asymptomatic HTN

[gman33]

What do you do with asymptomatic HTN?

ACEP would tell us to do nothing, but many of us don't.
Especially with the patient sent in for that specific complaint.

I don't work up or do anything with most of these patients, but sometimes the numbers just look bad.
200 systolic or 120 diastolic and I almost feel obligated to check some labs or give a med.

There is no real data showing this is the right thing to do.

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[Zebra Hunter]

I sent someone home with a 230/120 BP yesterday. I would have done nothing had the NP in triage not ordered a host of labs. Since I had the creatinine back, however, I did end up putting him on lisinopril since he was only on norvasc at home.

 

[BoardingDoc]

What do you do with asymptomatic HTN?

ACEP would tell us to do nothing, but many of us don't.
Especially with the patient sent in for that specific complaint.

I don't work up or do anything with most of these patients, but sometimes the numbers just look bad.
200 systolic or 120 diastolic and I almost feel obligated to check some labs or give a med.

There is no real data showing this is the right thing to do.

Not an attending but my current practice (derived from what some of my attendings do) is

If patient came in of own volition --> D/C home. Do nothing.
If sent in by PCP -->
---> A: try to figure out why they were sent, either from callin note or by calling PCP to ask what concern was. If concern = HTN and nothing else, explain that the patient looks great and probably needs tweaking of their meds as an outpatient. Offer to increase their metop from 25 to 50 or whatever before DCing.
---> B: did the patient not take their meds? Give them their meds, recheck BP and D/C home.

 

[goodoldalky]

In the age of web md, yahoo answers, Google, uninformed primary care providers, medico legal liability, and press ganey, it is pretty difficult to do nothing and discharge the patient home. It takes an inordinate amount of time to try and explain yourself to all interested parties, and the public at large/juries typically think there is a causation between severe hypertension and the stroke that happened 2 months later, etc.

I will typically try to lower their BP by no amount in particular with PO meds (usually laying in a bed for 30 minutes does this, not the norvasc or whatever), and barring easy pcp access will check electrolytes and start something out of the hctz/amlodipine/ace classes. This is much more well received by all interested parties despite the lack of strong evidence to suggest it should be done.

 

[canigetawhatwhat]

Do nothing. I may check labs and send them home if they are being stubborn. Call pcp afterwards if they are sent in and be like uhhhh what u want me to do, son?


If they have a headache, i never tell them Htn is causing their headache.
They get tylenol, it comes down due to pain being controlled and they go home

 

[xaelia]

Not obligated to do anything other than is acutely medically indicated.

Whatever service recovery efforts are precisely that.

 

[GeneralVeers]

I give them my canned speech about how blood pressure by itself is not an emergency unless there are symptoms, and in fact ACEP recommends that we do treat it. I further scare them by telling them I can give them a stroke by rapidly lowering their BP.

I discharge all the asymptomatic ones home and have them follow up with PCP. Seriously, home BP cuffs should be outlawed, or prescription only. There is no good reason for the average person to check their BP.

 

[Janders]

Home BP cuffs must be the bane of my existence. I do try to follow the ACEP recs, but I do also try to make the patient happy and encourage their long term health by not just saying "NO EMERGENCY! GTFO!" I find these people come in TWO flavors:

If the patient is the typically very worried elderly person, already on HTN-meds, who is asymptomatic but saw scary numbers like 180/90.
(1) I keep them in a nice dark room and cycle that pressure q 15 minutes and show them how nice and low it gets with no meds [great majority of time they'll drop to SBP 145]
(2)Then, I give them the canned speech about how truly crazy high BP like 300/150 could immediately kill them, but that is almost unheard of, and the real risk is over months-to-years. This combined with the known risk of immediately dropping them means we need to take our time getting it down, and not freak out in the next couple weeks if numbers are high.
(3a) IF I read them as reasonable and agreeable to my plan, I do not do any tests, and discharge them with PCP f/u. And promise I'll send a copy of the note to their PCP (automated by EMR).
(3b) IF I read them as seriously anxious and in need of magical reassurance, I get a BMP (for the Cr) and an EKG just to show we've checked their organs.
(4) If their pressure doesn't magically melt, and is sticking at 199 SBP, I have no issue calling their PCP and up-titrating one med slightly and getting them in to see them within a week. Really minimal effort for a happy patient and PCP.

If, on the other hand, the patient is a young person with seriously high BP who hasn't seen a doctor in many years and suddenly discovered SBP 230, I do try to take them a bit more seriously. These are typically overweight men who also have unknown DM2 and no PCP. So they don't precisely fit the ACEP recommendations as I don't think we really can say they have great outpatient f/u (usually haven't seen a PCP in 5 years if they do have one). As such I try to make everything seem important mostly to scare and educate them into establishing care and following up with a PCP. So:
(1) EKG, bmp
(2) quiet room
(3) If labs benign-ish, and BP still insane-high, start HCTZ or Lisinopril and get them into see a PCP in a week. I have no issue writing for a 7 day supply of these meds. Have the RN give them a pep talk about getting their health in order so we don't see them for something MORE seriously like a stroke at age 40 in a couple years.

These patients do NOT get IV meds; they do NOT get admitted; on the 5% I start or modify a med, I don't keep them around to recheck a BP. The real key is to make sure you don't belittle or ignore their concerns, but instead validate them and teach them the Long-term nature of BP risks, and encourage them to followup closely with their PCP.

In the last 24 hours I had a "HTN emergency" sent in by UC (SBP 150, epistaxis...) and a PCP (asymptomatic 165/100) and had an insurance company request QA on a chart where asymptomatic HTN wasn't aggressively treated [and would have caused a HORRIBLE outcome if the ED MD dropped the BP rapidly in this particular patient!]. Swimming against the tide, we are...

 

[MSUSpartan642]

Had a patient come in today. Completely asymptomatic. 278/145.

Typically I will discharge the "reasonable" htn without symptoms without a work up. But this was just to high for me to be comfortable with.

Labs all turned out normal and PCP wanted to keep him. Not sure I would feel to comfortable d/c'ing someone still at 220/110 after a lil nitro paste anyway.


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[deleted109597]

Had a patient come in today. Completely asymptomatic. 278/145.

Typically I will discharge the "reasonable" htn without symptoms without a work up. But this was just to high for me to be comfortable with.

Labs all turned out normal and PCP wanted to keep him. Not sure I would feel to comfortable d/c'ing someone still at 220/110 after a lil nitro paste anyway.


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Why did you use nitropaste as an antihypertensive?

 

[MSUSpartan642]

Well I gave 10 mg of hydralazine IVP first, shortly after the my attending came in and requested to place nitro paste.

Don't think it was necessary since the guy wasn't have chest pain, but what do I know.


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[name?]

Well I gave 10 mg of hydralazine IVP first

Literally the only times I have witnessed acute strokes due to IV BP control was over-anxious medicine residents getting crazy with hydralazine...after a few hemiparetic patients, I decided that drug was off my list.

 

[canigetawhatwhat]

Literally the only times I have witnessed acute strokes due to IV BP control was over-anxious medicine residents getting crazy with hydralazine...after a few hemiparetic patients, I decided that drug was off my list.

What do you recommend?

IF I lower somebody with iv push meds (usually to make floor nurses happy), I go Labetalol 20 then 40 then hydral 10.
Unless they bradycardic, i use hydral right away.

Help me understand you.

 

[name?]

What do you recommend?

IF I lower somebody with iv push meds (usually to make floor nurses happy), I go Labetalol 20 then 40 then hydral 10.
Unless they bradycardic, i use hydral right away.

Help me understand you.

If someone needs emergent blood pressure control due to hypertensive emergency, I would happily use nicardipine gtt, nitro gtt, nipride gtt, labetalol titrated as per your post above or as a gtt.

All of these are fairly safe and have the added bonus of having a clear end point. I feel like hydralazine is a drug that people give when they feel compelled to do something that usually doesn't need to be done--Don't just do something! Stand there!

If there's no emergency, then PO meds are safer and and have the added benefit of being transferred to outpatient use.

Now, for the NPO patient who needs routine BP control, IV hydralazine is perfectly reasonable in some populations, but is now out of the ED (hopefully) and not my concern.

 

[link2swim06]

Well I gave 10 mg of hydralazine IVP first, shortly after the my attending came in and requested to place nitro paste.

Don't think it was necessary since the guy wasn't have chest pain, but what do I know.


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IV hydralazine is one of the worst medications invented. IF you actually think it is a hypertensive emergency it's not the first line choice. Quite frankly it is given to calm down nursing.

One of two things occur:

You have "corrected" a blood pressure for a few hours that has been abnormal for the past 3,000 days. Good work, that surely made a difference.

-or-

Due to it's variable effect, it drops your patient off the autoregulatory curve and they have a stroke. Again good work.

 

[shookwell]

I usually discharge home without any workup. No labs, no ECG. If they ran out of meds I give them a refill. If they are anxious about how high their BP is and want me to "do something" then I give them an oral dose of whatever medication they are already on.

Using IV medication on a patient with asymptomatic hypertension is a terrible idea.

 

[leviathan]

If asymptomatic then discharge home for the PCP to manage. They know the patient far better than you and have far more time to get them on the right meds. Or refer them to an internal medicine clinic.

 

[engineeredout]

Giving people a one time dose of anti hypertensives ( like when I see clonidine thrown at someone) is stupid. Great - you've proven that with anti hypertensives you can cause blood pressure to lower. Thank you for verifying modern pharmaceuticals.

It's like when I see someone who is in the ER for an ankle sprain, triage RN checks an accu check due to that history of DM, and the BG is 400. Don't worry though, well give 10U of insulin to this asymptomatic diabetic, proving that insulin can cause blood sugar to go down. Call NEJM and get this **** published.

 

[goodoldalky]

Home BP cuffs must be the bane of my existence. I do try to follow the ACEP recs, but I do also try to make the patient happy and encourage their long term health by not just saying "NO EMERGENCY! GTFO!" I find these people come in TWO flavors:

If the patient is the typically very worried elderly person, already on HTN-meds, who is asymptomatic but saw scary numbers like 180/90.
(1) I keep them in a nice dark room and cycle that pressure q 15 minutes and show them how nice and low it gets with no meds [great majority of time they'll drop to SBP 145]
(2)Then, I give them the canned speech about how truly crazy high BP like 300/150 could immediately kill them, but that is almost unheard of, and the real risk is over months-to-years. This combined with the known risk of immediately dropping them means we need to take our time getting it down, and not freak out in the next couple weeks if numbers are high.
(3a) IF I read them as reasonable and agreeable to my plan, I do not do any tests, and discharge them with PCP f/u. And promise I'll send a copy of the note to their PCP (automated by EMR).
(3b) IF I read them as seriously anxious and in need of magical reassurance, I get a BMP (for the Cr) and an EKG just to show we've checked their organs.
(4) If their pressure doesn't magically melt, and is sticking at 199 SBP, I have no issue calling their PCP and up-titrating one med slightly and getting them in to see them within a week. Really minimal effort for a happy patient and PCP.

If, on the other hand, the patient is a young person with seriously high BP who hasn't seen a doctor in many years and suddenly discovered SBP 230, I do try to take them a bit more seriously. These are typically overweight men who also have unknown DM2 and no PCP. So they don't precisely fit the ACEP recommendations as I don't think we really can say they have great outpatient f/u (usually haven't seen a PCP in 5 years if they do have one). As such I try to make everything seem important mostly to scare and educate them into establishing care and following up with a PCP. So:
(1) EKG, bmp
(2) quiet room
(3) If labs benign-ish, and BP still insane-high, start HCTZ or Lisinopril and get them into see a PCP in a week. I have no issue writing for a 7 day supply of these meds. Have the RN give them a pep talk about getting their health in order so we don't see them for something MORE seriously like a stroke at age 40 in a couple years.

These patients do NOT get IV meds; they do NOT get admitted; on the 5% I start or modify a med, I don't keep them around to recheck a BP. The real key is to make sure you don't belittle or ignore their concerns, but instead validate them and teach them the Long-term nature of BP risks, and encourage them to followup closely with their PCP.

In the last 24 hours I had a "HTN emergency" sent in by UC (SBP 150, epistaxis...) and a PCP (asymptomatic 165/100) and had an insurance company request QA on a chart where asymptomatic HTN wasn't aggressively treated [and would have caused a HORRIBLE outcome if the ED MD dropped the BP rapidly in this particular patient!]. Swimming against the tide, we are...

Janders why do you do an ECG if they don't have chest pain? Curious. Seems like you would be explaining away lots of nonspecific t wave inversions in your charts when I would have rather not ordered it to begin with. J/w

 

[deleted109597]

Giving people a one time dose of anti hypertensives ( like when I see clonidine thrown at someone) is stupid. Great - you've proven that with anti hypertensives you can cause blood pressure to lower. Thank you for verifying modern pharmaceuticals.

It's like when I see someone who is in the ER for an ankle sprain, triage RN checks an accu check due to that history of DM, and the BG is 400. Don't worry though, well give 10U of insulin to this asymptomatic diabetic, proving that insulin can cause blood sugar to go down. Call NEJM and get this **** published.

I like to use the "well, if we are just going to make their numbers look better regardless of whether or not it helps the patient, we should probably cut one of their legs off so their discharge weight is closer to normal than their current weight."

 

[GeneralVeers]

Janders why do you do an ECG if they don't have chest pain? Curious. Seems like you would be explaining away lots of nonspecific t wave inversions in your charts when I would have rather not ordered it to begin with. J/w

Exactly. On most of these elderly patients you will find something, even if it's not causing a problem. T-wave inversions, mild hyponatremia, mild CR elevations, etc.

The problem is that there is a wide variation of practice among our colleagues. Probably 70% of the docs at my place will order some form of testing on the asymptomatic hypertensives. At least 50% will treat with hydralazine or clonidine. Nurses then feel this is the standard of care, and start questioning why I'm discharging the patient without any tests or treatment.

 

[Janders]

With our current quality metric of door-to-EKG <7min, the EKG is fait accompli by the time I am involved.

Thank you quality metric land.

 

[Petypet]

Exactly. On most of these elderly patients you will find something, even if it's not causing a problem. T-wave inversions, mild hyponatremia, mild CR elevations, etc.

Once you get some mild abnormality does that equate an admit or still outpatient f/u?

 

[Siggy]

You have "corrected" a blood pressure for a few hours that has been abnormal for the past 3,000 days. Good work, that surely made a difference.

-or-

Due to it's variable effect, it drops your patient off the autoregulatory curve and they have a stroke. Again good work.

Great... now how do I convince my senior medicine residents and the nursing staff that we don't need Hydralazine 5mg IV q 4 PRN SBP >160 on basically every patient?

 

[Siggy]

Nurses then feel this is the standard of care, and start questioning why I'm discharging the patient without any tests or treatment.

...and good luck waving guidelines in people's faces... they don't care. I'm still trying to convince people that we don't have to give pancreatitis with sterile necrosis merrem... per the most recent guidelines... from 2013. People just feel comfortable doing something... even if it's more detrimental than doing nothing.

 

[deleted109597]

...and good luck waving guidelines in people's faces... they don't care. I'm still trying to convince people that we don't have to give pancreatitis with sterile necrosis merrem... per the most recent guidelines... from 2013. People just feel comfortable doing something... even if it's more detrimental than doing nothing.

Come to the land of the unwashed. I have nephrologists demanding bicarb and kayexalate, internists demanding NPO status for pancreatitis, surgeons demanding HIDA scans...

 

[Siggy]

I still have plenty of people demanding kayexalate. At least with the pancreatitis/NPO status, we're doing the, "NPO until the patient wants to eat, then feed them." However I did feel like a rebel on my last one when I went straight to a low fat diet in the mild pancreatitis instead of starting with clears.

Instead I have an attending who thinks that sepsis and a lactate of 6 doesn't meet severe sepsis criteria.

 

[Psai]

With our current quality metric of door-to-EKG <7min, the EKG is fait accompli by the time I am involved.

Thank you quality metric land.

That is a very bizarre metric. Your pay as a physician depends on how quickly the ekg tech can slap some stickers on a patient, whether they need an ekg or not?

 

[Vandalia]

That is a very bizarre metric. Your pay as a physician depends on how quickly the ekg tech can slap some stickers on a patient, whether they need an ekg or not?

Welcome to the real world...

 

[PlutoBoy]

I give them my canned speech about how blood pressure by itself is not an emergency unless there are symptoms, and in fact ACEP recommends that we do treat it. I further scare them by telling them I can give them a stroke by rapidly lowering their BP.

I discharge all the asymptomatic ones home and have them follow up with PCP. Seriously, home BP cuffs should be outlawed, or prescription only. There is no good reason for the average person to check their BP.

lol

 

[gman33]

Ok, now how about asymptomatic hypotension?

In a young health patient, I usually do nothing unless hx suggests otherwise.

Elderly usually get a look for source and at least some fluids.

Recently had a Middle Aged patient with a fall and no injuries. Very obese.
Bp per cuff in 80s
Got some labs and imaging and some fluids.
Signed out to partner awaiting a few things which came back negative.

He put in a cvc, started pressors and admitted to icu.

I think the bp from the cuff was just bogus.

 

[canigetawhatwhat]

Ok, now how about asymptomatic hypotension?

In a young health patient, I usually do nothing unless hx suggests otherwise.

Elderly usually get a look for source and at least some fluids.

Recently had a Middle Aged patient with a fall and no injuries. Very obese.
Bp per cuff in 80s
Got some labs and imaging and some fluids.
Signed out to partner awaiting a few things which came back negative.

He put in a cvc, started pressors and admitted to icu.

I think the bp from the cuff was just bogus.

Most will get a observation stay from me unless there are previous visits with similar bps documented.

 

[shoal]

Most will get a observation stay from me unless there are previous visits with similar bps documented.

agreed. nothing much more omninious than hypotension especially in the elderly. i admit almost all. i remember a medicine resident during second year asking why i was admitting a 86yo F patient for transient hypotension. i explained, they still scouffed. patient codes and dies the next day.

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[PlutoBoy]

Ok, now how about asymptomatic hypotension?

In a young health patient, I usually do nothing unless hx suggests otherwise.

Elderly usually get a look for source and at least some fluids.

Recently had a Middle Aged patient with a fall and no injuries. Very obese.
Bp per cuff in 80s
Got some labs and imaging and some fluids.
Signed out to partner awaiting a few things which came back negative.

He put in a cvc, started pressors and admitted to icu.

I think the bp from the cuff was just bogus.

I would have done the same thing your colleague did. Add abx too if there is the slightest doubt I don't care (unless it is clear cut isolated dehydration). De-escalate later.

To me, SBP in the 80s = No bueno.

 

[PlutoBoy]

Most will get a observation stay from me unless there are previous visits with similar bps documented.

Of course. And rule out adrenal insufficiency while you are at it (if no signs of septic shock).

 

[gro2001]

This is one of those areas where my thinking has drifted away from the typical EM brouhaha. I don't mind treating asymptomatic HTN that has scary high numbers. I will outline some reasons for this.

1) Personal anecdote. I know, worst possible reason perhaps, yet there it is. I saw a patient as a senior resident that was more or less asymptomatic hypertension. Thought it would be a great case for the sub-i to see. Sub-i sees the patient, does a thorough history and exam, I see the patient too, examine the patient (including a full neuro exam), attending sees the patient, also does a full neuro exam. Not just an ER full neuro exam either, but a lets-teach-the-med-students type of exam. We have a great discussion about asymptomatic HTN, and how we shouldn't treat it, more harm then good, etc etc. The patient then immediately proceeds to become altered from the bleed in their brain, intubated, neuro ICU. Now, would treating the asymptomatic HTN sooner prevent the hemorrhagic stroke in this patient? Probably not. But you feel like a schmuck not treating the BP in retrospect.

2) Patient convenience. Not treating asymptomatic HTN is just fine when you can get someone to a PMD relatively quickly. That is not possible for some patients and some departments. For those, I don't see a reason not to start someone on some BP meds. Usually 25 mg HCTZ once daily or 5 mg amlodipine once daily. Chart looks good, patients like it, I feel better, and if they aren't going to see a PMD for weeks, its probably better for them too.

3) Department politics. Given that asymptomatic HTN is a common thing people (PMDs, RNs, patients, etc) expect to be treated, it is often a little bit (or a lot) of a fight not to. This issue is just not important enough for me to fight over and taint my relationship with my RNs, consultants, PMDs or get a lower PG score over. I've said this before, but it bears repeating: you get one issue that you can legitimately make a stand on and be outside the norm of orthodoxy. Any more than that, and you are 'that guy'. We had an attending in residency who made fighting the asymptomatic HTN battle his thing. Wouldn't treat any asymptomatic number at all. Had a spiel and powerpoint presentation ready to go. I appreciate him and my training was better for having seen that way of practicing, but this is not my issue. I want to save my protest for something else. I am also happy to give kayexylate if the nephrologist wants it, platelets for the SAH on 81 mg ASA if the neurosurgeon wants it, NPO for pancreatitis if the hospitalist wants it, MD note for sniffles if the patient wants it, silly general nursing order the RN wants, etc, so that when I do stomp my foot at something, I am more likely to be taken seriously.

 

[GeneralVeers]

This is one of those areas where my thinking has drifted away from the typical EM brouhaha. I don't mind treating asymptomatic HTN that has scary high numbers. I will outline some reasons for this.

1) Personal anecdote. I know, worst possible reason perhaps, yet there it is. I saw a patient as a senior resident that was more or less asymptomatic hypertension. Thought it would be a great case for the sub-i to see. Sub-i sees the patient, does a thorough history and exam, I see the patient too, examine the patient (including a full neuro exam), attending sees the patient, also does a full neuro exam. Not just an ER full neuro exam either, but a lets-teach-the-med-students type of exam. We have a great discussion about asymptomatic HTN, and how we shouldn't treat it, more harm then good, etc etc. The patient then immediately proceeds to become altered from the bleed in their brain, intubated, neuro ICU. Now, would treating the asymptomatic HTN sooner prevent the hemorrhagic stroke in this patient? Probably not. But you feel like a schmuck not treating the BP in retrospect.

2) Patient convenience. Not treating asymptomatic HTN is just fine when you can get someone to a PMD relatively quickly. That is not possible for some patients and some departments. For those, I don't see a reason not to start someone on some BP meds. Usually 25 mg HCTZ once daily or 5 mg amlodipine once daily. Chart looks good, patients like it, I feel better, and if they aren't going to see a PMD for weeks, its probably better for them too.

3) Department politics. Given that asymptomatic HTN is a common thing people (PMDs, RNs, patients, etc) expect to be treated, it is often a little bit (or a lot) of a fight not to. This issue is just not important enough for me to fight over and taint my relationship with my RNs, consultants, PMDs or get a lower PG score over. I've said this before, but it bears repeating: you get one issue that you can legitimately make a stand on and be outside the norm of orthodoxy. Any more than that, and you are 'that guy'. We had an attending in residency who made fighting the asymptomatic HTN battle his thing. Wouldn't treat any asymptomatic number at all. Had a spiel and powerpoint presentation ready to go. I appreciate him and my training was better for having seen that way of practicing, but this is not my issue. I want to save my protest for something else. I am also happy to give kayexylate if the nephrologist wants it, platelets for the SAH on 81 mg ASA if the neurosurgeon wants it, NPO for pancreatitis if the hospitalist wants it, MD note for sniffles if the patient wants it, silly general nursing order the RN wants, etc, so that when I do stomp my foot at something, I am more likely to be taken seriously.

Can't disagree with you more. Asymptomatic hypertension is one of the things where you can cause direct patient harm by treating it. That is why I fight against it. I'm not going to give any treatment which will no benefit the patient but has even a small risk of harm

 

[goodoldalky]

This is one of those areas where my thinking has drifted away from the typical EM brouhaha. I don't mind treating asymptomatic HTN that has scary high numbers. I will outline some reasons for this.

1) Personal anecdote. I know, worst possible reason perhaps, yet there it is. I saw a patient as a senior resident that was more or less asymptomatic hypertension. Thought it would be a great case for the sub-i to see. Sub-i sees the patient, does a thorough history and exam, I see the patient too, examine the patient (including a full neuro exam), attending sees the patient, also does a full neuro exam. Not just an ER full neuro exam either, but a lets-teach-the-med-students type of exam. We have a great discussion about asymptomatic HTN, and how we shouldn't treat it, more harm then good, etc etc. The patient then immediately proceeds to become altered from the bleed in their brain, intubated, neuro ICU. Now, would treating the asymptomatic HTN sooner prevent the hemorrhagic stroke in this patient? Probably not. But you feel like a schmuck not treating the BP in retrospect.

2) Patient convenience. Not treating asymptomatic HTN is just fine when you can get someone to a PMD relatively quickly. That is not possible for some patients and some departments. For those, I don't see a reason not to start someone on some BP meds. Usually 25 mg HCTZ once daily or 5 mg amlodipine once daily. Chart looks good, patients like it, I feel better, and if they aren't going to see a PMD for weeks, its probably better for them too.

3) Department politics. Given that asymptomatic HTN is a common thing people (PMDs, RNs, patients, etc) expect to be treated, it is often a little bit (or a lot) of a fight not to. This issue is just not important enough for me to fight over and taint my relationship with my RNs, consultants, PMDs or get a lower PG score over. I've said this before, but it bears repeating: you get one issue that you can legitimately make a stand on and be outside the norm of orthodoxy. Any more than that, and you are 'that guy'. We had an attending in residency who made fighting the asymptomatic HTN battle his thing. Wouldn't treat any asymptomatic number at all. Had a spiel and powerpoint presentation ready to go. I appreciate him and my training was better for having seen that way of practicing, but this is not my issue. I want to save my protest for something else. I am also happy to give kayexylate if the nephrologist wants it, platelets for the SAH on 81 mg ASA if the neurosurgeon wants it, NPO for pancreatitis if the hospitalist wants it, MD note for sniffles if the patient wants it, silly general nursing order the RN wants, etc, so that when I do stomp my foot at something, I am more likely to be taken seriously.

I will say that I saw a patient once who's only neuro abnormality was a visual field deficit, mild headache, BP 220+. Similar case. I picked the visual fields up after the CT since it was occipital (and large), couldn't believe he otherwise had no focal finding. I wasn't going to order a CT, I think the family gave me hell about it and I caved thank God. Saved my @$$. Most people do not check visual fields but since that case, if I am justifying no CT I will do them every time in a borderline patient.

 

[shookwell]

I agree with most of above about asymptomatic hypotension. Unless it's a young, small person or someone with a history of similar BPs, will probably get some workup. Probably observation if they are old or I'm not sure if there is anything going on.

 

[Janders]

That is a very bizarre metric. Your pay as a physician depends on how quickly the ekg tech can slap some stickers on a patient, whether they need an ekg or not?

Bizarre? Actually its one of the metrics I think makes some sense. What is bizarre is how they've twisted it to reduce payments...
http://www.qualitymeasures.ahrq.gov/content.aspx?id=49597

Its a rather old metric, and the real national standard time is door-to-EKG in 10 minutes or less for patients presenting with chest pain.
A marker of reliable and robust enough staffing and systems to give proper care to potential STEMI patients.
Part of the package of acute MI metrics which encouraged rapid cath lab and development of regional cath lab stat transfer systems. One of the actual successes of quality metrics.

However, yes, some insurance companies have MODIFIED the metric down to less than 7 minutes, and state they'll withhold some payment if you don't meet this quality marker.

Now, you think there is ANY evidence that an EKG at 6 minutes is superior than 9? Of course not. 10 minutes itself is an arbitrary but somewhat palatable number. 6 minutes is starting to get to the point you can barely get the stickers on and the name spelled right and your time is up....

 

[gro2001]

Can't disagree with you more. Asymptomatic hypertension is one of the things where you can cause direct patient harm by treating it. That is why I fight against it. I'm not going to give any treatment which will no benefit the patient but has even a small risk of harm

I think there is asymptomatic HTN and 'asymptomatic HTN'. I am not saying I do this on everyone who technically meets the criteria of HTN who ends up in my ER. Someone coming in with one reading BP of 160/80? Probably not going to treat that. Who knows what their actual BP usually is. They may not even have HTN. Maybe I am going to make they hypotensive with my meds once they get out of the ER and their BP gets back to what it usually runs at. Those are legitimate concerns, and I share them, so I won't treat that guy. But someone coming in with a BP of 220/120 isn't just having a touch of the 'white coat syndrome'. I am not going to aim for anywhere near for normotension with them, but if it's going to take them a few weeks to establish care with a PMD, my 25 mg of HCTZ won't hurt. It's just not going to make them stroke out from hypo-perfusing their brain.

 

[deleted109597]

Everybody remember that we are supposed to document, give guidance, and discharge instructions for anybody with high blood pressures because it's one of the new core measures of the acute no appointment necessary urgency primary care clinic/ER that we run.

 

[VA Hopeful Dr]

I think there is asymptomatic HTN and 'asymptomatic HTN'. I am not saying I do this on everyone who technically meets the criteria of HTN who ends up in my ER. Someone coming in with one reading BP of 160/80? Probably not going to treat that. Who knows what their actual BP usually is. They may not even have HTN. Maybe I am going to make they hypotensive with my meds once they get out of the ER and their BP gets back to what it usually runs at. Those are legitimate concerns, and I share them, so I won't treat that guy. But someone coming in with a BP of 220/120 isn't just having a touch of the 'white coat syndrome'. I am not going to aim for anywhere near for normotension with them, but if it's going to take them a few weeks to establish care with a PMD, my 25 mg of HCTZ won't hurt. It's just not going to make them stroke out from hypo-perfusing their brain.

I said this on another thread, but as a PCP I'd much prefer a CCB over an ACE or diuretic. That way when I get my own BMP I don't have to wonder if that elevated creatinine is from their longstanding HTN or from the ACE.

 

[PlutoBoy]

Can't disagree with you more. Asymptomatic hypertension is one of the things where you can cause direct patient harm by treating it. That is why I fight against it. I'm not going to give any treatment which will no benefit the patient but has even a small risk of harm

Why do you disagree with him? What do you think the internist will do? If you can start amlodipine po and send him home just do it.

Start amlodipine. No risks of electrolyte abnormalities so you don't have to worry about that happening in the near future.

 

[PlutoBoy]

I said this on another thread, but as a PCP I'd much prefer a CCB over an ACE or diuretic. That way when I get my own BMP I don't have to wonder if that elevated creatinine is from their longstanding HTN or from the ACE.

I guess we are in agreement.

 

[GeneralVeers]

I said this on another thread, but as a PCP I'd much prefer a CCB over an ACE or diuretic. That way when I get my own BMP I don't have to wonder if that elevated creatinine is from their longstanding HTN or from the ACE.

I'm not an internist or family practice doctor. I'm not trained in the management of chronic hypertension. If they need a medication started they have to see their PCP. If the internist/hospitalist wants to do it, great! I'm happy to put their special skillset to use.

 

[VA Hopeful Dr]

I'm not an internist or family practice doctor. I'm not trained in the management of chronic hypertension. If they need a medication started they have to see their PCP. If the internist/hospitalist wants to do it, great! I'm happy to put their special skillset to use.

Agreed, but my post was more a request for the ED doctors who do start meds in the ED from the guy who will be seeing these patients in follow up.

 

[gro2001]

Agreed, but my post was more a request for the ED doctors who do start meds in the ED from the guy who will be seeing these patients in follow up.

How often do you see someone with a creatinine bump from 25 mg HCTZ for a few weeks? I am genuinely asking. I thought it wasn't a big deal.

 

[VA Hopeful Dr]

How often do you see someone with a creatinine bump from 25 mg HCTZ for a few weeks? I am genuinely asking. I thought it wasn't a big deal.

Creatinine, maybe never. Electrolyte drop, I'd say about once/month when I ran the Medicaid clinic for the Catholic hospital. Heck, I put my father-in-law in the hospital with a sodium of 115 from HCTZ (Happy Easter!). The creatinine was more for ACE-Is.

 

[PlutoBoy]

How often do you see someone with a creatinine bump from 25 mg HCTZ for a few weeks? I am genuinely asking. I thought it wasn't a big deal.

After you have seen enough cases of thiazide induced hyponatremia you kind of learn to hate the drug.

Also, the antihypertensive effect of most drugs, including HCTZ, is more pronounced in the lower dose range. After a certain dose you end up with little extra antihypertensive effect (act and just add side effects. I pretty much never use HCTZ 25 mg.

This is important because you will be doing much better medicine and being more effective by using two or three drugs at half the maximum dose than one drug at maximum dose or worse, twice the standard dose.

My $0.02.