1. Increased Blood Pressure in the Emergency Department: Pain, Anxiety, or Undiagnosed Hypertension AHRQ Annual Meeting 2008 Paula Tanabe, PhD, MPH, RN Northwestern University, Feinberg School of Medicine Department of Emergency Medicine and the Institute for Healthcare Studies

2. Acknowledgements Funded by the Agency for Healthcare Research and Quality, RO3 -HSO15619-01

3. Background Approximately 29% of adults in the US have HTN 33.5% of these adults are undiagnosed 1,2 HTN leads to cardiac disease, strokes and renal failure 3,4 Adults from low socioeconomic backgrounds and African Americans have a higher morbidity and mortality 5,6 2003 JNC 7 guidelines re-defined hypertension as 2 or more SBP >140 mm Hg or DBP > 90 mm Hg Guidelines advocate improvement in recognition and treatment of HTN 7

4. Emergency Department Opportunity Many patients use the ED as their primary health care provider Other patients with physicians do not routinely visit their physician 2006 American College of Emergency Physicians Clinical Policy recommends: “If BP measurements are persistently elevated with a SBP >140 mm Hg or DBP > 90 mm Hg, the patient should be referred for follow-up of possible HTN and BP management” 8 ACEP policy acknowledges the meaning of elevated ED blood pressures is unclear and often these elevated BPs are attributed to pain or anxiety; data is needed

5. Study Aims 1.Determine proportion of patients with no history of HTN and two ED blood pressure readings >140/90 who have sustained blood pressure elevations measured at home after ED discharge 2.Describe characteristics associated with sustained BP increase 3.Examine the relationship between pain and anxiety and the change in BP after ED discharge

6. Methods Design, Setting  Prospective cohort of ED patients  Large urban, academic medical center with an EM residency program

7. Sample Inclusion Criteria  Initial ED SBP >140 or DBP >90 mm Hg  No history of HTN  Repeat ED SBP >140 or DBP >90 mm Hg

8. Exclusion Criteria  Non-English speaking  Admitted to the hospital  Unable to operate home BP monitor  Pregnant  Medical or psychiatric instability  Inadequate contact information  Discharged with anti-HTN prescription

9. Study Protocol  RAs enrolled subjects Mon.-Thurs. 9A-9P, Fri. and Sat 9A-5P  Brief patient interview  Instructed subjects on use of home BP monitor  Home BP monitor: UA 787EJ Home BP monitor (British Hypertension Society approved) – Monitor stored up to 30 readings  Patients were asked to record home BP twice daily for 1 week

10. Methods of Return Triage desk Post office, postage paid envelope Dominick’s pharmacy

11. Study Variables Sustained blood pressure elevation  Highest and lowest SBP and DBP deleted  Mean monitor SBP and DBP calculated  Classified as sustained elevation if SBP >140 or DBP >90 mm Hg

12. Pain and Anxiety ED Pain score (0-10 verbal descriptor scale) ED Anxiety score –Spielberger State Anxiety Scale –Scoring patient report: 20-80, low to high anxiety

13. Analysis Chi-square and Fisher’s exact test (categorical variables), t test (continuous variables) Standard logistic regression Pearson correlation coefficients to determine the correlations between the –Change from ED to home SBP and DBP with the ED mean pain score and anxiety score –If elevated ED BP is due to pain or anxiety, we anticipated a negative correlation

14. Results  189 subjects enrolled  171 (90%) returned monitor  156/171 (91%) had adequate BP data  Mean (SD) age = 47 (13)  50% Female  35% Black, 60% White, 7 (n) Hispanic

15. Results  54% had sustained HTN  40% prehypertension  6% patients had a “normal” JNC7 BP

16. Prevalence of Home Sustained HTN Based on ED Blood Pressures Home JNC Classification Stage I ED BP No. (%) Stage II ED BP No. (%) Normal (<120, <80) 5(6)6(8) Pre-hypertension (120-139, 80-90) 41(52)24(33) Stage I (140-159, 90-99) 29(36)31(23) Stage II (>160, >100) 5(6)21(28)

17. Demographic Characteristics Sustained HTN N(%) Normal BP N(%) Female52(64)29(36) Male32(43)43(57) Black36(69)16(31) White44(45)53(55)

18. Patient Characteristics Associated with Elevated Home Blood Pressure CharacteristicAdjusted Odds Ratio 95% CI Age / 10 years1.391.03-1.88 Black race vs. white (ref.) 2.501.16-5.40 Female vs. male (ref.) 1.940.95-3.96 ED SBP, (per 10 mm Hg) 1.030.99-1.05

19. Relationship between self-reported anxiety and pain and the difference between patients’ home and ED systolic blood pressure (SBP)

20. Limitations  Single site  English-speaking only patients  Most patients had insurance  Home vs. office BP measurements  We believe our study under-estimates the findings based on these limitations

21. Conclusions  A high proportion of ED patients with elevated BPs were found to have sustained BP elevation at home  ED patients with 2 or more blood pressures > 140/90 should not be assumed to be anxious or in pain and are at risk for undiagnosed HTN

22. Conclusions  The ED is an important setting for identifying patients with undetected HTN  Mechanisms to standardize and automate BP re-assessment orders and prompt discharge instructions are needed  Future research is needed to determine referral mechanisms and brief interventions to motivate patients to follow-up

23. Acknowledgments, Study Team Stephen D. Persell, MD, MPH 2 James G. Adams, MD 1 Jennifer McCormick, BS 1 Zoran Martinovich, PhD 3 David W. Baker, MD, MPH 2 Lori McGee, Steve Gorman and Alexis Bergan-Guzman for their assistance with patient enrollment Northwestern University, Feinberg School of Medicine 1 Emergency Medicine, 2 General Internal Medicine, 3 Psychiatry

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