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.

 

[JacobMcCandles]

There’s basically no way you can educate another physician (or NP/PA) without them taking it personal or, as the kids would say, as a microaggression. You’ll then get a nasty gram saying that you’re unprofessional.

 

[thegenius]

There’s basically no way you can educate another physician (or NP/PA) without them taking it personal or, as the kids would say, as a microaggression. You’ll then get a nasty gram saying that you’re unprofessional.

This makes sense.


What also makes sense is there are doctors out there that still want to learn, and they have already learned that asymptomatic HTN doesn't go to the ER. We don't interact with them because they don't send them in. So perhaps we just deal with a subset of docs who send these to the ER no matter what.

 

[RustedFox]

There's no winning this battle.
Just give a dose of whatever and discharge.

Yeah. I know.

 

[southerndoc]

I just say "thank you for the RVUs" and do what the PCP should have done.

 

[hoot504]

but apparently there were EKG changes.

Whenever I hear this (usually sent from PCP or UC) I know already the EKG is completely normal.

 

[Jabbed]

I had a patient recently that was sent by their PCP for the second time in a week. Of all things, they were only on TID labetalol.

Quack.

 

[Apollyon]

I had a patient recently that was sent by their PCP for the second time in a week. Of all things, they were only on TID labetalol.

Quack.

Better than HCTZ! At least labetalol is for HTN.

 

[AlmostAnMD]

I once had a patient that was sent by pcp for him

I left a rational note about it, encouraged him to take his BP tid and log it to show a trend, talked about his normal ekg and labs, review with his pcp, discuss return precautions, etc.

I randomly checked his chart a few weeks later (habit) and when he went back to his pcp there was a quote that was something like "sent to ed and ED DOC DID NOTHING. "

Looool

Don't miss that at all

While we're on the subject of referrals had another one that pcp sent for diarrhea. I discharged and saw later in the day he direct admitted the patient (why didn't you do that earlier??) Who spent 2 days in this hosptial with a gi consult and left with the same immodium I prescribed. **** like this drove me insane

 

[VA Hopeful Dr]

Better than HCTZ! At least labetalol is for HTN.

I'm confused here

 

[JacobMcCandles]

Whenever I hear this (usually sent from PCP or UC) I know already the EKG is completely normal.

But the computer read…

 

[WhatJobDoIPick]

I mostly do what y'all do above.

Usually check labs despite ACEP guidance to show I "care."

If an uncomplicated person with normal labs with a ridiculous blood pressure comes in who is not on meds, I will start 25 mg Losartan qd.

I'll take the easy RVUs and move on.

I feel bad for the patient who is stuck with an ER bill because their PCP is an idiot.

 

[sloh]

I once had a patient that was sent by pcp for him

I left a rational note about it, encouraged him to take his BP tid and log it to show a trend, talked about his normal ekg and labs, review with his pcp, discuss return precautions, etc.

I randomly checked his chart a few weeks later (habit) and when he went back to his pcp there was a quote that was something like "sent to ed and ED DOC DID NOTHING. "

Looool

Don't miss that at all

While we're on the subject of referrals had another one that pcp sent for diarrhea. I discharged and saw later in the day he direct admitted the patient (why didn't you do that earlier??) Who spent 2 days in this hosptial with a gi consult and left with the same immodium I prescribed. **** like this drove me insane

The important question is did GI capitalize on this opportunity to scope the patient?!

 

[Birdstrike]

In these instances you’re not treating blood pressure, but anxiety.

 

[Apollyon]

I'm confused here

HCTZ is a diuretic used for nearly homeopathic reasons to "do something" for HTN. Labetalol is an antihypertensive, so, differentially more than nothing or homeopathic.

 

[WhatJobDoIPick]

HCTZ is a diuretic used for nearly homeopathic reasons to "do something" for HTN. Labetalol is an antihypertensive, so, differentially more than nothing or homeopathic.

Ummm. K.

 

[Apollyon]

Ummm. K.

Maybe I'm just showing my age. I don't know what you use now to "to do something" when not really doing something.

 

[CopaceticOne]

Maybe I'm just showing my age. I don't know what you use now to "to do something" when not really doing something.

Yes you are. HCTZ and other thiazide diuretics are first line drugs for HTN.

Antihypertensive Medications - StatPearls - NCBI Bookshelf

 

[BoardingDoc]

Yes you are. HCTZ and other thiazide diuretics are first line drugs for HTN.

Antihypertensive Medications - StatPearls - NCBI Bookshelf

While I agree that hctz has its purpose (and it's certainly classified as an antihypertensive) you might want to pick a study that doesn't specifically recommend against using hctz. There's plenty of data out there showing that it seems to work as well as similar meds like chlorthalidone but with fewer side effects.

https://www.nejm.org/doi/full/10.1056/NEJMoa2212270?utm_source=openevidence

 

[CopaceticOne]

While I agree that hctz has its purpose (and it's certainly classified as an antihypertensive) you might want to pick a study that doesn't specifically recommend against using hctz. There's plenty of data out there showing that it seems to work as well as similar meds like chlorthalidone but with fewer side effects.

https://www.nejm.org/doi/full/10.1056/NEJMoa2212270?utm_source=openevidence

It isn’t the med I go to, but it is a first line which was the point I was making. For some people thiazides do work well.

Personally, I don’t start people on HCTZ as a first choice - my go-tos are ACEi/ARB vs CCB.

Beta blockers are not a 1st line med.

 

[JacobMcCandles]

I typically stick with UpToDate with regard to starting blood pressure meds when I start them.

 

[dj-Roomba]

Amlodipine is a very safe choice to start with

 

[trackrunner321]

If asymptomatic, my cut-off is 220/120. If less than this, discharge home.

 

[TooMuchResearch]

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.

Health system most of our EDs are in did outpatient system education for this before covid. I think the training is wearing off. All transfers to the ED are inevitable for one of many reasons, so I don't usually get in the way.

 

[TooMuchResearch]

Amlodipine is a very safe choice to start with

This is what I generally do.

They attempted to give us some education on first line outpatient BP meds to start and the response was: We're emergency physicians ffs.

 

[Groove]

Amlodipine is a very safe choice to start with

Terrible noncompliance in females. They notice the ankle edema immediately, stop taking it and feel guilty so they never tell you they stopped taking it.

 

[bravotwozero]

Yeah it's either ankle edema, possible angio edema from ace, vs patient peeing all the time and dropping his K from diuretics, take your pick. Womenfolk not liking their cankles is the least of my worries.

 

[Porfirio]

Amlodipine is a very safe choice to start with

5mg here.

 

[dj-Roomba]

5mg here.

Less likely to develop LE edema with 5 mg. As an FM fresh out of residency I won't send asymptomatic HTN to the ED. But triage RN or MA most definitely will.

 

[WhatJobDoIPick]

Any "referral" to the ED should require a conversation with an attending physician (medical director of urgent care, supervising physician of whatever noctor is messing around in clinic,.etc etc). I don't care if it's 3am. The "triage" RN should have to wake up the attending of whatever office it is to get approval to send to the ED. I'm awake, so you should be too. This conversation should be documented and scrutinized by payors eyc such that if it is determined that the "referral" was for nonsense, the "referring" source eats the cost of the ED visit.

 

[Porfirio]

Any "referral" to the ED should require a conversation with an attending physician (medical director of urgent care, supervising physician of whatever noctor is messing around in clinic,.etc etc). I don't care if it's 3am. The "triage" RN should have to wake up the attending of whatever office it is to get approval to send to the ED. I'm awake, so you should be too. This conversation should be documented and scrutinized by payors eyc such that if it is determined that the "referral" was for nonsense, the "referring" source eats the cost of the ED visit.

Yeah, I would rather see the patient. The medmal nightmare from this would be horrible.

 

[WhatJobDoIPick]

Yeah, I would rather see the patient. The medmal nightmare from this would be horrible.

How would this expose you to any med mal risk? No patient encounter = no relationship to patient

 

[TooMuchResearch]

How would this expose you to any med mal risk? No patient encounter = no relationship to patient

You gave medical advice? You have liability.

 

[BoardingDoc]

How would this expose you to any med mal risk? No patient encounter = no relationship to patient

"Patient presented to clinic with <xxx>. I recommended that they be evaluated in the emergency department. I subsequently spoke with Dr. @WhatJobDoIPick over the phone. He informed me that the patient did NOT need to be evaluated in the ER. Based on this discussion, I discharged the patient home in accordance with the recommendations of Dr. @WhatJobDoIPick "

The patient subsequently goes home and dies because Jenny McJennyson wanted to send you the patient for the mild cellulitis of their left arm. They forgot to mention that they also got an EKG on the patient which showed a massive STEMI. Or the patient was obviously having a stroke and the NP simply didn't catch it and was focused on something completely different (literally happened to me my 1st year as an attending working fast track BTW).

The court sees the NP documentation and the dead patient. Would you like to pay by check or by card?

As to the obvious scenario where you also document the conversation and what was discussed: if you're doing that anyway, see the damn patient and get paid for it.

 

[WhatJobDoIPick]

"Patient presented to clinic with <xxx>. I recommended that they be evaluated in the emergency department. I subsequently spoke with Dr. @WhatJobDoIPick over the phone. He informed me that the patient did NOT need to be evaluated in the ER. Based on this discussion, I discharged the patient home in accordance with the recommendations of Dr. @WhatJobDoIPick "

The patient subsequently goes home and dies because Jenny McJennyson wanted to send you the patient for the mild cellulitis of their left arm. They forgot to mention that they also got an EKG on the patient which showed a massive STEMI. Or the patient was obviously having a stroke and the NP simply didn't catch it and was focused on something completely different (literally happened to me my 1st year as an attending working fast track BTW).

The court sees the NP documentation and the dead patient. Would you like to pay by check or by card?

As to the obvious scenario where you also document the conversation and what was discussed: if you're doing that anyway, see the damn patient and get paid for it.

That's not what I was saying.

I'm saying the noctor / nurse / MA needs to wake up whatever attending that is responsible for them and have them agree that patient needs to be sent to the ED. And then, if an EP designates that the visit was for BS, they eat the cost.