Do Patients with Elevated Blood Pressure have Persistently Elevated Blood Pressure on Home Monitoring?

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Do Patients with Elevated Blood Pressure have
Persistently Elevated Blood Pressure on Home
Monitoring?

• P. Tanabe, PhD, MPH, RN1
• SD Persell, MD, MPH2, JG Adams, MD1
• J. McCormick, BS1, Z. Martinovich, PhD3
• DW Baker, MD, MPH2
• Northwestern University, Feinberg School of
  Medicine
• 1Emergency Medicine, 2General Internal Medicine,
  3Psychiatry

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Acknowledgements

• Funded by the Agency for Healthcare Research and
  Quality, RO3 -HSO15619-01
• Lori McGee, Steve Gorman and Alexis Bergan-Guzman
  for their assistance with patient enrollment

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Background

• 2003 Joint National Committee 7 guidelines
  re-defined hypertension as 2 or more BPs gt140/90
• 2006 ACEP Clinical Policy recommends If BP
  measurements are persistently elevated with a SBP
  gt140 mm Hg or DBP gt90 mm Hg, the patient should
  be referred for follow-up of possible HTN and BP
  management
• ACEP policy acknowledges the meaning of elevated
  ED blood pressures is unclear and often these
  elevated BPs are attributed to pain or anxiety

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Study Aims

• Determine proportion of patients with no history
  of HTN and two ED blood pressure readings gt140/90
  who have sustained blood pressure elevations
  measured at home after ED discharge

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MethodsDesign, Setting

• Prospective cohort of ED patients
• Large urban, academic medical center with an EM
  residency program

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Sample Inclusion Criteria

• Initial ED SBP gt140 or DBP gt90 mm Hg
• No history of HTN
• Repeat ED SBP gt140 or DBP gt90 mm Hg

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Exclusion Criteria

• Non-English speaking
• Admitted to the hospital
• Unable to operate home BP monitor
• Pregnant
• Medical or psychiatric instability
• Inadequate contact information
• Discharged with anti-HTN prescription

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Study Protocol

• RAs enrolled subjects Mon.-Thurs. 9A-9P, Fri. and
  Sat 9A-5P
• Brief patient interview
• Instructed subjects on use of home BP monitor
• Patients were asked to record home BP twice daily
  for 1 week
• Home BP monitor UA 787 Home BP monitor (British
  Hypertension Society approved) Monitor stored
  up to 30 readings

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Methods of Return

• Triage desk
• Post office, postage paid envelope
• Dominicks pharmacy

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Analysis

• Highest and lowest SBP and DBP deleted
• Mean monitor SBP and DBP calculated
• Classified as sustained elevation if SBP gt140 or
  DBP gt90 mm Hg

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Results

• 189 subjects enrolled
• 171 (90) returned monitor
• 156/171 (91) had adequate BP data
• Mean (SD) age 47 (13)
• 50 Female, 35 Black, 60 White, 7 Hispanic
• 84 (54) had sustained HTN

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Demographic Characteristics
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Limitations

• Single site
• English-speaking only patients

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Conclusions

• A high proportion of ED patients with elevated
  BPs were found to have sustained BP elevation at
  home
• ED patients with 2 or more blood pressures
  gt140/90 should not be assumed to be anxious or in
  pain
• Patients with 2 or more blood pressures gt140/90
  are at risk for undiagnosed HTN

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Conclusions

• The ED is an important setting for identifying
  patients with undetected HTN
• Mechanisms to standardize and automate BP
  re-assessment orders and prompt discharge
  instructions are needed