Implementation of a clinical pathway for the evaluation of asymptomatic hypertension in the emergency department

Introduction

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.

Methods

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.

Results

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.

Conclusion

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.