Medical College of Wisconsin Department of Emergency Medicine, Milwaukee, WI, United States; Clement Zablocki VA Medical Center, Milwaukee, WI, United States.
Medical College of Wisconsin Department of Emergency Medicine, Milwaukee, WI, United States.
Am J Emerg Med. 2024 Dec;86:37-40. doi: 10.1016/j.ajem.2024.09.042. Epub 2024 Sep 21.
According to the guidelines of the American Heart Association and American College of Emergency Physicians, respectively, there is no indication for immediate lowering of asymptomatic hypertension in the Emergency Department (ED), and no requirement for routine diagnostic testing in these patients. Despite this, asymptomatic hypertension represents a recurring source of referrals for ED evaluation from other healthcare settings, or from patient self-referral, with significant practice variation in the evaluation and treatment of this complaint.
This is a pre-post study of a pathway to standardize care of patients presenting to a tertiary academic Veteran's Health Administration ED with asymptomatic hypertension. Inclusion criteria were patients with ICD10 codes of hypertension who were confirmed via chart review to have sought care for a complaint of elevated blood pressure readings from 2018 to 2022, with the pathway having been implementing in 2022. Patients were excluded if they had symptoms of possible end organ pathology due to hypertension, such as chest pain, headache, or shortness of breath, or if they were reproductive age women who had not undergone a sterilization procedure. The primary outcome was major adverse cardiovascular event within 30 days of ED visit. Secondary outcomes included: diagnostic tests performed, administration of antihypertensives in the ED, and length of stay. Descriptive statistics and statistical analysis were performed.
There were a total of 295 unique patients and 324 patient encounters that met the inclusion/exclusion criteria, with 46 encounters that took place after pathway implementation. There were no major adverse cardiovascular events either before or after pathway implementation. Chest radiographs were reduced from 10 % to 0 % (p = 0.005) after pathway respectively. There were also declines in laboratory testing, EKGs, and administration of oral antihypertensives, but these differences were not statistically significant. At no point did any diagnostic testing identify any previously undiagnosed medical conditions. There were no instances of intravenous hypertensives being given after pathway implementation. Despite the reductions in diagnostic testing, there was no change in ED length of stay for patients with asymptomatic hypertension.
Our findings redemonstrate that patients presenting to the ED with asymptomatic hypertension are at low risk for short-term complications of hypertension, and that diagnostic testing is low yield in this population. While we were able to achieve reductions in unnecessary testing, further work is needed to educate clinicians and improve adherence to evidence based principles when caring for these patients.
根据美国心脏协会和美国急诊医师学院的指南，急诊科（ED）中无症状高血压没有立即降压的指征，也不需要对这些患者进行常规诊断性检查。尽管如此，无症状高血压仍然是其他医疗保健机构或患者自行转介到 ED 进行评估的一个反复出现的原因，并且在评估和治疗这种投诉方面存在显著的实践差异。
这是一项关于标准化治疗无症状高血压患者的途径的前后研究，这些患者就诊于一家三级学术退伍军人健康管理 ED。纳入标准为 ICD10 编码为高血压的患者，通过图表审查确认因血压升高而寻求医疗护理，时间为 2018 年至 2022 年，该途径于 2022 年实施。如果患者有高血压引起的可能终末器官病理的症状，如胸痛、头痛或呼吸急促，或者如果患者是未接受绝育手术的育龄期妇女，则将其排除在外。主要结局为 ED 就诊后 30 天内发生主要不良心血管事件。次要结局包括：在 ED 进行的诊断性检查、降压药物的使用以及住院时间。进行了描述性统计和统计分析。
共有 295 名患者和 324 名患者符合纳入/排除标准，其中 46 名患者在途径实施后就诊。在途径实施前后均未发生主要不良心血管事件。路径实施后，胸部 X 光片从 10%减少到 0%（p=0.005）。实验室检查、心电图和口服降压药的使用也有所减少，但这些差异无统计学意义。在任何时候，都没有任何诊断性检查发现任何以前未诊断的疾病。在途径实施后，没有患者静脉注射高血压药物。尽管诊断性检查减少了，但无症状高血压患者的 ED 住院时间没有变化。
我们的研究结果再次表明，到 ED 就诊的无症状高血压患者短期内发生高血压并发症的风险较低，并且该人群的诊断性检查效果不佳。虽然我们能够减少不必要的检查，但仍需要进一步努力教育临床医生并改善对这些患者的循证原则的遵守。
