Increased Blood Pressure in the Emergency Department: Pain, Anxiety, or Undiagnosed Hypertension AHR

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Increased Blood Pressure in the Emergency
Department Pain, Anxiety, or Undiagnosed
HypertensionAHRQ Annual Meeting 2008

• Paula Tanabe, PhD, MPH, RN
• Northwestern University, Feinberg School of
  Medicine
• Department of Emergency Medicine and the
• Institute for Healthcare Studies

2
Acknowledgements

• Funded by the Agency for Healthcare Research and
  Quality, RO3 -HSO15619-01

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Background

• Approximately 29 of adults in the US have HTN
• 33.5 of these adults are undiagnosed1,2
• HTN leads to cardiac disease, strokes and renal
  failure3,4
• Adults from low socioeconomic backgrounds and
  African Americans have a higher morbidity and
  mortality5,6
• 2003 JNC 7 guidelines re-defined hypertension as
  2 or more SBP gt140 mm Hg or DBP gt 90 mm Hg
• Guidelines advocate improvement in recognition
  and treatment of HTN7

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Emergency Department Opportunity

• Many patients use the ED as their primary health
  care provider
• Other patients with physicians do not routinely
  visit their physician
• 2006 American College of Emergency Physicians
  Clinical Policy recommends If BP measurements
  are persistently elevated with a SBP gt140 mm Hg
  or DBP gt 90 mm Hg, the patient should be
  referred for follow-up of possible HTN and BP
  management8
• ACEP policy acknowledges the meaning of elevated
  ED blood pressures is unclear and often these
  elevated BPs are attributed to pain or anxiety
  data is needed

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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
• Describe characteristics associated with
  sustained BP increase
• Examine the relationship between pain and anxiety
  and the change in BP 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
• Home BP monitor UA 787EJ Home BP monitor
  (British Hypertension Society approved) Monitor
  stored up to 30 readings
• Patients were asked to record home BP twice daily
  for 1 week

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Methods of Return

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

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Study Variables

• Sustained blood pressure elevation
• 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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Pain and Anxiety

• ED Pain score (0-10 verbal descriptor scale)
• ED Anxiety score
• Spielberger State Anxiety Scale
• Scoring patient report 20-80, low to high
  anxiety

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Analysis

• Chi-square and Fishers exact test (categorical
  variables), t test (continuous variables)
• Standard logistic regression
• Pearson correlation coefficients to determine the
  correlations between the
• Change from ED to home SBP and DBP with the ED
  mean pain score and anxiety score
• If elevated ED BP is due to pain or anxiety, we
  anticipated a negative correlation

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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 (n) Hispanic

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Results

• 54 had sustained HTN
• 40 prehypertension
• 6 patients had a normal JNC7 BP

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Prevalence of Home Sustained HTN Based on ED
Blood Pressures
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Demographic Characteristics
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Patient Characteristics Associated with Elevated
Home Blood Pressure
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Relationship between self-reported anxiety and
pain and the difference between patients home
and ED systolic blood pressure (SBP)
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Limitations

• Single site
• English-speaking only patients
• Most patients had insurance
• Home vs. office BP measurements
• We believe our study under-estimates the findings
  based on these limitations

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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 and 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
• Future research is needed to determine referral
  mechanisms and brief interventions to motivate
  patients to follow-up

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Acknowledgments, Study Team

• Stephen D. Persell, MD, MPH2
• James G. Adams, MD1
• Jennifer McCormick, BS1
• Zoran Martinovich, PhD3
• David W. Baker, MD, MPH2
• Lori McGee, Steve Gorman and Alexis Bergan-Guzman
  for their assistance with patient enrollment
• Northwestern University, Feinberg School of
  Medicine
• 1Emergency Medicine, 2General Internal Medicine,
  3Psychiatry

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