Asymptomatic HTN

[thegenius]

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You guys actually bother trying to educate other doctors on why it's pointless to send them in?

One of our PCP's sent in a woman who was ~200/100. No symptoms but apparently there were EKG changes. I looked at them and they were subtle STD or even non-existent. One of those kinds that you can barely see. I tried letting the PCP know there isn't much for us to do, and even said our national guidelines write to not treat and to let outpatient doctors treat. She was an outpatient doctor and sent her in anyway.

I don't even know if it's worth it these days.

 

[Porfirio]

Not worth it. They are coming to me regardless of what I say.

Hopefully, the PCP doesn’t waste more of my time and call ahead of time to tell me the patient is coming in.

 

[Groove]

These don't really bother me anymore. I'm happy to be the last doctor to lay hands on the patient if the PCP is nervous. These are some of the lowest risk patients that we see, are low stress and great job security. I love having a handful of these each shift. So easy.

 

[thegenius]

These don't really bother me anymore. I'm happy to be the last doctor to lay hands on the patient if the PCP is nervous. These are some of the lowest risk patients that we see, are low stress and great job security. I love having a handful of these each shift. So easy.

The issue is not that. Of course these are easy and essentially zero risk.

It's more about how you as the ER doc and the ER is viewed when one of their own MDs send someone to the ED for something - and then it isn't done. Sometimes I write in my note that there is no testing indicated. I write this is ACEP's policy. I even pasted a link from the ACEP clinical guideline in the past. And the outpatient PCP doctor will read that note. I've yet to have an outpatient doctor respond to the hospital or my boss that I'm insensitive and not nice, but I'm sure that's happened to others and will eventually happen to me.

Maybe this brings out a broader thought. When I call consults and they say "do X" or "do nothing" and it's not what I learned, I ask why. It's surprising what I learn and it informs my practice. If I hear it enough, I change my own practice.

Perhaps I'm naive enough to think other doctors might act similarly.

Ultimately the patients lose because they are tossed around from doctor to ER to doctor and wonder why nothing ever happens with their 190/90 BP that obviously needs to come down.

 

[thegenius]

So @Porfirio and @Groove do you just do nothing in most cases and send them off? Or do you get labs and lower the BP? This is not about what's right, what is right is not in dispute. The right thing to do is nothing.

 

[Groove]

So @Porfirio and @Groove do you just do nothing in most cases and send them off? Or do you get labs and lower the BP? This is not about what's right, what is right is not in dispute. The right thing to do is nothing.

It kind of just depends. Asymptomatic Hypertension has often been a pet peeve of mine in our field as it's poorly defined by ACEP and it's generally assumed to adhere to JNC 7 guidelines ~180/110. The problem is there's a real gray zone for these super extreme blood pressures that are technically asymptomatic. 180/110 is one thing but what about 250/130? Both are asymptomatic yet you'd be very challenged to find any cardiologist (hypertension 'expert') that would tell you to send home the 250/130 were you to consult them. Most would tell you to admit even if their specific recommendations aren't necessarily evidence based so there's always with me...the real world difference between following "guidelines" and realizing that there are very clear challenges to optics should a case suffer an unforeseen outcome resulting in suit.

Then you've got the issue of patient satisfaction and nursing police.

For me, I just apply a dose of common sense. If they are eating/drinking/voiding/stooling with no reported reduction in urine output then often I can make an excuse to not even get labs as their is no stigmata or historical feature to suggest "critical metabolic abnormality". Maybe a one time dose of something in the ED. Maybe some PRN clonidine with PRN parameters. Some patients I have a more convicted feeling after some obs that they have legit undiagnosed HTN and are at risk to go for several weeks without being able to follow up with a PCP. I might start them on losartan, chlorthalidone, etc.. Are we obligated to play "PCP" in the ED? Of course not, but the reality is that many of our patients can go weeks or even months without seeing a PCP and I find it kind of fun to fiddle with HTN or DM meds. It has given me something new to learn about after all the EM knowledge base has turned stale a long time ago. I even like reading about all the preventative medicine stuff these days.

Anyway, you are right in the end....we aren't obligated to do anything and certainly have an evidence based leg to stand on so to speak but I think the reality is that most of these cases require a bit more facile.

To answer your question specifically though about management.... Yes, I probably treat more of my "asymptomatic hypertensive urgencies" in the ER than ones that I don't assuming their blood pressure is really elevated. I sleep better, worry less about them, have better job security because I'm not generating patient or nursing complaints. Do I worry about other EM docs shaking their head and calling me weak for caving in to patient/nursing/hospital expectations or not following ACEP guidelines to the letter? Not really. Not anymore.

 

[Mount Asclepius]

I’ve occasionally wondered if general health, medical care as a field, and the financial cost to society with measuring blood pressures hyper focusing on both high and low readings, we’d be just as well off if we never checked blood pressure at all or even knew what blood pressure as a concept was. Pain scores as a fifth vital sign were just slightly worse than blood pressure as a fourth vital sign.

 

[Mount Asclepius]

I typically treat their headache. Surprisingly their blood pressure improves and they are happy with the value perfectly okay with discharge. It doesn't even require the chicken or the egg fight. Headache better, blood pressure better, patient satisfied, physician satisfied.

 

[watermanMD]

I typically treat their headache. Surprisingly their blood pressure improves and they are happy with the value perfectly okay with discharge. It doesn't even require the chicken or the egg fight. Headache better, blood pressure better, patient satisfied, physician satisfied.

Yep. I’ve started giving 1g MgSO4 lately, too, which seems to help with HA and BP

 

[Porfirio]

So @Porfirio and @Groove do you just do nothing in most cases and send them off? Or do you get labs and lower the BP? This is not about what's right, what is right is not in dispute. The right thing to do is nothing.

I live in CMG/Corp medicine hellscape. I make it the patient’s choice. Some patients do not listen, but they never complain.

 

[Interpolfanclub]

I typically treat their headache. Surprisingly their blood pressure improves and they are happy with the value perfectly okay with discharge. It doesn't even require the chicken or the egg fight. Headache better, blood pressure better, patient satisfied, physician satisfied.

I do this all the time. I also practice in the South and EVERYONE thinks their HA is from their pressure. It's difficult to convince the otherwise because it's really a cultural thing. But I try and explain their BP going up is probably a response to their HA and not the other way around. Meds, labs, reassurance, maybe an rx for something, next.