CLINICAL STUDY

Diagnosis, Treatment, and Referral ofHypertension in an Emergency Department

Tushar Shah, MD; Wilbert S. Aronow, MD; Stephen J. Peterson, MD

The authors prospectively audited 500 randomlyselected charts of patients seen during a 6-monthperiod ending in October 2008, in the emergencydepartment of a university medical center for theprevalence of hypertension and how it wasmanaged. Of the 187 patients with hypertension,14 (8%) were treated for hypertension in theemergency department and 99 (53%) werehospitalized or referred to a physician or clinicfor follow-up of their hypertension. Muchimprovement is needed, especially since many ofthe patients seen in the emergency department donot have a primary care physician. Prev Cardiol.2009;12:173–175. �2009 Wiley Periodicals, Inc.

Hypertension is a major risk factor for coro-nary events,1–6 stroke,1,2,6–9 congestive heart

failure,1,2,10,11 and peripheral arterial disease.12–16

Emergency department physicians have done apoor job in recognizing, treating, and referringpatients with hypertension for follow-up care.17–21

Compounding this problem, many patients seenfor medical care in the emergency department(ED) do not have a primary care physician oraccess to primary care.

In March 2006, the American College of Emer-gency Physicians (ACEP) Clinical Policies Sub-committee recommended that patients withhypertension should be referred for follow-up ofhypertension and treatment.22 The present study isa prospective study performed during April 2008through October 2008 in which 500 randomlyselected charts of patients seen during a 6-month

period in the ED of a university medical centerwere audited to determine the prevalence of hyper-tension, how it was managed, and the prevalence ofreferral for follow-up of their hypertension.

METHODSIn a prospective study, we audited 500 randomlyselected charts of patients seen during a 6-monthperiod (April 2008 through October 2008) in theED of Westchester Medical Center ⁄New York Med-ical College for the prevalence of hypertension andhow it was managed. There were no inclusion orexclusion criteria for selection of these patients.There was no control population involved. Age,sex, race, and blood pressure (BP) of each patienttaken in the ED were recorded. Hypertension wasdiagnosed if systolic BP was �140 mm Hg or dia-stolic BP was �90 mm Hg. The last BP recorded inthe chart prior to treatment was recorded.

In patients with hypertension, a history of hyper-tension, atherosclerotic vascular disease, diabetesmellitus, congestive heart failure, and chronic renaldisease were recorded. Whether hypertension wastreated in the ED, whether the patient was hospital-ized, and whether the patient was referred to a phy-sician or clinic for follow-up of their hypertensionwere also recorded. The physicians and nurses inthe ED were unaware that this study was beingperformed.

This study was approved by the New York Med-ical College institutional review board and by theinstitutional review board of Westchester MedicalCenter. After this study was completed, the investi-gators met with the physician director of the ED todiscuss the results of this study and how they couldbe improved. A follow-up study will be performedto evaluate the success of the measures instituted.

RESULTSThe 500 patients included 260 men and 240women, with a mean age of 53�13 years. Of the500 patients, 260 (52%) were white, 116 (23%)were African American, 101 (20%) were Hispanic,and 23 (5%) were Asian.

BP was not measured in 11 of 500 patients (2%).Of the 489 patients in whom BP was measured, 187

From the Department of Medicine, General Medicineand Cardiology Divisions, New York Medical College,Valhalla, NYAddress for correspondence:Wilbert S. Aronow, MD, Cardiology Division, New YorkMedical College, Macy Pavilion, Room 138, Valhalla,NY 10595E-mail: wsaronow@aol.comManuscript received January 12, 2009;revised February 11, 2009; accepted March 19, 2009

doi: 10.1111/j.1751-7141.2009.00034.x

173FALL 2009 PREVENTIVE CARDIOLOGY

(38%) had hypertension. Systolic and diastolichypertension were present in 103 of 489 patients(21%), isolated systolic hypertension in 81 of 489patients (17%), and isolated diastolic hypertensionin 3 of 489 patients (1%). A history of hyper-tension was present in 103 of 187 patients (55%)with hypertension. Of 187 patients with hyper-tension, 31 (17%) had a history of coronary arterydisease, 43 (23%) had a history of diabetes mell-itus, 16 (9%) had a history of chronic renal dis-ease, and 4 (2%) had a history of congestive heartfailure.

Table I shows the prevalence of different levelsof systolic and diastolic hypertension in the 489patients in whom BP was measured in the ED.

Of the 187 patients with hypertension, 14 (8%)received treatment for hypertension in the ED.Table II shows the prevalence of treatment ofhypertension for different levels of systolic anddiastolic hypertension in the ED.

Table III shows the prevalence of treatment ofhypertension in the ED or hospitalization for differ-ent levels of systolic and diastolic hypertension. Ofthe 187 patients with hypertension, 99 (53%) werehospitalized or referred to a physician or clinic forfollow-up of their hypertension.

DISCUSSIONHypertension should be treated to reduce cardiovas-cular events and mortality.1,23 ED physicians havedone a poor job in recognizing, treating, and refer-ring patients with hypertension for follow-upcare.17–21 In an ED of a tertiary care teaching hospi-tal, 1574 patients had hypertension.17 Of thesepatients, a discharge diagnosis of hypertension wasrecorded in 93 patients (6%), antihypertensive treat-ment was given in the ED to 38 patients (2%), dis-charge instructions for follow-up of BP were givento 82 patients (5%), and a prescription for antihy-pertensive drugs was given to 33 patients (2%).17

Of 137 patients seen in a university ED whoneeded referral for hypertension management, 5(4%) were referred.18 Of 37 patients with hyperten-sion seen in the ED of an academic medical center,27 (73%) did not have their BP rechecked and werenot referred for follow-up of their hypertension.19

Of 269 patients with BP �180 ⁄110 mm Hg seen inthe ED of an academic medical center, 56 patients(21%) received antihypertensive treatment.20

A survey of 306 physicians and nurses in 4 EDsin academic medical centers found that both physi-cians and nurses considered hypertension a low pri-ority.21 On the basis of the available data, theACEP Clinical Policies Subcommittee recommendedin March 2006 that patients with hypertensionshould be referred for follow-up of hypertensionand treatment.22

The present prospective study showed thathypertension was present in 187 of the 489 patients(38%) in whom BP was measured. Of the 187patients with hypertension, 14 (8%) were treatedfor hypertension in the ED and 99 (53%) werehospitalized or referred to a physician or clinic for

Table I. Prevalence of Different Levels of Systolic and

Diastolic Hypertension in 489 Patients in Whom BloodPressure Was Measured in the Emergency Department

Blood Pressure No. (%)

Systolic blood pressure, mm Hg�220 1 (<1)�210 7 (1)

�200 8 (2)�190 9 (2)�180 19 (4)�170 25 (5)

�160 57 (12)�150 94 (19)�140 184 (38)

Diastolic blood pressure, mm Hg�120 3 (1)�110 10 (2)

�100 33 (7)�90 106 (22)

Table II. Prevalence of Treatment of Hypertension for

Different Levels of Systolic and Diastolic Hypertension inthe Emergency Department

Blood Pressure Prevalence (%)

Systolic blood pressure, mm Hg�190 9 ⁄ 9 (100)�180 12 ⁄ 19 (63)

�170 13 ⁄ 25 (52)�160 14 ⁄ 57 (25)

Diastolic blood pressure, mm Hg�120 3 ⁄ 3 (100)

�110 9 ⁄ 10 (90)�100 9 ⁄ 33 (27)

Table III. Prevalence of Treatment of Hypertension in

the Emergency Department or Hospitalization forDifferent Levels of Systolic and Diastolic Hypertension

BLOOD PRESSURE PREVALENCE (%)

Systolic blood pressure, mm Hg�190 9 ⁄ 9 (100)�180 17 ⁄ 19 (90)

�170 22 ⁄ 25 (88)�160 38 ⁄ 57 (67)

Diastolic blood pressure, mm Hg�120 3 ⁄ 3 (100)

�110 10 ⁄ 10 (100)�100 22 ⁄ 33 (6.7)

PREVENTIVE CARDIOLOGY FALL 2009174

follow-up of their hypertension. Although thesedata are better than those reported,17–21 muchimprovement is needed, especially since many ofthe patients seen in the ED do not have a primarycare physician.

The physician director of our ED is very muchinterested in improving the quality of medical careprovided in the ED. He will use their current elec-tronic medical system and enhance this system withan Allscripts program (Chicago, IL) in which abnor-mal BP values will be addressed. Following institu-tion of these measures, we will perform a follow-upprospective study to investigate the managementof hypertension in the ED and the referral ofpatients with hypertension for follow-up of theirhypertension.

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