Asymptomatic HTN

[Mount Asclepius]

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We also haven’t won the battle in what society will pay for us to rule out badness in the worried well. We are forced to see them, but society won’t pay us what they pay for a joint replacement in a 90 year old. Ortho wrote reimbursement and we just clean up the distal radius reduction scraps in between chest pain rule outs and negative abdominal CTs. I agree that we don’t add much value to treating the worried well, but it’s the elephant in the room that eventually is going to need to be addressed. Otherwise we will crank up the pph volume of these patients in order to reach high income physician pay, where as those not in control of their billing will be forced to be high-burnout cogs in the CMG/PE machine.

 

[Porfirio]

We also haven’t won the battle in what society will pay for us to rule out badness in the worried well. We are forced to see them, but society won’t pay us what they pay for a joint replacement in a 90 year old. Ortho wrote reimbursement and we just clean up the distal radius reduction scraps in between chest pain rule outs and negative abdominal CTs. I agree that we don’t add much value to treating the worried well, but it’s the elephant in the room that eventually is going to need to be addressed. Otherwise we will crank up the pph volume of these patients in order to reach high income physician pay, where as those not in control of their billing will be forced to be high-burnout cogs in the CMG/PE machine.

I don’t think society has control of this.

Hospital Admin, Insurance Admin, and CMGs have this control. If you want to add Governmental agencies, them too.

The control we have is only to walk with our feet. The job culture now is to reward those who job hop or are PRN. There is no reason to stay other than the $$$/hr. You have to be willing to walk away.

 

[Mount Asclepius]

I don’t think society has control of this.

Hospital Admin, Insurance Admin, and CMGs have this control. If you want to add Governmental agencies, them too.

The control we have is only to walk with our feet. The job culture now is to reward those who job hop or are PRN. There is no reason to stay other than the $$$/hr. You have to be willing to walk away.

I used the term society loosely, really meaning those in control as you noted.

 

[ShockIndex]

There is now an AHA Scientific Statement AGAINST acutely treating asymptomatic hypertension.

https://www.ahajournals.org/doi/10.1161/HYP.0000000000000238

Thus, there should no need for anyone to educate other physicians. Simply ask for their email, attach this article, and tell them that you are following guidelines from the authoritative professional society on the matter.

 

[JacobMcCandles]

There should only be either hypertensive emergency or asymptomatic hypertension. There's no in between. I'm glad they got rid of the "hypertensive urgency" language but they should go further.

 

[AlmostAnMD]

There should only be either hypertensive emergency or asymptomatic hypertension. There's no in between. I'm glad they got rid of the "hypertensive urgency" language but they should go further.

Could petition AHA to rename hypertensive urgency to vascular fibromyalgia

 

[CopaceticOne]

There is now an AHA Scientific Statement AGAINST acutely treating asymptomatic hypertension.

https://www.ahajournals.org/doi/10.1161/HYP.0000000000000238

Thus, there should no need for anyone to educate other physicians. Simply ask for their email, attach this article, and tell them that you are following guidelines from the authoritative professional society on the matter.

Sincere question - In your opinion(s) if PCP office lab can’t get lab results for a few days because of send out process, would that support sending to higher level of care, a la ED?

 

[Janders]

I’ve become more accommodating with HTN in the ED.

Most people are asymptomatic. Anxious. It doesn’t hurt much to pull and EKG and or BMp

And then talk to them like a human. Explain there are downsides to rapid treatment. The best thing is to see their PCP in a week or two, see if they are riding high, and decide on tx.

Now there is a significant subset when you see them they are 200/100. They’ve been told they have HTN for years. They’ve avoided treatment (usually these are men in their 40s-50s). For some reasons they Checked BP today. Their wife : GF drug them in

I have zero issue starting them on a single agent. But they also most benefit from rapid follow up.

 

[RustedFox]

Sincere question - In your opinion(s) if PCP office lab can’t get lab results for a few days because of send out process, would that support sending to higher level of care, a la ED?

No.
Asymptomatic HTN is asymptomatic HTN.

They -will- tell you that they have some symptom. Ignore that.

 

[CopaceticOne]

No. Asymptomatic HTN is asymptomatic HTN.

They -will- tell you that they have some symptom. Ignore that.

That AHA paper says BMP to assess for end organ dysfunction (kidneys), EKG (heart), fundoscopic exam (retina).

So what you’re saying is don’t follow evidence & recs. Just enjoy the inevitable malpractice suit that will come their way.

Yup, makes sense.

 

[RustedFox]

That AHA paper says BMP to assess for end organ dysfunction (kidneys), EKG (heart), fundoscopic exam (retina).

So what you’re saying is don’t follow evidence & recs. Just enjoy the inevitable malpractice suit that will come their way.

Yup, makes sense.

"I just don't feel right, so I checked my blood pressure and..." is what they typically say. I ignore that nonsense.

 

[CopaceticOne]

"I just don't feel right, so I checked my blood pressure and..." is what they typically say. I ignore that nonsense.

Cool story.

But I’ll just go ahead and disagree with you on this.

 

[TysonCook]

That AHA paper says BMP to assess for end organ dysfunction (kidneys), EKG (heart), fundoscopic exam (retina).

So what you’re saying is don’t follow evidence & recs. Just enjoy the inevitable malpractice suit that will come their way.

Yup, makes sense.

This.
We (as a system) have discussed the cost/benefit ratio for buying every ED a retina scanner so we can go down this road.
Ugh.

Either you're symptomatic, or you're not. The worst offenders by far are the nurse triage lines (that aren't run by a nurse) that tell every patient to go to the ED... then the patient gets pissed that you're not doing anything.

 

[VA Hopeful Dr]

This.
We (as a system) have discussed the cost/benefit ratio for buying every ED a retina scanner so we can go down this road.
Ugh.

Either you're symptomatic, or you're not. The worst offenders by far are the nurse triage lines (that aren't run by a nurse) that tell every patient to go to the ED... then the patient gets pissed that you're not doing anything.

We have those in the office for diabetic eye screenings, totally not needed for the ED but pretty cool nonetheless.

 

[JacobMcCandles]

That AHA paper says BMP to assess for end organ dysfunction (kidneys), EKG (heart), fundoscopic exam (retina).

I propose we have every ophthalmologist buy an EKG machine and POC testing and we just send all these people there.

 

[eyeeye_captain]

I propose we have every ophthalmologist buy an EKG machine and POC testing and we just send all these people there.

 

[CopaceticOne]

I propose we have every ophthalmologist buy an EKG machine and POC testing and we just send all these people there.

I like your thinking. But for real, I can do an EKG & a simple fundoscopic exam. That’s why I asked specifically about labs that won’t come back for a couple of days.

Because at the end of the day, good PCPs keep people out of the ED by properly managing chronic medical issues. It’s the acute ones that may necessitate a more immediate higher level of care.

 

[Brigade4Radiant]

not worth the complaint about not taking their bp seriously and how everyone else lowers their blood pressure

 

[ShockIndex]

Sincere question - In your opinion(s) if PCP office lab can’t get lab results for a few days because of send out process, would that support sending to higher level of care, a la ED?

I think that it is reasonable in certain, rare circumstances, and the PCP's office might be behaving in accordance with both the AHA paper and the spirit of ACEP's own clinical policy on asymptomatic HTN if they had a concern and couldn't get a timely creatinine. That is to say, the ACEP policy notes that in patients with poor follow-up, a screening creatinine might identify patients in need of admission. That is a Level C recommendation but what you describe effectively falls in that category. Asymptomatic Elevated Blood Pressure.

So, if a PCP has a particular concern in an asymptomatic patient such as the trajectory of a patient's BP (ie normally normotensive and now suddenly in the AHA "asymptomatic but markedly elevated" category) I will not fault them for sending the patient to the ED for a renal panel / BMP if it cannot be obtained in a timely (ie 24 hrs) manner in a clinic. I will also not fault any EP who sees that patient and says, "Get the frack outta here - ain't nobody got time for that." That is because it is not my practice to routinely or even occasionally screen an asymptomatic hypertensive; I've perhaps done that on my own conscious volition a couple of times in a 20-year career. Nor do I think that we should be picking up the out-patient's lab slack.

Finally, it's important to note that the AHA paper complements the ACEP policy with respect to not attempting to acutely lower the BP in patients without end organ damage. The AHA paper really doesn't help us with identifying patients who should be screened for organ dysfunction. Better yet, the AHA paper doesn't explicitly tell us NOT to screen asymptomatic patients. There is a tone in this thread that an absence of symptoms is sufficient to rule out hypertensive emergencies and I generally believe this to be correct. However, embedded in both the AHA and ACEP polices is this notion of selective screening certain symptomatic patient populations. This seems to generally center around asymptomatic changes in creatinine that would need treatment. I suspect there is some disagreement on prevalence and risk tolerance on this issue of asymptomatic AKIs among the ED and PCP cohorts, and the various professional guidance seems to allow wiggle room on this question.

 

[CopaceticOne]

I think that it is reasonable in certain, rare circumstances, and the PCP's office might be behaving in accordance with both the AHA paper and the spirit of ACEP's own clinical policy on asymptomatic HTN if they had a concern and couldn't get a timely creatinine. That is to say, the ACEP policy notes that in patients with poor follow-up, a screening creatinine might identify patients in need of admission. That is a Level C recommendation but what you describe effectively falls in that category. Asymptomatic Elevated Blood Pressure.

So, if a PCP has a particular concern in an asymptomatic patient such as the trajectory of a patient's BP (ie normally normotensive and now suddenly in the AHA "asymptomatic but markedly elevated" category) I will not fault them for sending the patient to the ED for a renal panel / BMP if it cannot be obtained in a timely (ie 24 hrs) manner in a clinic. I will also not fault any EP who sees that patient and says, "Get the frack outta here - ain't nobody got time for that." That is because it is not my practice to routinely or even occasionally screen an asymptomatic hypertensive; I've perhaps done that on my own conscious volition a couple of times in a 20-year career. Nor do I think that we should be picking up the out-patient's lab slack.

Finally, it's important to note that the AHA paper complements the ACEP policy with respect to not attempting to acutely lower the BP in patients without end organ damage. The AHA paper really doesn't help us with identifying patients who should be screened for organ dysfunction. Better yet, the AHA paper doesn't explicitly tell us NOT to screen asymptomatic patients. There is a tone in this thread that an absence of symptoms is sufficient to rule out hypertensive emergencies and I generally believe this to be correct. However, embedded in both the AHA and ACEP polices is this notion of selective screening certain symptomatic patient populations. This seems to generally center around asymptomatic changes in creatinine that would need treatment. I suspect there is some disagreement on prevalence and risk tolerance on this issue of asymptomatic AKIs among the ED and PCP cohorts, and the various professional guidance seems to allow wiggle room on this question.

Thank you for your reasoned reply!

 

[RustedFox]

Cool story.

But I’ll just go ahead and disagree with you on this.

A-okay.
If I worked up every hysterical senior, I'd not have the time to do anything else.

 

[VA Hopeful Dr]

I like your thinking. But for real, I can do an EKG & a simple fundoscopic exam. That’s why I asked specifically about labs that won’t come back for a couple of days.

Because at the end of the day, good PCPs keep people out of the ED by properly managing chronic medical issues. It’s the acute ones that may necessitate a more immediate higher level of care.

Do a UA. No blood, no protein, probably fine

 

[CopaceticOne]

Do a UA. No blood, no protein, probably fine

Good call - inexpensive w/ quick in-office result. Reasonable enough for folks who just need to finally start a med.

 

[Arcan57]

Do a UA. No blood, no protein, probably fine

So there's blood and protein, now what? You do a Cr and it's 1.6 with nl lytes and no anion gap. So you... tell the patient to follow up with their PCP. Or maybe admit them to the special "Not a thing" ward where you pile the asymptomatic acute renal failures in with all the asymptomatic R/O DKA patients the clinic sends to us rather than managing their DM.

 

[JacobMcCandles]

Do a UA. No blood, no protein, probably fine

Look at Mr. Showoff who can get a UA within 4 hours in the ED.

 

[CopaceticOne]

So there's blood and protein, now what? You do a Cr and it's 1.6 with nl lytes and no anion gap. So you... tell the patient to follow up with their PCP. Or maybe admit them to the special "Not a thing" ward where you pile the asymptomatic acute renal failures in with all the asymptomatic R/O DKA patients the clinic sends to us rather than managing their DM.

The point @VA Hopeful Dr was making was that we can easily do dipstick UAs in PCP clinic.

The whole point of my question, and subsequent posts, was how to keep patients OUT of the ED while doing the necessary things to evaluate for undifferentiated badness that might require an admission.

 

[thegenius]

No.
Asymptomatic HTN is asymptomatic HTN.

They -will- tell you that they have some symptom. Ignore that.

That's key.

If they look comfortable, there is no medical emergency.

 

[thegenius]

Do a UA. No blood, no protein, probably fine

Even then, I spoke to a Nephrologist once because I had a pt with asymptomatic HTN with one of those two (I can't remember which one), I think it was 1+ protein. Not an issue he said and gave his reason.

 

[RustedFox]

That's key.

If they look comfortable, there is no medical emergency.

This is what the rabbit is missing.

"I felt weiirrd, so I took my blood pressure AND..." (while they're nimbly typing on their phone and eating garbage and fighting with their spouse).

 

[ShockIndex]

The point @VA Hopeful Dr was making was that we can easily do dipstick UAs in PCP clinic.

The whole point of my question, and subsequent posts, was how to keep patients OUT of the ED while doing the necessary things to evaluate for undifferentiated badness that might require an admission.

I’m not sufficiently familiar with the test characteristics of a UA in ruling out an AKI in hypertensive emergencies to use it as a standalone test. That is to say, there is probably a reason why both ACEP and AHA recommend direct measurements of creatinine over a UA in that exceedingly uncommon scenario that you originally proposed.

On the other hand, I do have practical reservations with using a UA over serum creatinine to accomplish your task. First, ED nurses seem extraordinarily afraid of piss. They literally seem to avoid eye contact with it. Typically, that amply filled cup will sit on the counter, filled to the rim with golden goodness, until discharge unless I hound the nurse to put a sticker on it and send it to the lab.

Second, I can’t get a clean catch urine to save my life. Inevitability, the sample is sent with a short-curly floater or a report of “motile sperm” from the patient’s earlier visit to Five Guys (apparently not just a burger joint). So, getting a “normal” UA that saves time on the back end (sorry, can’t help it) seems wishful.

Finally, there is the aspect of collegiality in the highly unusual situation that you proposed. If a PCP takes the time to contact me about their patient for whom they have a particular concern, I’m far more likely to send the requested test than perform an alternative in its stead.

So bottom line, if I’m worried about an AKI then I measure the renal function.

 

[thegenius]

This is what the rabbit is missing.

"I felt weiirrd, so I took my blood pressure AND..." (while they're nimbly typing on their phone and eating garbage and fighting with their spouse).

"I had this funny feeling in my pants"

"so I took my blood pressure"

👀


"When I had a funny feeling in my pants, my GF took care of that."
"I didn't think to check my BP."

 

[RustedFox]

"I had this funny feeling in my pants"

"so I took my blood pressure"

👀


"When I had a funny feeling in my pants, my GF took care of that."
"I didn't think to check my BP."

Like this is 90% of my asymptomatic HTN visits; they're not at all having a medical emergency, but they do have "first world problems."

 

[Mount Asclepius]

Symptoms of Hypertension:
1) Anxiety
2) Headache (it's the egg, not the chicken)
3) General malaise more commonly phrased "I didn't feel right" or "something seemed off"
4) Incarceration
5) My doctor (NP) said I could have a stroke or a heart attack if I didn't come immediately to the ED
6) Dizziness - can be any part of your body that feels dizzy
7) I checked my blood pressure 12 times today and it was really high (was there a symptom? see #1)
8) Anxiety
9) I had a nosebleed after I stuck my finger to the hilt in there and then checked my blood pressure. It was high.
10) I haven't been taking my medication as it didn't make me feel good. My BP was high and my wife wanted me to come in and get checked out.

So... what's symptomatic hypertension? Please don't tell me headache, dizziness, lightheadedness, fatigue, etc. And no, ACS, AHDF, CVA and AKI don't count. Those are end organ damage and diagnoses. What symptom do you get from plain old hypertension? I hate our current nomenclature.

 

[VA Hopeful Dr]

So there's blood and protein, now what? You do a Cr and it's 1.6 with nl lytes and no anion gap. So you... tell the patient to follow up with their PCP. Or maybe admit them to the special "Not a thing" ward where you pile the asymptomatic acute renal failures in with all the asymptomatic R/O DKA patients the clinic sends to us rather than managing their DM.

I am a PCP and that post was in direct response to someone else asking what to do if you're in an outpatient office without a fast turn around time for labs.

 

[TooMuchResearch]

That AHA paper says BMP to assess for end organ dysfunction (kidneys), EKG (heart), fundoscopic exam (retina).

So what you’re saying is don’t follow evidence & recs. Just enjoy the inevitable malpractice suit that will come their way.

Yup, makes sense.

What do I do with ECG findings that show signs of hypertension, a BMP that's a little off, or... actually I don't even remember what I would want to see on fundoscope but I definitely wouldn't be able to see it anyway and don't care as an emergency physician for an asymptomatic chronic medical problem.

 

[CopaceticOne]

What do I do with ECG findings that show signs of hypertension, a BMP that's a little off, or... actually I don't even remember what I would want to see on fundoscope but I definitely wouldn't be able to see it anyway and don't care as an emergency physician for an asymptomatic chronic medical problem.

Cool story

 

[Arcan57]

I am a PCP and that post was in direct response to someone else asking what to do if you're in an outpatient office without a fast turn around time for labs.

Understood, and a UA is not an unreasonable screen for kidney problems. But in the absence of concerning symptoms, I'd argue that you don't need a fast turnaround time on labs. I'd go even farther and say that approaching HTN as "number too high = emergency"actually sabotages the chronic management of HTN. Patients internalize fear over a very high number while also passively receiving the message that 170/90 must be ok because everyone didn't freak out at that number.

To be clear, I'm not saying that you personally do this or are mismanaging your patients' blood pressure. This is just what I've seen from a representative sample of patients sent in to the ED for asymptomatic HTN over the last 20 yrs. And it's compounded by trends in hospital LOS and utilization management. In the day of yore, you could admit a non-compliant HTN patient and they would stay in the hospital until they were titrated to an appropriate, stable BP on oral meds. Now days, hospitals exist to stabilize patients enough that they will likely survive an outpatient course of treatment. And an asymptomatic patient is almost always, by definition, stable.

 

[VA Hopeful Dr]

Understood, and a UA is not an unreasonable screen for kidney problems. But in the absence of concerning symptoms, I'd argue that you don't need a fast turnaround time on labs. I'd go even farther and say that approaching HTN as "number too high = emergency"actually sabotages the chronic management of HTN. Patients internalize fear over a very high number while also passively receiving the message that 170/90 must be ok because everyone didn't freak out at that number.

To be clear, I'm not saying that you personally do this or are mismanaging your patients' blood pressure. This is just what I've seen from a representative sample of patients sent in to the ED for asymptomatic HTN over the last 20 yrs. And it's compounded by trends in hospital LOS and utilization management. In the day of yore, you could admit a non-compliant HTN patient and they would stay in the hospital until they were titrated to an appropriate, stable BP on oral meds. Now days, hospitals exist to stabilize patients enough that they will likely survive an outpatient course of treatment. And an asymptomatic patient is almost always, by definition, stable.

Preaching to the choir, but if you are a PCP who wants to have a reasonable way to prove that a patient's kidneys are not acutely failing this is a quick way to reasonably do so.

I don't do this anymore, but when I first got out of residency this is what I would do.

 

[JacobMcCandles]

I’ve learned that these patients need everything yet also nothing. I think it’s reasonable to check an EKG and BMP in the ED. I also think it’s reasonable to do nothing and give them information for a new PCP.

 

[ShockIndex]

I would not check an ECG in an asymptomatic patient with HTN - no matter the number. This will only lead to diagnostic confusion and more testing. That is because the most common abnormalities in HTN, LVH and strain patterns, are not indicative of acute end organ damage.

 

[RustedFox]

So... what's symptomatic hypertension? Please don't tell me headache, dizziness, lightheadedness, fatigue, etc. And no, ACS, AHDF, CVA and AKI don't count. Those are end organ damage and diagnoses. What symptom do you get from plain old hypertension? I hate our current nomenclature.

In before the rabbit dismisses you with "cool story, thanks".

 

[turkeyjerky]

Does anyone else work in a dept where everything above is the anomaly?

in my dept, these patient seem to always get a full panel of labs, including serial hsTrops, +/- cxr, +/- head CT, and generally a dose or two of po clonidine, IV labetalol or IV hydralazine. Many of these patients have an Rx for prn home clonidine for sbp > 180.

This often leads to repeat visits the next day b/c their bp is “back up” where I have to figure out a way to tactfully explain that my partners are either idiots or doing a bunch of unnecessary things in order to placate them.

 

[ShockIndex]

Does anyone else work in a dept where everything above is the anomaly?

in my dept, these patient seem to always get a full panel of labs, including serial hsTrops, +/- cxr, +/- head CT, and generally a dose or two of po clonidine, IV labetalol or IV hydralazine. Many of these patients have an Rx for prn home clonidine for sbp > 180.

This often leads to repeat visits the next day b/c their bp is “back up” where I have to figure out a way to tactfully explain that my partners are either idiots or doing a bunch of unnecessary things in order to placate them.

The diagnostic shotgun approach started getting out of control back when we began putting providers in triage (roughly 2010ish). This parallels the massive escalation in diagnostics that occurred with other conditions presenting to triage during that era.

On the other hand, I’d say that aggressively treating these numbers has actually pulled back a bit over the past 15-20 years as more of us have come to the understanding that lowering a number without end organ damage is more harmful than beneficial.

What the AHA paper had hoped to accomplish was putting a final nail in the coffin of acutely managing elevated numbers that are not associated with end organ damage. There are still some holdouts largely driven by ancient nursing culture that force our hands. Case in point, we’ve all been told that the floor nurses refuse signout on a patient unless you get the BP below some arbitrary number. This AHA policy paper is finally an authoritative organization calling out such behavior as bad medicine.

 

[Porfirio]

My last shift was seeing 6 out of 8 of my first patients within the first 1.5 hrs of my shift as nothing but primary care complaints or PCP sent them. I didn’t care much because I was paid $400 per hr to see them. Took me 5 mins to see each one, 2 mins to write the note and 2 minutes to say good-bye.

 

[RustedFox]

My last shift was seeing 6 out of 8 of my first patients within the first 1.5 hrs of my shift as nothing but primary care complaints or PCP sent them. I didn’t care much because I was paid $400 per hr to see them. Took me 5 mins to see each one, 2 mins to write the note and 2 minutes to say good-bye.

What did you spend the other minute doing?

 

[TooMuchResearch]

I’ve learned that these patients need everything yet also nothing. I think it’s reasonable to check an EKG and BMP in the ED. I also think it’s reasonable to do nothing and give them information for a new PCP.

What do you do with the ECG when the patient feels fine

 

[TooMuchResearch]

Does anyone else work in a dept where everything above is the anomaly?

in my dept, these patient seem to always get a full panel of labs, including serial hsTrops, +/- cxr, +/- head CT, and generally a dose or two of po clonidine, IV labetalol or IV hydralazine. Many of these patients have an Rx for prn home clonidine for sbp > 180.

This often leads to repeat visits the next day b/c their bp is “back up” where I have to figure out a way to tactfully explain that my partners are either idiots or doing a bunch of unnecessary things in order to placate them.

If I catch these orders from triage in time, I cancel them.

 

[Arcan57]

I would not check an ECG in an asymptomatic patient with HTN - no matter the number. This will only lead to diagnostic confusion and more testing. That is because the most common abnormalities in HTN, LVH and strain patterns, are not indicative of acute end organ damage.

LVH with left axis deviation and poor R wave progression is America's EKG. Neither reassuring nor diagnostic, it is the weak and dizzy of EKGs.

 

[RustedFox]

LVH with left axis deviation and poor R wave progression is America's EKG. Neither reassuring nor diagnostic, it is the weak and dizzy of EKGs.

Genius comment.
Chef's kiss.

 

[JacobMcCandles]

What do you do with the ECG when the patient feels fine

I didn’t say I routinely do a workup on these patients but I understand the docs who do.

But, I will say it’s nice to have a baseline EKG on some of these people because they’ll 100% be back at some point.