Hypertensive Urgency: Can Geriatricians Skip Referral to the Emergency Department?

Study confirms less dire outcomes for hypertensive episodes

By Amanda Lathia, MD

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A recently published study validates geriatricians’ customary practice for asymptomatic patients presenting in the office with hypertensive urgency: listen carefully and don’t overreact.

The study, led by former Cleveland Clinic fellows Krishna K. Patel, MD, and Laura Young, MD, and published in JAMA Internal Medicine, confirms that only a very small percentage of patients presenting with hypertensive urgency face major adverse cardiovascular events (MACE) and that the vast majority do not need to be sent to the emergency department (ED) or hospitalized. MACE includes acute coronary syndrome and stroke or transient ischemic attack, uncontrolled hypertension (≥ 140/90 mm Hg), and hospital admissions.

Let’s avoid over-diagnosis

The retrospective cohort study included 58,535 unique patient office visits throughout Cleveland Clinic Health System who met the selection criteria. Hypertensive urgency was defined as systolic blood pressure ≥ 180 mm Hg and/or diastolic blood pressure ≥ 110 mm Hg. The majority of patients sent to the ED had no follow-up testing – probably because their blood pressure normalized by the time they arrived. The ED visit didn’t result in any additional useful information, a frustrating experience for the patient and a waste of healthcare dollars.

The authors conclude: “Hypertensive urgency is common, but the rate of MACE in asymptomatic patients is very low. Visits to the ED were associated with more hospitalizations, but not improved outcomes.” In most cases, outpatient management was sufficient.

Overreacting to numbers

As a culture, we tend to overreact to numbers. In geriatric medicine, we try to address a variety of factors and include them in the equation when deciding whether or not to hospitalize.

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Also, many patients report having white coat hypertension, a one-time number that, without symptoms, is not indicative of normal pressure. If a reading seems to be an isolated number, I often recommend that the patient or their care partner check blood pressure at home and send me a message or call with a list of readings.

Familiarity counts

This study did not report whether the physician who referred to the ED or hospital was the patient’s primary care physician or someone who knew them well. That makes a big difference. If I’m seeing a patient for first time and his/her pressure is significantly elevated, I may be more likely to send him or her to the ED.

What about patient preference and compliance?

Some patients, particularly if they are worried or upset, want to go to ED for further evaluation, even if you recommend against it. Can you say no? I would explain my opinion and recommendations, but in the end, we must respect the patient’s and/or family’s wishes as long as they have the capacity to make the decision in question.\

Compliance is a factor related to familiarity and preference. If you are unsure whether the patient is taking medications as prescribed or whether they have a care partner to help them, you may be more apt to refer, especially when blood pressure is very high.

All of these factors may point to a bigger issue: inadequate patient safety in the home and the need for additional support or a different care setting.

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Symptomatic severe hypertension

Severe hypertension can be serious, of course. If the patient is symptomatic, I would advise going to the ED. Symptoms may include vision changes, headache, confusion, light-headedness, dizziness or just “not feeling right,” or any stroke or heart attack symptoms.

Above all, listen

I think the most important thing to do is to listen to your patients. We are not just treating a number. Find out what their goals are, their preferences, and look at the whole picture. Then consider comorbidities, life expectancy, as well as resources and support systems. We have to put together an entire picture to determine what’s best for each patient.

In her commentary on the article, Iona Heath, MD, BChir, of the Royal College of General Practitioners in London, England, says: “We seem to have a condition, defined by a raised blood-pressure reading, that causes an enormous amount of anxiety to patients and clinicians alike but that does not require hospital admission and has a good prognosis.” She adds: “Perhaps unsurprisingly, patients who felt well turned out to be well.”

Dr. Lathia is a staff physician in the Center for Geriatric Medicine.