency departments from 2006 to 2013. J Am Heart Assoc. 2016;5:e004511.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Vahia AT, Siddiqui M, Stahl V, Brody A, Levy P, J Miller. Blood pressure in the emergency department is an independent predictor of 6 and 12 month cardiovascular events. Acad Emerg Med. 2017;9;24.Google Scholar
  7. 7.
    Levy P, Ye H, Compton S, et al. Subclinical hypertensive heart disease in black patients with elevated blood pressure in an inner-city emergency department. Ann Emerg Med. 2012;60:467–74.CrossRefPubMedGoogle Scholar
  8. 8.
    Limkakeng AT, Drake W, Mani G, et al. Left ventricular dysfunction screening in hypertensive patients with N-terminal pro-B-type natriuretic peptide and electrocardiogram. Am J Emerg Med. 2012;30:214–7.CrossRefPubMedGoogle Scholar
  9. 9.
    •• Whelton PK, Carey RM, Aronow WS, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. Nov. 7, 2017. A major update in hypertension management, which will greatly influence clinical care in the upcoming decade. Google Scholar
  10. 10.
    Muntner P, Carey RM, Gidding S, et al. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. Circulation. 2018;137:109–18.CrossRefPubMedGoogle Scholar
  11. 11.
    Levy PD, Cline D. Asymptomatic hypertension in the emergency department: a matter of critical public health importance. Acad Emerg Med. 2009;16:1251–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Decker WW, Godwin SA, Hess EP, Lenamond CC, Jagoda AS. Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department. Ann Emerg Med. 2006;47:237–49.CrossRefPubMedGoogle Scholar
  13. 13.
    Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM. 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;62:59–68.CrossRefPubMedGoogle Scholar
  14. 14.
    Adhikari S, Mathiasen R, Lander L. Elevated blood pressure in the emergency department: lack of adherence to clinical practice guidelines. Blood Press Monit. 2016;21:54–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Lehrmann JF, Tanabe P, Baumann BM, Jones MK, Martinovich Z, Adams JG. Knowledge translation of the American College of Emergency Physicians clinical policy on hypertension. Acad Emerg Med. 2007;14:1090–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Baumann BM, Cline DM, Cienki JJ, Egging D, Lehrmann JF, Tanabe P. Provider self-report and practice: reassessment and referral of emergency department patients with elevated blood pressure. Am J Hypertens. 2009;22:604–10.CrossRefPubMedGoogle Scholar
  17. 17.
    Brody A, Reed B, Goldberg E, McNaughton C, Levy P. Barriers to emergency physician diagnosis and treatment of asymptomatic hypertension. Acad Emerg Med. 2015;22:S398–9.CrossRefGoogle Scholar
  18. 18.
    Khatib R, Schwalm JD, Yusuf S, Haynes RB, McKee M, Khan M, et al. Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and meta-analysis of qualitative and quantitative studies. PLoS One. 2014;9:e84238.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Tanabe P, Cline DM, Cienki JJ, Egging D, Lehrmann JF, Baumann BM. Barriers to screening and intervention for ED patients at risk for undiagnosed or uncontrolled hypertension. J Emerg Nurs. 2011;37:17–23.CrossRefPubMedGoogle Scholar
  20. 20.
    •• Patel KK, Young L, Howell EH, et al. Characteristics and outcomes of patients presenting with hypertensive urgency in the office setting. JAMA Intern Med. 2016;176:981–8. A large population based study demonstrating the safety of outpatient management of patients with severely elevated blood pressure. CrossRefPubMedGoogle Scholar
  21. 21.
    McNaughton CD, Brody A, Levy PD. Appropriate management of asymptomatic hypertension. JAMA Intern Med. 2016;176:1723–4.CrossRefPubMedGoogle Scholar
  22. 22.
    Myers MG, Godwin M. Automated office blood pressure. Can J Cardiol. 2012;28:341–6.CrossRefPubMedGoogle Scholar
  23. 23.
    Goldberg EM, Wilson T, Saucier C, et al. Achieving the BpTRUth: emergency department hypertension screening and the Centers for Medicare & Medicaid Services quality measure. J Am Soc Hypertens. 2017;11:290–4.CrossRefPubMedGoogle Scholar
  24. 24.
    Shayne PH, Pitts SR. Severely increased blood pressure in the emergency department. Ann Emerg Med. 2003;41:513–29.CrossRefPubMedGoogle Scholar
  25. 25.
    Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans: an AHA scientific statement from the Council on High Blood Pressure Research Professional and Public Education Subcommittee. J Clin Hypertens (Greenwich). 2005;7:102–9.CrossRefGoogle Scholar
  26. 26.
    Mahn JJ, Dubey E, Brody A, et al. Test characteristics of electrocardiography for detection of left ventricular hypertrophy in asymptomatic emergency department patients with hypertension. Acad Emerg Med. 2014;21:996–1002.CrossRefPubMedGoogle Scholar
  27. 27.
    Miller JB, Arter A, Wilson SS, et al. Appropriateness of bolus antihypertensive therapy for elevated blood pressure in the emergency department. West J Emerg Med. 2017;18:957–62.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Axon RN, Garrell R, Pfahl K, et al. Attitudes and practices of resident physicians regarding hypertension in the inpatient setting. J Clin Hypertens (Greenwich). 2010;12:698–705.CrossRefGoogle Scholar
  29. 29.
    Axon RN, Turner M, Buckley R. An update on inpatient hypertension management. Curr Cardiol Rep. 2015;17:94.CrossRefPubMedGoogle Scholar
  30. 30.
    Gattis WA, O'Connor CM, Gallup DS, et al. Predischarge initiation of carvedilol in patients hospitalized for decompensated heart failure: results of the Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial. J Am Coll Cardiol. 2004;43:1534–41.CrossRefPubMedGoogle Scholar
  31. 31.
    Jankowski P, Kawecka-Jaszcz K, Bilo G, Pajak A. Determinants of poor hypertension management in patients with ischaemic heart disease. Blood Press. 2005;14:284–92.CrossRefPubMedGoogle Scholar
  32. 32.
    Campbell P, Baker WL, Bendel SD, White WB. Intravenous hydralazine for blood pressure management in the hospitalized patient: its use is often unjustified. J Am Soc Hypertens. 2011;5:473–7.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Weder AB, Erickson S. Treatment of hypertension in the inpatient setting: use of intravenous labetalol and hydralazine. J Clin Hypertens (Greenwich). 2010;12:29–33.CrossRefGoogle Scholar
  34. 34.
    Brody A, Rahman T, Reed B, et al. Safety and efficacy of antihypertensive prescription at emergency department discharge. Acad Emerg Med. 2015;22:632–5.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    • Jaffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved blood pressure control associated with a large-scale hypertension program. JAMA. 2013;310:699–705. A description of a successful systems based approach to blood pressure control. CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Bobrow K, Farmer AJ, Springer D, et al. Mobile phone text messages to support treatment adherence in adults with high blood pressure (SMS-text adherence support [StAR]): a single-blind, randomized trial. Circulation. 2016;133:592–600.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Mao AY, Chen C, Magana C, Caballero Barajas K, Olayiwola JN. A mobile phone-based health coaching intervention for weight loss and blood pressure reduction in a national payer population: a retrospective study. JMIR Mhealth Uhealth. 2017;5:e80.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Buis L, Hirzel L, Dawood RM, et al. Text messaging to improve hypertension medication adherence in African Americans from primary care and emergency department settings: results from two randomized feasibility studies. JMIR Mhealth Uhealth. 2017;5:e9.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Buis LR, Artinian NT, Schwiebert L, Yarandi H, Levy PD. Text messaging to improve hypertension medication adherence in African Americans: BPMED intervention development and study protocol. JMIR Res Protoc. 2015;4:e1.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Greer AL. Advances in the study of diffusion of innovation in health care organizations. Milbank Mem Fund Q Health Soc. 1977;55:505–32.CrossRefPubMedGoogle Scholar
  41. 41.
    Bowen S, Zwi AB. Pathways to “evidence-informed” policy and practice: a framework for action. PLoS Med. 2005;2:e166.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Levy PD, Mahn JJ, Miller J, et al. Blood pressure treatment and outcomes in hypertensive patients without acute target organ damage: a retrospective cohort. Am J Emerg Med. 2015;33:1219–24.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Aaron M. Brody
    • 1
  • Joseph Miller
    • 2
    • 3
  • Rimma Polevoy
    • 3
  • Asaad Nakhle
    • 3
  • Phillip D. Levy
    • 1
  1. 1.Department of Emergency MedicineWayne State University School of MedicineDetroitUSA
  2. 2.Department of Emergency MedicineHenry Ford Hospital and Wayne State UniversityDetroitUSA
  3. 3.Department of Internal MedicineHenry Ford Hospital and Wayne State UniversityDetroitUSA

Personalised recommendations