Hypertension affects more than 65 million individuals in the U.S., accounting for nearly 30% of the adult population.1 Less than 50% of those with hypertension are taking appropriate pharmacotherapy.2 Hypertension contributes to cardiovascular events, including cerebrovascular accident, transient ischemic attack, hypertensive retinopathy, renal failure, myocardial infarction, and heart failure.1 Chronic hypertension mainly is an asymptomatic condition, earning the nickname “the silent killer.”2 An acute, symptomatic elevation in blood pressure (BP) often is referred to as hypertensive emergency. Symptoms of end-organ damage can include headache, blurry vision, chest pain, shortness of breath, altered mental status, epistaxis, and oliguria.2 Although rare, hypertensive emergencies should be treated immediately. The Seventh Report of the Joint National Committee (JNC 7), and the more recent JNC 8, have published guidelines on managing chronic hypertension.3,4 However, neither report provides guidance on hypertensive emergency or the appropriate actions in cases of extremely elevated BP in an asymptomatic patient.3,4
Acute hypertensive episodes—often referred to as hypertensive crises—are responsible for nearly 8 million hospitalizations each year and 20 million visits to the emergency department (ED).5,6 Most of these visits are same-day “treat-and-release” events.5 There is no universally accepted BP value associated with a hypertensive crisis, but most resources state that a BP ≥ 180/110 mm Hg requires attention.2,7 Without other symptoms, elevated BP is not an emergency, yet ED referral for acute management is common.7
Three terms fall under the umbrella of hypertensive crises: hypertensive emergency, hypertensive urgency, and asymptomatic hypertension (AH).2 In a 2007 article, the American College of Chest Physicians defined hypertensive emergency as BP ≥ 180/110 mm Hg with evidence of end-organ damage.2 Symptoms are almost always present in true hypertensive emergencies, and immediate medical intervention is required to halt further organ damage. In the same article, hypertensive urgency is defined as BP ≥ 180/110 mm Hg without end-organ damage.2 The definition of hypertensive urgency could be further refined to include the presence of cardiovascular and renal risk factors, although this additional point is not consistent across the literature. Asymptomatic hypertension is similar to hypertensive urgency; however, there is an absence of signs or symptoms of end-organ damage.2 There is ambiguity in the literature concerning managing hypertensive urgency and AH, but both share a basic tenet: Immediate BP reduction is not essential. Gradual dosage adjustment(s) of oral medications, preferably by a primary care provider (PCP), and follow-up within 7 days are recommended.7
Limited evidence exists to guide ED providers in managing AH. Long-term outcomes and guidelines intended for the primary care setting should not be extrapolated to acute management in the ED. With limited treatment guidelines, providers might be more likely to refer patients with AH to the ED for evaluation. In 2013, the American College of Emergency Physicians (ACEP) created a clinical policy concerning AH in the ED. The ACEP concluded that screening for target organ injury and medical intervention in the ED does not reduce rates of adverse events (AEs) and could lead to overtreatment and acute hypoperfusion.7 More recently, Patel and colleagues published findings on hypertensive urgency in the ambulatory care setting, which similarly found that referral to the ED was associated with increased use of health care resources and no change in short-term major AEs.8 The ACEP recommends that patients presenting with AH be referred to primary care clinics where long-term monitoring and medication adjustments can be achieved more cost-effectively.7
The objective of this retrospective evaluation was to assess the incidence and management of AH within a VA ED. The authors aimed to provide insight into how these patients are managed and discuss alternatives to ED use.
Methods
This retrospective observational study was conducted within the North Florida/South Georgia Veterans Health System (NFSGVHS), which provides patient care at 2 medical centers in Gainesville and Lake City, Florida, as well as 11 outpatient clinics located throughout North Florida and South Georgia. The NFSGVHS serves rural and urban veteran populations. Study approval was granted by the NFSGVHS Institutional Review Board and Research and Development Committee.
Inclusion/Exclusion Criteria
Adult patients who were ordered at least 1 antihypertensive medication in the ED from July 1, 2011 to July 1, 2014, in addition to being asymptomatic with BP ≥ 180/110 mm Hg at ED triage were included. Based on clinical experience, the authors estimated that 3 years would provide a sample size of more than 100 patients. Patients were excluded if they presented with any acute symptoms or were hospitalized for further management.
Data Collection
Baseline demographics were collected for all participants. During the ED encounter, pre- and postintervention vital signs were recorded and prespecified laboratory data obtained. Interrater reliability was accounted for by performing random reviews of previously collected data to ensure consistency during the chart review process. Renal end-organ damage was defined using Acute Kidney Injury Network criteria, a serum creatinine 50% above baseline, or an absolute increase in baseline serum creatinine by 0.3 mg/dL.9 Additional laboratory markers of organ damage included cardiac troponin levels. Urinalysis results also were assessed to determine the presence of hematuria or proteinuria. Patient-reported nonadherence with medications was determined by reviewing ED provider and/or nurse documentation notes for the index ED encounter.