Increased Blood Pressure in the Emergency Department: Pain, Anxiety, or Undiagnosed Hypertension AHRQ Annual Meeting 20

1. 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

3. 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 >140 mm Hg or DBP > 90 mm Hg Guidelines advocate improvement in recognition and treatment of HTN7

4. 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 >140 mm Hg or DBP > 90 mm Hg, the patient should be referred for follow-up of possible HTN and BP management”8 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

5. Study Aims Determine proportion of patients with no history of HTN and two ED blood pressure readings >140/90 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

6. MethodsDesign, Setting Prospective cohort of ED patients Large urban, academic medical center with an EM residency program

7. Sample Inclusion Criteria Initial ED SBP >140 or DBP >90 mm Hg No history of HTN Repeat ED SBP >140 or DBP >90 mm Hg

8. 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

9. 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

10. Methods of Return Triage desk Post office, postage paid envelope Dominick’s pharmacy

11. 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 >140 or DBP >90 mm Hg

12. 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

13. Analysis Chi-square and Fisher’s 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

14. 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

15. Results 54% had sustained HTN 40% prehypertension 6% patients had a “normal” JNC7 BP

16. Prevalence of Home Sustained HTN Based on ED Blood Pressures

17. Demographic Characteristics

18. Patient Characteristics Associated with Elevated Home Blood Pressure

19. Relationship between self-reported anxiety and pain and the difference between patients’ home and ED systolic blood pressure (SBP)