Phillip Levy, MD, MPH, was shocked when he looked at the data on subclinical heart disease in his largely black emergency department population. More than 90 percent of the 161 hypertensive patients he screened had evidence of subclinical hypertensive heart disease, a disturbing number by any calculation.
“We were surprised at the degree of left ventricular hypertrophy,” said Dr. Levy, an associate professor and the associate director of clinical research in emergency medicine and the assistant director of clinical research in the Cardiovascular Research Institute at Wayne State University School of Medicine in Detroit. The startlingly high numbers he found in his inner city ED sound a warning for other EPs to consider a disease that might be prevalent but not readily apparent.
“High blood pressure is such a common condition in the emergency department,” he said. “A lot of these people are suffering from damage, but we don't know that. We only figure it out when there is some consequence.”
Dr. Levy called for better identification of those with poorly controlled blood pressure and more effective disease prevention. His research studied a convenience sample of 161 patients 35 and older with blood pressure higher than 140/90 mm Hg on two measurements a standard evaluation that included echocardiography. (Ann Emerg Med 2012;60:467.) Slightly more than 51 percent were men, and 93.8 percent were black. The researchers defined subclinical heart disease as left ventricular hypertrophy and systolic or diastolic dysfunction. Nearly all patients in the study had a history of hypertension, and 68.3 percent were on antihypertensive treatment. Mean blood pressures were 183.9 mm Hg (systolic) and 109.5 mm Hg (diastolic).
The researchers found evidence of subclinical hypertensive heart disease in 146 patients with 131 showing evidence of diastolic dysfunction. Eighty-nine (61%) had evidence of left ventricular hypertrophy that was associated with diastolic filling abnormalities in 75 (57%).
Dr. Levy conceded that his patient population is skewed, but insisted that his findings still point to a tremendous need. “People need to realize that we should think globally and act locally. If I see this problem in my community, I need to respond to it,” he said.
Brigitte Baumann, MD, MSCE, the head of clinical research in emergency medicine at Cooper University Hospital and Cooper Medical School of Rowan University in Camden, NJ, said emergency physicians should be addressing undiagnosed hypertension in ED patients. “I think Dr. Levy's study is important and underscores the need for providing referrals for outpatient needs. It's almost a slap in the face to some of us who may not think that referral and assessment in the emergency department is as important,” said Dr. Baumann, who wrote an editorial calling Dr. Levy's data “compelling.” (Ann Emerg Med 2012;60:475.)
She noted, however, that the population he addressed is unusual and different from the one she sees in Camden. “Sixty-eight percent were on an antihypertensive, and more than 58 percent had medical insurance. That is high compared with our population,” Dr. Baumann said, adding that many patients were known hypertensives. “I think what he is showing is that they are undergoing care, and it's probably suboptimal.”
The results would be different in a white population, she said. “I'm not sure by how much. The takeaway message is that this study shows what happens if we don't do what we should be doing.”
Craig A. Umscheid, MD, MSCE, an assistant professor of medicine and epidemiology at the Hospital of the University of Pennsylvania, said his 2008 study showed that a large percentage (43%) of ED patients had untreated and undocumented hypertension. (Acad Emerg Med 2008;15:529.) The problem was undocumented in eight percent of those with untreated hypertension, he said.
“That's a high number,” said Dr. Umscheid, also the director of Penn Medicine's Center for Evidence-based Practice and the senior associate director of the ECRI-Penn AHRQ Evidence-based Practice Center at the University of Pennsylvania. “The emergency department could be a potential area in which to diagnose people who were not previously diagnosed and treated.”
He pointed out, however, that many of those with hypertension were in the range of 140 to 160 systolic. “That said, I think that there is still an opportunity that could be seized,” Dr. Umscheid said, noting that emergency physicians can sometimes think hypertension in the ED is a result of being there for other complaints. A number of studies have suggested, he said, that the higher a patient's blood pressure in the ED, the more likely it is to be really high outside the ED.
The real issue is what to do with ED patients who have high blood pressure. Clinical guidelines from the American College of Emergency Physicians found little evidence to guide the practitioner about which patients to test for asymptomatic elevated blood pressure “ED screening for creatinine level may identify a small group of patients with renal dysfunction in the setting of asymptomatic markedly elevated blood pressure, [but no] other diagnostic screening tests appear to be useful.”
The ACEP policy concluded that routine ED medical intervention is not required for patients with markedly high blood pressure, though they said EPs may treat the condition in the ED or initiate long-term therapy for certain patients, such as those who may be lost to follow-up. The policy also recommended referring patients with asymptomatic markedly elevated blood pressure for outpatient follow-up.”
Therein lies the rub, said all three physicians interviewed for this article. “You can refer all you want,” said Dr. Baumann, but many patients have no place to go. “Improved access to health care is part of the problem. We cannot dump preventive health care and health care maintenance on the emergency department.”
Dr. Umscheid said he recognized that the emergency department is not the ideal place for treatment, but he noted that some patients may not have other options, and the threat of devastating health consequences is real.
“At the least, I guess you could send them to their primary care doctor,” he said. “You tell them their pressures were high, and they get it checked. Put the responsibility on the patient, and have them make an informed decision. You could potentially have them return to the ED, but that is not cost-effective for those with insurance. For those who are uninsured, a follow-up ED visit for hypertension and initiation of management might be reasonable,” he said, cautioning that he is not an emergency physician.
Dr. Levy said it may be important to try to develop some systematic community approaches for ED patients who cannot get plugged into the health system, like the one he established with funding from research grants. “We are looking at a whole new way to manage hypertension in the emergency department,” he said. “We offer a clinic to help people understand the consequences of not taking care of their blood pressure. We focus on patient education and empowerment.”
Click and Connect!Access the links in EMN by reading this issue on our website or in our iPad app, both available onwww.EM-News.com.