DISCLOSURES ED MANAGEMENT OF …...9/23/19 1 ED MANAGEMENT OF ASYMPTOMATIC HYPERTENSION Nathaniel...
Transcript of DISCLOSURES ED MANAGEMENT OF …...9/23/19 1 ED MANAGEMENT OF ASYMPTOMATIC HYPERTENSION Nathaniel...
9/23/19
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ED MANAGEMENT OF ASYMPTOMATIC HYPERTENSION
Nathaniel Shekem PA-CDepartment of Emergency Medicine
University of Iowa
DISCLOSURES
• None
OBJECTIVES• Discuss clinical importance of elevated BP in the ED
• Discuss definitions of hypertensive presentations
• Discuss an appropriate ED workup for asymptomatic hypertension
• Discuss potential harms of acute blood pressure lowering
• Discuss appropriate disposition for hypertensive ED patients
• Patient: “_______” told me to come to the emergency department because my blood pressure is too high and it needs to be lowered.
• Clinician: How do you feel?
• Patient: I feel fine. But ______ told me I’m going to have a stroke/brain bleed/heart attack/go on dialysis/die if I don’t lower it now.
• Chief Complaint
• Sent from pre-op anesthesia clinic due to high blood pressure. Patient was told not to take blood pressure medications due to surgery today. Patient has no complaints.
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IN A NUTSHELL…
• Don’t just do something, stand there!
HYPERTENSION
• Silent killer
• 30-50% of the US population has hypertension
• ED incidence of hypertension is 44%
• 27% in primary care setting
IS HYPERTENSIVE URGENCY A REAL THING?
• Blood pressure >180/120
• Implications of the term “urgency”
• 2013 ACEP Guidelines
• “Asymptomatic markedly elevated blood pressure”
Elevated Blood Pressure in the ED
End Organ Damage No End Organ Damage
Hypertensive Emergency Asymptomatic Markedly Elevated Blood Pressure
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WHAT INDICATES END ORGAN DYSFUNCTION?
• Strong indication for acutely lowering blood pressure
• PO or IV
EVIDENCE FOR ACUTE BP LOWERING
• “There is no RCT evidence demonstrating that antihypertensive drugs reduce mortality or morbidity in patients with hypertensive emergencies”
2013 ACEP GUIDELINES
• Level C
• Should I routinely perform tests to assess for end organ damage?
• NO
• Maybe serum creatinine
2013 ACEP GUIDELINES • Level C
• Should I routinely treat asymptomatic hypertension in the ED setting?
• NO
• Maybe start an oral antihypertensive
• Definitely arrange follow up
UTILITY OF “SCREENING” TESTS
• >58,000 patient met criteria for “hypertensive urgency”
• “Abnormal” test found in 5-7%
• Likely chronic rather than acute
POSSIBLE HARMS
• Acute BP lowering
• Autoregulation
• Poor perfusion to critical organs
• Risk of ischemia or infarction
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PRO TIP
• 30 minutes in a quiet calm room
• Blood pressure improved to mean of 160/89 mm Hg in 30% of patients
RISK AFTER DISCHARGE• 58,000 outpatients
• BP >180/100 mm Hg
• Asymptomatic
• Rates of major events
• Hospitalized vs outpatient
• <1% in both groups at 7 days, 30 days, and 6 months
RISK AFTER DISCHARGE• >200,000 ED visits in Ontario
• Primary diagnosis “hypertension”
• 8% hospitalized
• <1% rate of major events at 30 days
• Mortality
• 90 days <1%
• 1 year 2.5%
• 2 years 4.1%
SHOULD I START MY PATIENT ON A BP MEDICATION?
• Treatment options
• Thiazides and CCBs for all
• ACEi/ARB less effective in black population
• Restart prior medications
• How quickly?
• Goal <160/100
• Decrease MAP 20-25% over several days
HOW WE CAN MAKE A DIFFERENCE
• Recognize elevated blood pressure readings
• Patient education
• Ensure appropriate follow up
• Consider starting an antihypertensive