Frequency of Serious Outcomes in Patients With Hypertension as a Chief Complaint in the Emergency Department

Methods

We obtained institutional review board approval for the present retrospective medical record review study. Patients were included if they were aged 18 years or older and if they presented to 1 of the EDs in our health network during 2008 with a chief complaint of hypertension. Our network, in Pennsylvania, is composed of 1 tertiary care suburban hospital and 2 community hospitals (1 urban, 1 suburban), with a cumulative annual census of more than 130,000 ED visits. We identified these patients by searching our ED's electronic medical record system (T-system, Inc) for medical records from the year 2008 with the key words “hypertension,” “high blood pressure,” or “blood pressure” in the chief complaint section. We then manually reviewed all the identified records and verified age and if the words “hyper tension,” “high blood pressure,” or “elevated blood pressure” were written in the first part of the chief complaint in the registration, nursing, or physician notes.

Records were excluded if patients were pregnant, if a request for blood pressure medication refill was found in the nursing or physician notes, or if 1 of the following additional serious complaints was listed with the chief complaint: headache, chest pain, shortness of breath, abdominal pain, confusion, syncope, vomiting, epistaxis, or neurologic deficit. All exclusion criteria were identified manually.

Results

From our electronic search, 316 medical records were identified. Of these, 91 did not meet the study's inclusion criteria and 3 were duplicate records. In addition, 73 records met the exclusion criteria—primarily for having another serious symptom in the chief complaint section of the medical record—and were thus not included in the study. A total of 149 medical records were analyzed (Figure).

Figure.

Study flow diagram of patient records assessed for hypertension as a chief complaint in the emergency department. ^a Another serious symptom in the chief complaint section of the medical record was the most common exclusion criterion met.

Sixty records (40%) were for men, and 89 records (60%) were for women (Table). The patient age range was 19 to 94 years, with a mean of 59.8 years and a median of 61 years. Of the 149 patients, 121 (81%) had a previous diagnosis of hypertension and 28 (19%) did not.

Five patients (3%) had a normal initial blood pressure in the ED. For initial measurement, systolic blood pressure ranged from 128 to 260 mm Hg (mean, 180.8 mm Hg; median, 178 mm Hg). Diastolic blood pressure ranged from 60 to 148 mm Hg (mean, 98.2 mm Hg; median, 98 mm Hg). Thirty-six records (24%) indicated that the patient's blood pressure had been checked frequently on the day of presentation to the ED (ie, >2 times before arrival).

In the ED, 16 patients (11%) did not undergo diagnostic tests; 13 (9%) underwent electrocardiography, 4 (3%) underwent a urine dipstick test, and 8 (5%) underwent both a urine dipstick test and electrocardiography. Other tests noted in the records included computed tomography of the head (22 patients [15%]) and chest radiography (44 patients [30%]). A total of 77 patients (52%) received medication while in the ED—44 received blood pressure medication and 33 received other medications, with acetaminophen and benzodiazepines being the most common (4 patients received potassium). Of all patients, 26 (17%) were admitted to the hospital and 123 (83%) were discharged or eloped.

Four patients (2.7%; 95% CI, 0.7-6.7) met our prespecified list of serious diagnoses: 3 had congestive heart failure, and 1 had kidney failure (worsening of chronic renal insufficiency). Two of the patients found to have congestive heart failure in the ED had a previous diagnosis of congestive heart failure; the new diagnosis was in a patient with a history of coronary artery disease, hypertension, and atrial fibrillation. Two patients with a serious diagnosis had a complaint of shortness of breath when probed, although no patients had shortness of breath as their chief complaint. Twelve patients (8%) returned to the ED within 7 days for a revisit. Many of these revisits were blood pressure rechecks. One patient had a serious diagnosis made at a revisit (exacerbation of congestive heart failure; found only at revisit).

Comment

As previously mentioned, to our knowledge our study is the first to examine patients who present to the ED with hypertensive concern. Although it has been shown that many patients with increased blood pressure in the ED are found to have chronic hypertension,⁷ we were surprised to find that more than 80% of patients in our study had hypertension that was already diagnosed. In this situation, physicians should arrange for better blood pressure control through discussion and follow-up with a primary physician. The ED visit may also present an opportunity for physicians to educate patients on their condition²; we have observed that, in an attempt to better manage hypertension, health care professionals sometimes frighten patients into concern over every temporary elevation in blood pressure.

Our primary purpose was to determine whether patients who present to the ED with a chief complaint of elevated blood pressure have serious outcomes. In our study, a low percentage (2.7%) of patients had serious outcomes within 7 days of ED presentation, despite some fairly extensive work-ups. Most serious outcomes were detected during clinical history and examination.

Our study had substantial limitations as a medical record review. The sample size was small, and some serious diagnoses may not have been included in the records. Also, some records indicated that treatment was provided in the ED. This treatment may have prevented some serious outcomes.

The strength of our findings must factor the lack of evaluation for interrater reliability in record abstraction and the choices the investigators made defining symptoms and whether to include or exclude them. For instance, had the 2 patients who complained of shortness of breath (not in the chief complaint) been excluded, the serious outcome percentage (even low as it was) would have been halved. In addition, although we believe the 7-day time frame for serious outcomes was realistic (most patients could schedule a visit with a primary care physician within that time), we made no attempt to independently contact these patients to determine if they had a serious outcome diagnosed after the 7-day period or at a hospital outside of our network. A prospective study would be required to address these concerns.

Future studies should examine if specific ED tests can safely be eliminated for patients with hypertension concern.

Conclusion

In patients who presented to the ED with elevated blood pressure as the chief complaint and with no other serious symptoms, the risk of a serious outcome was low. Future studies should address the usefulness of extensive workups in this patient population.