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

Acknowledgements. Funded by the Agency for Healthcare Research and Quality, RO3 -HSO15619-01. Background. Approximately 29% of adults in the US have HTN33.5% of these adults are undiagnosed1,2HTN leads to cardiac disease, strokes and renal failure3,4Adults from low socioeconomic backgrounds and African Americans have a higher morbidity and mortality5,62003 JNC 7 guidelines re-defined hypertension as 2 or more SBP >140 mm Hg or DBP > 90 mm HgGuidelines advocate improvement in recognition a140

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

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    1. Increased Blood Pressure in the Emergency Department: Pain, Anxiety, or Undiagnosed Hypertension AHRQ Annual Meeting 2008 Paula Tanabe, PhD, MPH, RN Northwestern University, Feinberg School of Medicine Department of Emergency Medicine and the Institute for Healthcare Studies

    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. Methods Design, 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)

    20. 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

    21. 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 >140/90 should not be assumed to be anxious or in pain and are at risk for undiagnosed HTN

    22. 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

    23. 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

    24. References 1. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. Dec 14 2002;360(9349):1903-1913. 2. Chobabanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA. 2003;289:2560-2571. 3. Almgren T, Persson B, Wilhelmsen L, et al. Stroke and coronary heart disease in treated hypertension -- a prospective cohort study over three decades. J Intern Med. Jun 2005;257(6):496-502. 4. Hsia J, Margolis KL, Eaton CB, et al. Prehypertension and cardiovascular disease risk in the Women's Health Initiative. Circulation. Feb 20 2007;115(7):855-860. 5. Mensah GA, Mokdad AH, Ford ES, et al. State of disparities in cardiovascular health in the United States. Circulation. Mar 15 2005;111(10):1233-1241. 6. Dennison CR, Post WS, Kim MT, et al. Underserved urban african american men: hypertension trial outcomes and mortality during 5 years. Am J Hypertens. Feb 2007;20(2):164-171. 7. Chobabanian AV, Bakris GL, Black HR, et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 2003;42:1206-1252. 8. Decker WW, Godwin SA, Hess EP, et al. Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department. Ann Emerg Med. 2006;47:237-249.

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