Most people who go through an emergency
department have their blood pressure taken. Of course,
what the ED physician fears most is unusually low blood
pressure, but what the readings actually show far more
often is unusually high blood pressure. Nine times out
of 10, this is dismissed and forgotten, either because
it's attributed to the pain and shock of their injury,
or is blamed on the stressful environment of the ED,
or is just not considered an emergency physician's problem.
It should be an emergency physician's
problem, argues an article in the Annals of Emergency
Medicine, because the idea that these patients'
blood pressure falls after they leave the ED is largely
a myth. Too many patients are being sent home with what
may well be an ignored and forgotten diagnosis of a
serious health problem.
MY
BP STORY
Your correspondent has seen this phenomenon, when I
checked into the emergency department after getting
a nasty elbow to the throat in a soccer match. I can't
remember what the reading was, but it was definitely
well above 150 mmHg systolic. I hadn't had my blood
pressure taken in years, and pointed to the dial with
raised eyebrows meant to signal my alarm (my voice was
gone). The nurse reassured me, saying something along
the lines of: "Don't worry, it's just the injury that
makes it shoot up temporarily."
Thus reassured, and armed with
an excuse to do nothing about it, I never followed it
up. I was sent upstairs to intensive care for two days,
where they obviously tracked my blood pressure. When
I thought about it later, I decided the reading must
have dropped, or they would have said something. Now,
having read this study, I'm not so sure. What is certain
is that the ED never tried to follow it up. In fact,
they actively told me to forget it.
HELP
OPPORTUNITY
This is the kind of scenario that bothers Paula Tanabe
and her co-authors, who followed up patients discharged
from a Chicago ED, without any hypertension treatment
or advice, following a reading in the ED over 140/90
mmHg systolic/diastolic blood pressure, the standard
threshold for stage I hypertension.
The patients were given home blood
pressure monitors, and took multiple readings over a
week. The team found that 51% of them still had hypertension
according to their average home readings, and most of
the rest had prehypertension. Those who had scored high
on validated measures of pain or stress in the ED saw
no greater drop at home than the others.
The average drop in pressure from
ED to home was 19.5 mmHg systolic, and a paltry 3.5
mmHg diastolic. This is even less than it seems, because
we already know that home readings are usually lower.
If these patients had been called back to the ED for
re-measurement, it's likely that even more than 51%
would have had scores over 140/90 mmHg.
Since many patients have little
interaction with healthcare outside of the ED setting,
this is an ideal opportunity for a public health intervention
to catch the undiagnosed hypertensives, the authors
argue.
They aren't the first to do so,
but with EDs seemingly getting busier every day, there
is resistance, or at least inertia, that has long held
this idea back. There shouldn't be - giving information
or referrals to those who score hypertensive in ED is
really an administrative task that needn't consume the
time of clinical staff.
Yes, the ED is a busy place where
chaos reigns and crisis is never far away. It's true
that the patient's immediate needs can seem a lot more
pressing. But if we take a step back and consider, very
few of these patients are likely to die from their emergency.
About half of them are likely to die from cardiovascular
disease. So which is the real emergency?
For more on hypertension, see
"Edging
closer to a hypertension vaccine".
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