A recent analysis indicates that hypertension is a highly prevalent, significant issue for physicians nationwide, including those practicing in emergency medicine. Since 2001, the emergency department (ED) component of the CDC’s annual National Hospital Ambulatory Medical Care Survey (NHAMCS) has collected data on blood pressure measurements recorded in ED settings. The CDC’s National Center for Health Statistics (NCHS) published a brief report on BP measurements at ED visits in adults using data from the NHAMCS ED. A significant finding was that elevated BP was more common at visits to the ED than at visits to primary care providers (Figure 1).
High BP Common in the ED
Severely elevated BP was found at 16.3% of ED visits, compared with 6.8% of primary care visits. Moderately high BP was found at 27.2% of ED visits, compared with 20.2% of primary care visits. For the report, moderately elevated BP was defined as a systolic BP reading of 140 to 159 mm Hg or a diastolic reading of 90 to 99 mm Hg. Severely high BP was defined as a measurement of 160/100 mm Hg or greater. “Emergency physicians see many patients every day, many of whom are elderly,” says Stephen R. Pitts, MD, MPH. “These individuals often have BP levels higher than 160/100 mm Hg.”
The CDC report also indicated that both severely and moderately elevated BP at ED visits were most common among men (Figure 2) and older age groups. Severely elevated BP was more common at ED visits by non-Hispanic African-Americans (19.7%), followed by Non-Hispanic Caucasians (15.3%) and Hispanics (15.3%). Severely elevated BP was also more common at ED visits by Medicare beneficiaries (19.6%) than by those with private insurance (16.3%) or Medicaid (14.1%). Moderately elevated BP was more common at ED visits by uninsured and privately insured patients than by Medicaid beneficiaries, though this was not statistically significant.
Analyzing the Reasons Behind BP Levels
“One of the reasons that BP levels are higher in the ED than in primary care is because primary care visits are typically reserved for scheduled appointments for people without new complaints,” says Dr. Pitts. “People who go to the ED for care, by definition, have a chief complaint that needs to be addressed. Oftentimes, that problem is a consequence of more chronic, underlying illnesses like hypertension or the complaint itself increases BP. It’s a common misconception that elevated BP in the ED is the result of the ED setting being a stressful place. There are no data, however, to prove that belief to be true.”
According to Linda F. McCaig, MPH, the higher rate of elevated BP at ED visits made by non- Hispanic African-Americans when compared with other racial and ethnic groups is likely attributable to a higher prevalence of hypertension in this population. Additionally, African-Americans had a higher overall ED visit rate (77 visits per 100 persons) than Caucasians (37 visits per 100 persons) in data from 2008. “This may indicate a lack of access to primary care, thus increasing the likelihood of having uncontrolled BP,” Dr. McCaig says.
Dr. Pitts adds that emergency physicians should recognize the implications of high BP being common throughout EDs in the United States. “When high BP is detected in the ED, the implications are different than when these patients are identified in primary care settings. Patients will need to be treated initially, but also educated as to why they’re receiving treatment in the first place. EDs need to facilitate referrals to primary care services when clinically appropriate.”
Making a Difference in the ED
Currently, there are national objectives that have been initiated to prevent heart disease and stroke by reducing the proportion of adults with hypertension and increasing the number of adults with well-controlled BP. For ED physicians, it can be challenging to abide by these objectives because other chief complaints may require more immediate attention. In some cases, asymptomatic hypertension may be overlooked or be deemed a lesser priority. “Patient education is paramount, and efforts are needed to ensure that these people go to follow-up appointments with their primary care providers,” says Dr. McCaig. “We hope that such efforts would make the management of chronic hypertension less problematic in the ED so that emergency physicians can focus their energy on addressing patients’ chief complaints.”
Readings & Resources (click to view)
Niska RW. Blood pressure measurements at emergency department visits by adults: United States, 2007–2008. NCHS data brief, no 72. Hyattsville, MD: National Center for Health Statistics. 2011. Available at: www.cdc.gov/nchs/data/databriefs/db72.pdf.
Egan BM, Zhao Y, Axon RN. U.S. trends in prevalence, awareness, treatment, and control of hypertension, 1988–2008. JAMA. 2010;303:2043-2050.
Decker WW, Godwin SA, Hess EP, Lenamond CC, Jagoda AS; American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Asymptomatic Hypertension in the ED. 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.
Chobanian 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.
Garcia TC, Bernstein AB, Bush MA. Emergency department visitors and visits: who used the emergency room in 2007? NCHS data brief, no 38. Hyattsville, MD: National Center for Health Statistics. 2010. Available at: www.cdc.gov/nchs/data/databriefs/db38.htm.
U.S. Department of Health and Human Services. Healthy People 2020 topics and objectives: Heart disease and stroke. HDS–5.1 and HDS–12. Available at: www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=21.
McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary. Advance Data from Vital and Health Statistics; no. 335. Hyattsville, MD: National Center for Health Statistics. 2003. Available at: www.cdc.gov/nchs/data/ad/ad335.pdf.