Clonidine...

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DrQuinn

DrQuinn

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any of you guys using clonidine?

I am giving a lecture in a few days on "Hypertension in the ED." Not the boring stuff about hypertensive emergencies (those are too easy) but about the whole "urgency" myth, what to use, is it ok to send pts home on scripts, etc etc... more of a "real world" lecture than straight didactics. Anyways, ther'es not much in the literature about clonidine use (except for the rebound htn from withdrawal). Wondering when you guys use this and in what situations. I tend to obviously give it during withdrawal of clonidine (as well as opioids), and and used to slap on a catapress and send them out with scripts for their old stuff if they were noncompliant with BP meds....

yes, I know the literature doesn't support acutely lowering of BP in acute hypertensive episodes... but I just love sending patients out on patches (same with fentanyl patch).

Q
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are you going to discuss management of clonidine o.d.?
apparently there are anecdotal reports of narcan being of some benefit in pediatric clonidine o.d.
I tend to use the clonidine patches mostly for opiate withdrawl.
rumor has it that clonidine tabs actually have street value.....
 
emedpa said:
are you going to discuss management of clonidine o.d.?
apparently there are anecdotal reports of narcan being of some benefit in pediatric clonidine o.d.
I tend to use the clonidine patches mostly for opiate withdrawl.
rumor has it that clonidine tabs actually have street value.....
Click to expand...

It's no rumor - well known. One of our cards guys was a resident at Hopkins, and he said they NEVER EVER wrote for clonidine pills - the patch only - since the pills could be sold for $5/each to the opiate addicts that didn't have the money for a hit at the time. The clonidine takes the edge off the jones until they can beg/borrow/steal the money for the next shot.

Now, though, clonidine patches are being steeped into a tea for consumption (I had asked a few years back, in jest, if people were eating the patches).
 
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Apollyon said:
It's no rumor - well known. One of our cards guys was a resident at Hopkins, and he said they NEVER EVER wrote for clonidine pills - the patch only - since the pills could be sold for $5/each to the opiate addicts that didn't have the money for a hit at the time. The clonidine takes the edge off the jones until they can beg/borrow/steal the money for the next shot.

Now, though, clonidine patches are being steeped into a tea for consumption (I had asked a few years back, in jest, if people were eating the patches).
Click to expand...

I have heard junkies will go through the trash outside of cancer centers for used fentanyl patches. same deal.
 
emedpa said:
I have heard junkies will go through the trash outside of cancer centers for used fentanyl patches. same deal.
Click to expand...

Lovely. There should be a national push to put the patches on the groin for "better accessibility" or some other dumb reason, just for the "serves you right" justification for those that would steal the used patches.
 
Apollyon said:
It's no rumor - well known. One of our cards guys was a resident at Hopkins, and he said they NEVER EVER wrote for clonidine pills - the patch only - since the pills could be sold for $5/each to the opiate addicts that didn't have the money for a hit at the time. The clonidine takes the edge off the jones until they can beg/borrow/steal the money for the next shot.

Now, though, clonidine patches are being steeped into a tea for consumption (I had asked a few years back, in jest, if people were eating the patches).
Click to expand...

I don't consider myself a touchy, feely guy, but when we refuse to write for clonidine because it has a street value because it makes the withdrawl suck less ....


(I write for it.) The thing the addicts beg more for here is buprenex, which I don't give in the ED.

Around here, they will chew on the fentanyl patches like gum or soak them. I don't write for those, ever.

mike
 
Hmm. I have never written for Fentanyl patches (never will unless its a known cancer patient on Hospice or such). But I will put ONE on the patient, the 25 or 50 mcg/hr, and kick them out the door, with no other scripts besides Motrin/Flexeril....

Q
 
Yeah we use clonidine, 0.1 Q 1 hour for HTN if I'm going to be waiting for BMP UA anyway. Lots of times I just give labetalol or hydralazine. At our community place lots of the attendins want you to give them something PO if you're going to send them home "because if you give them something IV that means you thought they were sick." Fortunately that is not the prevailing opinion here.
 
Are you giving people clonidine for asymptomatic HTN that you happen to catch in the ED or am I missing something?

I just had it beat into my head last year on my EM rotations that treating asymptomatic HTN was not beneficial over doing nothing and having them follow-up.

So, is it still routine practice to give them something anyway? Seriously, I'm just curious. since I"m about to start residency i'd like the discussion of reality versus recommendations.

thanks all

later
 
i do absolutely nothing, and have them follow-up in an outpatient setting within the week. i haven't found any data to support lowering blood pressure acutely in asymptomatic hypertension. i dont even give them a script.

i did a journal club on this topic in february and even most attendings were surprised at the lack of data on treating vs not treating asymptomatic hypertension. it changed a lot of anecdotal practices here, and most people now do nothing. the few others will give clonidine in the ED because it bothers them to know their pts BP is so high, but nothing supports this practice. and no data suggests that patients treated in the ED do better than those with close follow-up.

if you find anything different in your search, pass it on.
 
sweet is right, there is no data for acutely lowering asymptomatic BP in the ED. Urgency is a little different, in BP should be lowered in 24 hours... and emergencies are easy to handle....

One thing I did find surprising upon my review, is that for hypertensive encephalopathy, a lot of hte newer articles and opinions are that we should NOT be using nitrates, especially nipride. Tintinalli says Nitroprusside is the treatment of choice. Very interesting!

I have a feeling that is stemming from the new expensive anti-BP IV meds that are there, but we'll probably never know.

Q
 
This is mostly for hypertensive "urgency" e.g. headache, no other findings or PCP referred HTN without symptoms. Someone should forward them the info that lowering BP in assymptomatic HTN isn't helpful!
 
DrQuinn said:
sweet is right, there is no data for acutely lowering asymptomatic BP in the ED. Urgency is a little different, in BP should be lowered in 24 hours... and emergencies are easy to handle....

One thing I did find surprising upon my review, is that for hypertensive encephalopathy, a lot of hte newer articles and opinions are that we should NOT be using nitrates, especially nipride. Tintinalli says Nitroprusside is the treatment of choice. Very interesting!

I have a feeling that is stemming from the new expensive anti-BP IV meds that are there, but we'll probably never know.

Q
Click to expand...

So what do you do when you get your decently hypertensive but asymptomatic psych pt that needs to be placed? That's when a dose of clonidine might be nice because sometimes we have the psychiatrists pretending their doctors. Otherwise, I rarely use clonidine. It's a bad OD and it causes bad rebound.... it's horrible for noncompliant (ie, ED) patients.

mike
 
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Why are you treating assymptomatic HTN?

Sure, if they're coming in for chest pain, HTN urgency/emergency, CVA or CHF, then you treat BP. Otherwise, treat pain and leave it alone. No evidence that says acute treatment of assymptomatic HTN is useful, and it's a pain in the butt.

When the medicine docs ask: What did you give for BP 200/100 with a chief complaint of abdominal pain? You say: Morphine.

I find that clonidine is helpful for hypertensive urgency. However, I've gotten lazy and I will give the same patients IV labetolol because it has such a reliable effect (and I admit all hypertensive urgencies. Call me conservative).

I've started using Labetolol and Hydralazine as my drugs of choice for HTN Emergencies. I hate drips for high BP (love 'em for low BP) - uses up a lot of nursing effort to get the pumps, and I find that every time I walk into the room I have to titrate. I do use double concentrated Nitro for CHF as first line because of the vasodilator effects.

I don't know about the rest of you, but I have never had a patient who I would describe as having hypertensive encephelopathy. Lots of bleeds, lots of strokes, lots of CP/CHF, never anyone who was truly altered from BP without focal neuro deficits or a bleed.
 
beyond all hope said:
Why are you treating assymptomatic HTN?

Sure, if they're coming in for chest pain, HTN urgency/emergency, CVA or CHF, then you treat BP. Otherwise, treat pain and leave it alone. No evidence that says acute treatment of assymptomatic HTN is useful, and it's a pain in the butt.

When the medicine docs ask: What did you give for BP 200/100 with a chief complaint of abdominal pain? You say: Morphine.

I find that clonidine is helpful for hypertensive urgency. However, I've gotten lazy and I will give the same patients IV labetolol because it has such a reliable effect (and I admit all hypertensive urgencies. Call me conservative).

I've started using Labetolol and Hydralazine as my drugs of choice for HTN Emergencies. I hate drips for high BP (love 'em for low BP) - uses up a lot of nursing effort to get the pumps, and I find that every time I walk into the room I have to titrate. I do use double concentrated Nitro for CHF as first line because of the vasodilator effects.

I don't know about the rest of you, but I have never had a patient who I would describe as having hypertensive encephelopathy. Lots of bleeds, lots of strokes, lots of CP/CHF, never anyone who was truly altered from BP without focal neuro deficits or a bleed.
Click to expand...

Had one on one of my audition EM rotations last year.

Guy presented with BP like 260/150 and was completely obtunded and answering inappropriately.

Negative head CT, no stroke, no bleed, no neuro deficits (other than LOC was gorked).

So, I guess I"m just lucky or am a poopoo magnet.

The ICU guys labelled him htn encephalopathy.

later
 
Yeah, I've only had one true case of hypertensive encephalopathy. 40 year old dude, very poor historian, came with with 230s/110's. Couldn't tell me what was wrong, just saying "I feel like crap, I hurt all over." Couldnt' narrow it down at all... used Esmolol and brought him down a bit, he cleared up and felt normal again... admitted him to the unit. Never did check his d/c summary...

Q
 
Before you go treating asymptomatic BP's that are below 220/110 you should realize that doing so is more likely to cause stroke than it is likely to reduce 30 day mortality. Sorry I don't have the citation available, but I heard in a very good ED conference lecture over a year ago. The facts stuck, but the specific study seems to have escaped my memory and I'm too lazy to find it now. As you probably know already, the reason that treating HTN acutely can cause a stroke is that autoregulation of cerebral blood flow adjusts in chronic hypertensives so that a higher mean arterial pressure is necessary to maintain cerebral perfusion pressure. When an EMP gets scared by the headache that would have responded to tylenol in the guy with a bp of 192/95 and tries to "normalize" his pressure the patient's MAP can fall off the low end of the CPP curve and next thing you know you're repeating someone's CT of the head...
 
Now, giving a chronic hypertensive a script and a single dose of his or her antihypertensive that he or she hasn't been taking, or hoping that pain treatment will be followed by a better BP are different stories all together.
 
agree with all of the above. we have some attendings that swear for the 220/110 but will go home set if you want to do something SL captopril is the way to go (now if you end up admitting and fiberoptically intubating for angioedma that's just extra procedures for you! 🙂 ) but they really hate captopril in this situation since it can be unpredictable and potentially could bottom someone out. I rarely treat these people...but i do have a hard time ignoring the asymptomatic DBP of 130 I see about once a month!
 
docB said:
Somebody (said the lazy guy meaning somebody other than me) ought to pull some of the relevent articles and put them in the journal club section.
Click to expand...
Semi-lazy guy (me) just did an hour lecture on hypertension in the ED. Basically, there has never been ANY studies on hypertensive urgency and the ED (although I think in the next few years it will change). There was one article last month in Annals about how often EM trained physicians do the "recommended" workup for acute hypertensive episode/hypertensive urgency:
Fundoscopy, BMP, UA, EKG, CXR...

It ended up being 6%.

Regardless, there are anecdotal reports of morbidity from acutely lowering BP in the ED in asymptomatic patients.

This topic has always interested me, so every time there is a lecture on "hypertension" at an EM convention, I go to it. I have been to three in the past two years. The concensus is:

National Speaker #1: Don't treat it acutely in the ED, but go ahead and give them a script to go home with, close follow up.

National Speaker #2: You can treat it if you want, but it is safe to D/C the patient from the ED hypertensive.

National Speaker #3: Don't treat it. Just document.

So, there is no concensus.

Q
 
Quinns right that there are no clinical trials showing any benefit to treating acute asymptomatic hypertension in the ED. The best review of available literature is here:

4: Decker WW, Godwin SA, Hess EP, Lenamond CC, Jagoda AS; American College of
Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on
Asymptomatic Hypertension in the ED.
Clinical policy: critical issues in the evaluation and management of adult
patients with asymptomatic hypertension in the emergency department.
Ann Emerg Med. 2006 Mar;47(3):237-49. No abstract available.
PMID: 16492490 [PubMed - indexed for MEDLINE]

Nice job Quinn choosing your senior lecture to coincide with a recently published comprehensive review 😀

The studies that Wilco is refering to are really case reports like these:

: Yanturali S, Akay S, Ayrik C, Cevik AA.
Adverse events associated with aggressive treatment of increased blood
pressure.
Int J Clin Pract. 2004 May;58(5):517-9.
PMID: 15206510 [PubMed - indexed for MEDLINE]

2: Fischberg GM, Lozano E, Rajamani K, Ameriso S, Fisher MJ.
Stroke precipitated by moderate blood pressure reduction.
J Emerg Med. 2000 Nov;19(4):339-46.
PMID: 11074327 [PubMed - indexed for MEDLINE]

3: Grossman E, Messerli FH, Grodzicki T, Kowey P.
Should a moratorium be placed on sublingual nifedipine capsules given for
hypertensive emergencies and pseudoemergencies?
JAMA. 1996 Oct 23-30;276(16):1328-31. Review.
PMID: 8861992 [PubMed - indexed for MEDLINE]

Most of this occurred back when we were still treating hypertensive urgency (whatever that is) with sublingual nifedipine 😱

Although you might argue that any acute intervention that results in a dramatic lowering of BP(clonidine, captopril, blood letting) could give the same result there is some evidence that the effects on cerebral blood flow are some what different amongst different pharmacologic agents:

6: Gemici K, Baran I, Bakar M, Demircan C, Ozdemir B, Cordan J.
Evaluation of the effect of the sublingually administered nifedipine and
captopril via transcranial doppler ultrasonography during hypertensive crisis.
Blood Press. 2003;12(1):46-8.
PMID: 12699135 [PubMed - indexed for MEDLINE]

On the other hand since as DocB points out I am often the patients alternate PCP there really isn't any difference between me starting someone with an otherwise negative workup except for LVH and a DBP of 120 on their initial HTN regimen and their PCP starting them. If you are going to act as a PCP here are the current recs for outpatient treatment of HTN

5: Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones
DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; National Heart, Lung, and
Blood Institute Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure; National High Blood Pressure Education
Program Coordinating Committee.
The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.
JAMA. 2003 May 21;289(19):2560-72. Epub 2003 May 14. Erratum in: JAMA. 2003 Jul
9;290(2):197.
PMID: 12748199 [PubMed - indexed for MEDLINE]

The only time this really comes up with me is like DocB mentioned when psych or detox won't take someone because their asyptomatic HTN is outside "their limits". In that case once I've adequately treated their ETOH withdrawl. I start them on a starter dose of an anti-HTN which seems to make detox happy. Personally I like B-blockers for the ETOH abusers with chronic HTN rather than HCTZ or ACE-I. Their electrolytes are usually sketchy enough without me messing with them. I tell them to follow up with their PCP once they are out of detox and then hope they do.
 
What do the rest of you do with your hypertensive patients? We have a ton of hypertensive, non-compliant people here. Most of my attendings want me to treat their blood pressure if it's over 170 systolic.

We also have a lot of patients who come in for sore throat, foot pain x 10 years, etc who coincidentally have SBP > 200. Since they're technically not symptomatic, would you send them home with that blood pressure?
 
GeneralVeers said:
What do the rest of you do with your hypertensive patients? We have a ton of hypertensive, non-compliant people here. Most of my attendings want me to treat their blood pressure if it's over 170 systolic.

We also have a lot of patients who come in for sore throat, foot pain x 10 years, etc who coincidentally have SBP > 200. Since they're technically not symptomatic, would you send them home with that blood pressure?
Click to expand...

YES! I would give them motrin or tylenol for their sorethroat and send them home with follow up and not think twice about it. I wouldn't even repeat their blood pressure.

You should do your research and next time your attending wants to treat a SBP 170 even 220+, present them with the facts, even if they don't change, you'll at least have literature to support your argument.

sf
 
sweetfynesse said:
You should do your research and next time your attending wants to treat a SBP 170 even 220+, present them with the facts, even if they don't change, you'll at least have literature to support your argument.

sf
Click to expand...


Thanks. I already know that there is evidence that decreasing BP rapidly puts the patient at worse risk than sending them home with elevated BP. I'll have to get specific papers to back that up.

Unfortunately some of our attendings are famous for not listening to evidence or reason, and insist on insane workups despite my best arguments.
 
Treating mild to moderate hypertension in the ED (i.e. not hypertensive urgency/emergency), particularly in people without established followup is pure folly. If you follow the JNC guidelines, you aren't even supposed to diagnose, let alone treat, hypertension based on a single visit. You'll do much better by your patients to refer them to the clinic and take 15 seconds to explain why it's important rather than giving them a script they aren't going to fill anyway.

Labetolol is my first choice for acute ED management of HTN. While it is largely a beta blocker, its weak alpha blockade is also helpful (in a 7:1 beta:alpha ratio or thereabouts).

Clonidine (a gentle dose: 0.1 to 0.2mg PO) is a good choice for people who are already beta blocked. It is not a good first choice in people who are not on a beta blocker, as you may have rebound tachycardia. I find that it also works well in dialysis patients.

As far as its use in opioid withdrawal, I agree that the patch is certainly prefererable both for its lower abuse/OD potential and convenience. Remember, however, that blood levels are a bit slow to rise with this transdermal delivery method. If you care enough to treat someone, you should give them a single PO dose of clonidine to treat their symptoms until they start to get effect from the patch.

While we're on the subject of patches, using a long-acting modality such as the fentanyl patch for acute pain management in the ED is not a good idea. This delivery method is only optimal in people who apply a patch regularly Q3 days, maintaining a constant blood level and effect. Since the patch does not acutely address pain like a PO med (oxycodone/hydrocodone/hydromorphone), people are likely to apply multiple patches and are at risk for OD. This, of note, is why people who are on chronic transdermal fentanyl or other long-acting opioid (like oxycontin) are also given a short acting PO med for acute pain exacerbations (with instructions to use the PRN med rather than alter their basal narcotic dose).
 
Bump on the following topic.

Do you do routine screening tests that JNC 7 recommends in the primary care setting in the ED? I have been researching these issues and not much evidence for getting a Cr, CXR, Ekg, etc. Recent article in the Annals by Karras out of Temple that states that those tests only altered management between 1-4% if the time; however, the tests were 50% abnormal. It is a small study and only done over 4 weeks, but may be clinically relevant. Also Karras has another study providing evidence of doing a urine dipstick to screen for ARF in these asymptomatic hypertension pts.

I find these interesting due to the fact at my busy, county training program where these patients do not have or go to follow up and have never been previously diagnosed with HTN that I personally would prefer to check some of these labs. Now treating them is a different story because you need at least 2 measurements of BP at 2 different times. Plus according to other studies, the measurement of the BP's in the ED are somewhat inaccurate.

Hence, my theory is if they have follow up with no hx of HTN, then no lab tests, no treatment, go to primary care. If they have hx of htn, give them their meds if they are out. If hx of htn and no medications at all and no recent lab tests, check some lab tests to make sure no chronic end organ damage, and start the appropriate antihypertensive based on their ethnicity and comorbid conditions (of course all with asymptomatic htn).

Let me know if you think any differently.
 
aaahhhbi said:
Bump on the following topic.

Do you do routine screening tests that JNC 7 recommends in the primary care setting in the ED?

I find these interesting due to the fact at my busy, county training program where these patients do not have or go to follow up and have never been previously diagnosed with HTN that I personally would prefer to check some of these labs. Now treating them is a different story because you need at least 2 measurements of BP at 2 different times.

Let me know if you think any differently.
Click to expand...

Why do you want to check routine labs and extend LOS and further crowd your waiting room, when you said you don't want to treat these abnormal labs? If a patient has asymptomatic hypertension, I check nothing and refer them back to their PCP.
 
I don't do anything for asymptomatic hypertension. I impress upon the patient the need for urgent follow up. I might refill a prescription for the meds if they have them there, have good reason, etc. I never prescribe clonidine.

With regards to htn/headache, (and I am to sleepy to pull the articles) there is no def association with elevated bp and hypertension. Its a spurioius association. Pt's get a headache, take their bp and its high and often put the two together. However, if you measure people's bp and see if they have headaches, the association goes to zippo.
(not to mention, pain can raise bp as well).

I have treated about 7-10 cases of hypertensive emergency/enceph. I like labetalol. I have never use nipride.
 
I send em home. It was high yesterday, too.
 
roja said:
I don't do anything for asymptomatic hypertension. I impress upon the patient the need for urgent follow up. I might refill a prescription for the meds if they have them there, have good reason, etc. I never prescribe clonidine.

With regards to htn/headache, (and I am to sleepy to pull the articles) there is no def association with elevated bp and hypertension. Its a spurioius association. Pt's get a headache, take their bp and its high and often put the two together. However, if you measure people's bp and see if they have headaches, the association goes to zippo.
(not to mention, pain can raise bp as well).

I have treated about 7-10 cases of hypertensive emergency/enceph. I like labetalol. I have never use nipride.
Click to expand...

from some notes i took on an especially good lecture - this one was about hypertensive encephalopathy

-an MAP > 150 leads to failure of autoregulation, vasogenic edema (esp in occipitoparietal region --> posterior leukoencephalopathy which is reversible)
-it's a diagnosis of exclusion so r/o ingestion/withdrawal, stoke, SAH, meningitis, etc
-these ppl are generally fluid depleted so give fluids generously
-lower MAP by 20-25% in first 30 min - 2 hrs
***do not give oral, transdermal, or sublingual tx, give IV therapy***
recommendations:
-labetalol 20 q 5/10/20 min (titrate)
-fenoldopam (improves GFR better than nipride)
-nicardipine gtt
***do NOT give clonidine (CNS) or hydralizine (can sharply decrease BP, variable 1/2 life in literature), or diuretics (remember, they're volume depleted)***
 
I think we do more of a public service and good for the patient in the long term by treating them while we've got 'em.

We have a HORRIBLY uncontrolled HTN population at my county program. My usual routine is BP high (ie: 180-200 SPB etc....). Usually, we have old visits to look at vitals. If BP is high then there are the two seperate visits.

Also if they're reading a novel in bed and there BP is 226/120 then I don't think they need TWO seperate visits. I think you could say they have HTN. Especially since our wait times are about 6 hours (two seperate BP's 6 hours apart good enough?).

Asymptomatic and NEVER been on BP meds before........UA dip for protein, if no protein/blood then start 'em on HCTZ or metoprolol, lowest dose.

If UA with protein/blood, check a BMP for Creatinine. Start on ACE (10 of lisinopri usually). If they're already spilling protein on the dipstick ACE is definately doing that person good.

I also don't believe in the whole HA and HTN correlation. I did a lecture on this a few months ago and the literature essentially says the HIGHER your DBP the LOWER incidence of headache in population studies.

Granted that was a all white european population study, but still, HA doesn't mean much to me. It's usually of the variety..........."my head hurts and that's how I know my BP is high.".

I don't label this urgency.

later
 
Also, I totally am hooked on CARDENE for HTN emergency, head bleeds with HTN etc...

that stuff is smooth and quick and easily titrated.

love the stuff.

later
 
aaahhhbi said:
Bump on the following topic.

Do you do routine screening tests that JNC 7 recommends in the primary care setting in the ED? I have been researching these issues and not much evidence for getting a Cr, CXR, Ekg, etc. Recent article in the Annals by Karras out of Temple that states that those tests only altered management between 1-4% if the time; however, the tests were 50% abnormal. It is a small study and only done over 4 weeks, but may be clinically relevant. Also Karras has another study providing evidence of doing a urine dipstick to screen for ARF in these asymptomatic hypertension pts.

I find these interesting due to the fact at my busy, county training program where these patients do not have or go to follow up and have never been previously diagnosed with HTN that I personally would prefer to check some of these labs. Now treating them is a different story because you need at least 2 measurements of BP at 2 different times. Plus according to other studies, the measurement of the BP's in the ED are somewhat inaccurate.

Hence, my theory is if they have follow up with no hx of HTN, then no lab tests, no treatment, go to primary care. If they have hx of htn, give them their meds if they are out. If hx of htn and no medications at all and no recent lab tests, check some lab tests to make sure no chronic end organ damage, and start the appropriate antihypertensive based on their ethnicity and comorbid conditions (of course all with asymptomatic htn).

Let me know if you think any differently.
Click to expand...

Dave Karras is sitting in the middle of one of the most uncontrolled bunch of hypertensives in the country. I think that doing a lot of testing on people with asymptomatic hypertension in the ED is throwing in the towel and saying that we are just going to start being everyone's PMD. While that reality may be in our future I still maintain that we are poor quality, expensive primary care docs.
 
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