Patients with systolic BP over 200 - How common is this?

[racerwad]

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The research is actually sparse and not real clear.

Pg 63
"Since 2005, a limited number of studies have been published directly addressing appropriate indications for medical treatment of asymptomatic markedly elevated blood pressure in the ED."

http://www.annemergmed.com/article/S0196-0644(13)00445-9/pdf

I agree that dropping the bp precipitously could cause a stroke. That's med school 101. However, not treating 220/110 could also put the patient at risk for a hemorrhagic stroke. You cannot just assume that since the patient is asymptomatic during your exam that he/she will remain unaffected. More than likely the patient will be fine before seeing their pcp, but maybe not. If you discharge them from the ED on Friday and they stroke out on Saturday, that's an issue. An attorney will then look at your plan for this very elevated bp and it would basically read "no treatment, f/u with pcp". Not good. Those are two of the main reasons why some choose to treat.

If anyone has any distinct guideline or schematics post them.

As you have linked in your post, ACEP in fact does have a clinical guideline for the management of asymptomatic hypertension. Namely, they suggest that no emergent workup is needed in an otherwise healthy person who presents to the ED with hypertension as the only abnormal finding.

As you have mentioned, there is little clear-cut evidence. It is fairly clear, however, that there is no harm in not treating or working up asymptomatic hypertension in the emergent setting. The undetected aneurysm is what is putting your hypothetical patient at risk for a stroke, not a single BP in a single visit at a random ED. I think it is fair to say that the BP (and imaginary aneurysm) have been developing for some time and giving someone some lisinopril once in the ED is going to make much difference. Anyone coming into the ED for any reason and then having a bad outcome after discharge is bad - this is obvious. However, we can't see into the future and so this is a perfect opportunity for shared decision making with the patient as well as giving them clear instructions about why it is important that they keep their followup PCP appointment (if one can be obtained, lol) and strict return precautions to the ED.

 

[gracie369]

As you have linked in your post, ACEP in fact does have a clinical guideline for the management of asymptomatic hypertension. Namely, they suggest that no emergent workup is needed in an otherwise healthy person who presents to the ED with hypertension as the only abnormal finding.

As you have mentioned, there is little clear-cut evidence. It is fairly clear, however, that there is no harm in not treating or working up asymptomatic hypertension in the emergent setting. The undetected aneurysm is what is putting your hypothetical patient at risk for a stroke, not a single BP in a single visit at a random ED. I think it is fair to say that the BP (and imaginary aneurysm) have been developing for some time and giving someone some lisinopril once in the ED is going to make much difference. Anyone coming into the ED for any reason and then having a bad outcome after discharge is bad - this is obvious. However, we can't see into the future and so this is a perfect opportunity for shared decision making with the patient as well as giving them clear instructions about why it is important that they keep their followup PCP appointment (if one can be obtained, lol) and strict return precautions to the ED.

Overall great points. Those guidelines for workup that you are referring to are actually level C based on the paper which leads us right back to...no solid research for good guidelines. Pg 61.

"Level C recommendations. Other strategies for patient management that are based on Class III studies or, in the absence of any adequate published literature, based on panel consensus."

Class III studies are usually case reports or case series.
Panel consensus-bunch of dudes sitting around asking each other what they would do.

 

[mimelim]

Overall great points. Those guidelines for workup that you are referring to are actually level C based on the paper which leads us right back to...no solid research for good guidelines. Pg 61.

"Level C recommendations. Other strategies for patient management that are based on Class III studies or, in the absence of any adequate published literature, based on panel consensus."

Class III studies are usually case reports or case series.
Panel consensus-bunch of dudes sitting around asking each other what they would do.

ie. how 90% of medicine is practiced, in surgery even higher.

 

[TooMuchResearch]

Overall great points. Those guidelines for workup that you are referring to are actually level C based on the paper which leads us right back to...no solid research for good guidelines. Pg 61.

"Level C recommendations. Other strategies for patient management that are based on Class III studies or, in the absence of any adequate published literature, based on panel consensus."

Class III studies are usually case reports or case series.
Panel consensus-bunch of dudes sitting around asking each other what they would do.

It's not good evidence, but it is a clinical practice guideline by my specialty college backing up my decision to do very little emergently.

 

[gracie369]

It's not good evidence.

Bingo.

 

[gracie369]

ie. how 90% of medicine is practiced, in surgery even higher.

Ding. Ding. That's just where we are at with many things and it's completely fine. I just have to chuckle when people on here and in "real life" act like our protocols were delivered to Moses on the mountain. When students/residents hear "evidence based" they need to go to the literature and find out what level of evidence is actually backing up that particular protocol.

 

[Psai]

Ding. Ding. That's just where we are at with many things and it's completely fine. I just have to chuckle when people on here and in "real life" act like our protocols were delivered to Moses on the mountain. When students/residents hear "evidence based" they need to go to the literature and find out what level of evidence is actually backing up that particular protocol.

God when midlevels on the internet talk about their evidence based whatever, it makes me want to tear my hair out. People have trouble understanding the most basic concepts

 

[Raryn]

Bingo.

In the situation where there's no evidence that intervening will help, there is some evidence that NOT intervening won't hurt, and there's plenty of plain-old common sense reasons against intervening (ex: patient's shouldn't be getting their primary care from the ED, they should be following up with someone who can actually see them long-term to get it), going with the evidence/guidelines to *not* intervene is perfectly reasonable. I think the burden should be on the people who claim we should be super aggressive with every hypertensive urgency, not those that advocate not being super aggressive.

 

[shoal]

as an EP, i see bp of 210/130 regullarly and it really irks me when their pcp etc send them to my ER as im not going to do anything for them if theyre asymptomatic. im not in the routine practice of starting a antihtn either. these have side effects, contraindications, and drug interactions. guess what, i dont know the literature as i dont perscribe these daily. its not an emergency nor is it acute and their pcp should handle it. if sent by pcp, i kindly order the labs to rule out end organ dysfunction and turf the asymptomatic patient back.

Can i write for hctz, lisinopril? you better believe it.

however,
1. im not following it up,
2. its not for an acute condition
3. high liability
4. poor practice patterns
5. reinforces incorrect patients expectations...

imho

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[gracie369]

.

Just curious. For hypertensive urgency what blood pressure would be concerning to you?

 

[gracie369]

In the situation where there's no evidence that intervening will help, there is some evidence that NOT intervening won't hurt, and there's plenty of plain-old common sense reasons against intervening (ex: patient's shouldn't be getting their primary care from the ED, they should be following up with someone who can actually see them long-term to get it), going with the evidence/guidelines to *not* intervene is perfectly reasonable. I think the burden should be on the people who claim we should be super aggressive with every hypertensive urgency, not those that advocate not being super aggressive.

I thought I already made my point but this is sdn. The bottom line is that the evidence is weak. Until we have RDBPC trials, treat the patient as you see fit. If you are comfortable discharging a patient with a sbp of 250-275 then do it. The odds are that they will make it to their pcp appointment without any issues. When we talk about treatment, it's not "super aggressive vs. not being super aggressive" as you've stated. If we do treat the bp is brought down carefully over several days. Their pcp can then take over.

 

[DrYoda]

I generally send asymptomatic HTN home from the ED as generalveers stated. If it's above 200 I am willing to write for HCTZ until they can get into their primary care provider. IMO there really isn't a benefit for testing anything in these cases, as much as they get rushed here from pharmacies and pcp offices. As for how common this is the answer is very.

 

[shoal]

Just curious. For hypertensive urgency what blood pressure would be concerning to you?

its not the number, its the symptoms or end organ dysfunction.

180/90 worst ha... you get a workup and if still having a bad headache after treatments and bp lowering after ct lp you get admitted.

chest pain + htn depends on the story, you likely get admitted.

confusion + htn admitted.

htn urgency is such a tough diagnosis. ive admitted asymptomatic htn before because pcp wants it and or patient/family is freaking out. medicine is still more an art then science.

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[VA Hopeful Dr]

I generally send asymptomatic HTN home from the ED as generalveers stated. If it's above 200 I am willing to write for HCTZ until they can get into their primary care provider. IMO there really isn't a benefit for testing anything in these cases, as much as they get rushed here from pharmacies and pcp offices. As for how common this is the answer is very.

If I might make a suggestion? As a PCP, I'd prefer something like norvasc or procardia - that way I don't need to worry about the electrolytes or creatinine in follow up from your ED visit like I would with diuretics or lisinopril.

 

[Zebra Hunter]

Just curious. For hypertensive urgency what blood pressure would be concerning to you?

I don't recognize "hypertensive urgency" as a real diagnosis. No symptoms, go home, maybe I give them some norvasc if they are on nothing.

 

[DrYoda]

If I might make a suggestion? As a PCP, I'd prefer something like norvasc or procardia - that way I don't need to worry about the electrolytes or creatinine in follow up from your ED visit like I would with diuretics or lisinopril.

Noted. Thank you for the feedback.

 

[TooMuchResearch]

If I might make a suggestion? As a PCP, I'd prefer something like norvasc or procardia - that way I don't need to worry about the electrolytes or creatinine in follow up from your ED visit like I would with diuretics or lisinopril.

Pardon my ignorance on this.

Norvasc is a first line agent? Because I would happily switch to this from lisinopril as I currently check renal function before starting lisinopril. I'd much prefer to check no labs and discharge with two weeks of Norvasc 5 mg (assuming 5 is the starting dose, again, please pardon my ignorance).

 

[cbrons]

This is super common, I'd guess I get a new patient like this at least once per week. You check for end organ damage (ecg, UA, fundoscopic exam) and start meds. It's rarely actually an emergency.

Can u tell that to the floor nurses at our hospitals?

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[cbrons]

The problem with these asymptomatic people in the E.D. trying to be "admitted for systolic over 200 is that aggressive treatment can be very harmful. If youve had a bp that high for that long, youve likely compensated to a point where adequate cerebral perfusion pressure depends on your bp being that high.

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[tantacles]

Thanks. That makes sense. I guess I wasn't considering that they might overshoot that much in effect.

It's not really that you're overshooting. In fact, you want the BP to go way down, hopefully eventually to normal levels. The problem is that with very fast reductions in blood pressure, the brain doesn't have time to adapt. Your brain adjusts to higher blood pressures and has adapted to it, so reducing the systolic blood pressure very quickly from 200 => 160 can cause issues.

 

[cbrons]

i currently work in the ED a scribe. Over 180 is an emergency.

First of all, no it is not an emergency.

Second, the majority of people in the ED have hypertension, chest pain, or a headache. Some have a combo of the three. Also not necessarily an emergency in and of itself.

Third of all, you being a scribe doesnt mean you have any idea what youre talking about. You might as well have said youre a janitor or a secretary or a security guard at the hospital for all the relevance of it.

 

[VA Hopeful Dr]

Pardon my ignorance on this.

Norvasc is a first line agent? Because I would happily switch to this from lisinopril as I currently check renal function before starting lisinopril. I'd much prefer to check no labs and discharge with two weeks of Norvasc 5 mg (assuming 5 is the starting dose, again, please pardon my ignorance).

JNC-8 says first line agents are HCTZ and CCB, and ACE-I for non African Americans.

 

[badasshairday]

OP. Kinda wierd you ask an anonymous forum full of mostly med students rather than the board certified physician you are shadowing.

 

[Raryn]

It's not really that you're overshooting. In fact, you want the BP to go way down, hopefully eventually to normal levels. The problem is that with very fast reductions in blood pressure, the brain doesn't have time to adapt. Your brain adjusts to higher blood pressures and has adapted to it, so reducing the systolic blood pressure very quickly from 200 => 160 can cause issues.

200=> 160 is fine actually. You can go 25% change in a few hours, you just shouldn't do more than that 25% in a day.

 

[link2swim06]

I have seen a diastolic of 185 once. I was impressed by that. I didn't send that person home (I'm in the ED).

Basically it's either an emergency or it is not. Symptomatic/end organ dysfunction is an "emergency." It's certainly not based on a number, but sending home a BP of 260/160 is going to look bad from a med mal standpoint if something happens in the next week.

To the premed who posted early.
180 systolic bp by itself is not an emergency if they are asymptomatic. Conversely, a 180 systolic bp in an aortic dissection is an emergency.

This is a case of treating a number, not the patient. Floor nurses are most guilty of this...but physicians with their endless hydrazine PRNs are guilty of it too.

 

[gracie369]

It's certainly not based on a number, but sending home a BP of 260/160 is going to look bad from a med mal standpoint if something happens in the next week.

Finally someone that somewhat gets it. Been trying to make this point for the last 5 posts. I've heard, "Oh but the patient is acclimated to this bp of 260/160!" FFS use your head. The arterial tree is not built to handle that type of pressure.

 

[gracie369]

its not the number, its the symptoms or end organ dysfunction

Based on that criteria you would then discharge an asymptomatic pt/no end organ dysfunction with a sbp of 290-300. Seems completely reasonable.

 

[shoal]

well sbp of 290 to 300 is a different game. 210-240 sure. never seen a 290

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[Rendar5]

Over 180 they get told to keep a BP diary and a list of signs of malignant htn to watch for, no testing and no meds. If they can't follow up or I don't trust them to, I give a prescription. If they have a pmd I'll sometimes call them up for a med rec. over 220 I will start meds to look good from a medico legal perspective. But still discharge. I will only admit if their doc is old school and wants to admit for "urgency" or some other similar reason, but never admit for medical reasons.

If they are symptomatic though that's another story.


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[racerwad]

Finally someone that somewhat gets it. Been trying to make this point for the last 5 posts. I've heard, "Oh but the patient is acclimated to this bp of 260/160!" FFS use your head. The arterial tree is not built to handle that type of pressure.

Listen, we get that you are afraid of big scary numbers and the "what ifs" that surround medical management. The chance that someone who rolls through an ED with a BP 260/160 and nothing else is amiss is highly unlikely. Few people are going to just look at that and not address it in some way (either through documentation of a thorough discussion with the pt, setting them up with outpatient follow up, or starting some basic anti-hypertensives). ACEP's guideline just allows us to not have to tie up resources working up something that is not an emergency. ACEP is not suggesting that an asymptomatic pt with hypertension doesn't need any medical care. You are taking this to an absurd level when you say that someone would DC home a pt with a BP of 290-300 without any further discussion or plan.

In the OP, that patient is already in the appropriate setting and should get some sort of medical and lifestyle intervention. You are confusing the guideline you quoted (which is intended for the acute care setting only) with the management of chronic hypertension overall. No one is saying that hypertension does not need to be managed.

Asymptomatic systolic BPs of 160-200 are pretty common. As you have pointed out, the evidence is scant but it shows that the best setting for the management of these chronic hypertensives is in the outpatient setting. Of course there comes a point where prudence dictates that we need to do something - no one is arguing that.

 

[njtrimed]

ie. how 90% of medicine is practiced, in surgery even higher.

Unfortunately, half of elective surgeries are performed on patients who walk in with blood pressures like this...

 

[Rendar5]

Based on that criteria you would then discharge an asymptomatic pt/no end organ dysfunction with a sbp of 290-300. Seems completely reasonable.

Never seen such a BP in 4 years as an attending. I'll get the occasional ESRD with SBP in the 260s. But that's profoundly rare. 230's not as rare and I have discharged that high without a problem before. (That patient had asymptomatic blood-pressure and a broken right wrist from a trip and fall. I didn't really care about that Number, and she was going to see her doctor In 2 days anyway). It's called involve the patient in the medical decision making process to protect urself medico legally.

 

[Raryn]

At the very least, we can all agree that seeing such an elevated blood pressure, giving a 1x dose of clonidine, rechecking it to see a single number that makes you more comfortable, and sending the patient home is a stupid idea. And I've seen a few ED visits where that happened.

Either it needs treatment or it doesn't. Quickly lowering it with a one time dose of something that very well might cause rebound is not safe and makes no sense.

 

[gracie369]

Listen, we get that you are afraid of big scary numbers and the "what ifs" that surround medical management. The chance that someone who rolls through an ED with a BP 260/160 and nothing else is amiss is highly unlikely. Few people are going to just look at that and not address it in some way (either through documentation of a thorough discussion with the pt, setting them up with outpatient follow up, or starting some basic anti-hypertensives). ACEP's guideline just allows us to not have to tie up resources working up something that is not an emergency. ACEP is not suggesting that an asymptomatic pt with hypertension doesn't need any medical care. You are taking this to an absurd level when you say that someone would DC home a pt with a BP of 290-300 without any further discussion or plan.

In the OP, that patient is already in the appropriate setting and should get some sort of medical and lifestyle intervention. You are confusing the guideline you quoted (which is intended for the acute care setting only) with the management of chronic hypertension overall. No one is saying that hypertension does not need to be managed.

Asymptomatic systolic BPs of 160-200 are pretty common. As you have pointed out, the evidence is scant but it shows that the best setting for the management of these chronic hypertensives is in the outpatient setting. Of course there comes a point where prudence dictates that we need to do something - no one is arguing that.

We? Do you always include yourself in a group? Does that make you feel safer? Your entire post is full of straw man arguments, assertions and assumptions which is frankly just a waste of my time. I was trying to have an academic discussion and you took it to dbag level. I never said that when not treating urgency the patient is then not going to get medical care. Where did you pull that crap from? I am also not confusing outpatient management and ED management of htn. I'm the one that had to explain to you the weak evidence supporting what you are doing. This would make you the confused one. In the end treat the patient as you see fit and I will do the same.

 

[gracie369]

Never seen such a BP in 4 years as an attending. I'll get the occasional ESRD with SBP in the 260s. But that's profoundly rare. 230's not as rare and I have discharged that high without a problem before. (That patient had asymptomatic blood-pressure and a broken right wrist from a trip and fall. I didn't really care about that Number, and she was going to see her doctor In 2 days anyway). It's called involve the patient in the medical decision making process to protect urself medico legally.

My post is being taken out of context. I was asking a previous poster what bp would they actually treat for urgency. He stated that the number does not matter, only symptoms or end-organ dysfunction. So I decided to do a high school level thought experiment by starting with a high number and working down to see what number he would actually treat. I was trying to demonstrate that words do have meaning. You have to be logical when you communicate. If you say that "the numbers do not matter" then logically you would d/c htn urgency with a sbp of 280. The lesson is to think things through before making statements. I obviously know that these pressures are wicked high and rarely seen.

 

[racerwad]

We? Do you always include yourself in a group? Does that make you feel safer? Your entire post is full of straw man arguments, assertions and assumptions which is frankly just a waste of my time. I was trying to have an academic discussion and you took it to dbag level. I never said that when not treating urgency the patient is then not going to get medical care. Where did you pull that crap from? I am also not confusing outpatient management and ED management of htn. I'm the one that had to explain to you the weak evidence supporting what you are doing. This would make you the confused one. In the end treat the patient as you see fit and I will do the same.

"We" is just an impartial pronoun. What straw man arguments are you talking about? You yourself characterized your "thought experiment" as high school level and I saw it in the same way - childlike. Could you explain how I took it to the "dbag" level?

You didn't explain anything about the nature of the evidence. You didn't even reference it correctly as a professional society's guidelines. In fact, in the very post you linked the SAEM article in, you asked if there were any guidelines, suggesting that you have no actual idea what you are talking about.

Honestly, you are making a big deal about nothing. Asymptomatic hypertension in the ED requires no workup, regardless of how high a number is. We (that pronoun again...in this context, I am referring to myself and all other EPs who use ACEP's htn guidelines in their practice) all agree that the evidence available is both poor and limited in volume. There really isn't much else to say despite the fact that you, like a child, keep goading people with absurdist "what if" scenarios.

 

[Rendar5]

My post is being taken out of context. I was asking a previous poster what bp would they actually treat for urgency. He stated that the number does not matter, only symptoms or end-organ dysfunction. So I decided to do a high school level thought experiment by starting with a high number and working down to see what number he would actually treat. I was trying to demonstrate that words do have meaning. You have to be logical when you communicate. If you say that "the numbers do not matter" then logically you would d/c htn urgency with a sbp of 280. The lesson is to think things through before making statements. I obviously know that these pressures are wicked high and rarely seen.

Actually, I believe you just explained The context that I took it in. I answered the question as you posted.

 

[LabMonster]

At the very least, we can all agree that seeing such an elevated blood pressure, giving a 1x dose of clonidine, rechecking it to see a single number that makes you more comfortable, and sending the patient home is a stupid idea. And I've seen a few ED visits where that happened.

Either it needs treatment or it doesn't. Quickly lowering it with a one time dose of something that very well might cause rebound is not safe and makes no sense.

I see this thread going on and on. To medical students: when an attending says treat "hypertensive emergency" please ask 1)why 2)how 3)what is their threshold and why?

A symptomatic patient with elevated BP needs to be treated according to their hypertensive emergency: encephalopathy, TIA, CVA, ACS, AKI, and most likely acute exacerbation of CHF (+/- with COPD involvement.)

Asymptomatic elevation in BP is a problem, but it is a chronic problem. It is a problem best dealt with by primary care.

BP is a number. It is one piece of a complex puzzle. Treating numbers has be shown to adversely affect patient outcomes. Use it as a piece of data, a way of managing treatment for your patients - whether ER, IM, ICU etc.

 

[Handel]

At the very least, we can all agree that seeing such an elevated blood pressure, giving a 1x dose of clonidine, rechecking it to see a single number that makes you more comfortable, and sending the patient home is a stupid idea. And I've seen a few ED visits where that happened.

Either it needs treatment or it doesn't. Quickly lowering it with a one time dose of something that very well might cause rebound is not safe and makes no sense.

Let me take it from the patient's perspective since I just had what I would categorize as a blood pressure emergency, though you, as the physician, might not have seen it as an emergency.

Background context: When I lost my health insurance, I also lost access to my BP meds. This last week, I began having wicked headaches that went on all day and night. It's not the first time this has happened. Since I have learned to associate these headaches with high blood pressure, I took my pressure (which I hadn't done for some time). It was something like 237/130. But it was mostly the headache, not the number, that made me go to one of those strip mall emergency places and, when they failed to control my blood pressure with clonidine, to the ER.

At the ER, the doctor did what you say she shouldn't have done, which is give me another dose of clonidine and recheck my BP until she saw a "safe" number. In fact, she did even more: ordered a brain scan, blood tests, and put some other medicine in my IV (though I forget what it was). After checking to make sure that the strip mall doctor had given me at least a 30 day prescription of lisinopril, she finally sent me home.

My point is that from my perspective as the patient, the wonderful thing is that she got rid of my debilitating headache. Three days out, it hasn't returned. That made the huge bill I'm going to get at least somewhat worth it. She was also kind enough to recommend a place where I can access a PCP that would monitor my blood pressure and issue prescriptions on a regular basis. Some other doctor would have just told me to "go to my primary physician," without acknowledging my predicament or helping me resolve it. Nope, she actually referred me to a place where I could seek long term care.

In any case, I don't know whether, in my case, you would have done what she did. Would the headache have made a difference to you? Sending me home without addressing it by lowering my BP would have been cruel.

 

[Promethean]

At the ER, the doctor did what you say she shouldn't have done, which is give me another dose of clonidine and recheck my BP until she saw a "safe" number. In fact, she did even more: ordered a brain scan, blood tests, and put some other medicine in my IV (though I forget what it was). After checking to make sure that the strip mall doctor had given me at least a 30 day prescription of lisinopril, she finally sent me home.

.....

In any case, I don't know whether, in my case, you would have done what she did. Would the headache have made a difference to you? Sending me home without addressing it by lowering my BP would have been cruel.

Treating the high number with a short term agent and discharging to home is a very different management strategy from what it sounds like the Emergency physician you saw did for you.

Your doctor treated you AND investigated for a cause AND ensured that you had ongoing treatment AND a plan for follow up care.

All those extra steps are what make the difference between mismanagement and quality medical care.

 

[Donald Juan]

Treating the high number with a short term agent and discharging to home is a very different management strategy from what it sounds like the Emergency physician you saw did for you.

Your doctor treated you AND investigated for a cause AND ensured that you had ongoing treatment AND a plan for follow up care.

All those extra steps are what make the difference between mismanagement and quality medical care.

Agree and just to piggyback, Handel was also symptomatic, which highly changes the management decision making.

 

[Crayola227]

Let me take it from the patient's perspective since I just had what I would categorize as a blood pressure emergency, though you, as the physician, might not have seen it as an emergency.

Background context: When I lost my health insurance, I also lost access to my BP meds. This last week, I began having wicked headaches that went on all day and night. It's not the first time this has happened. Since I have learned to associate these headaches with high blood pressure, I took my pressure (which I hadn't done for some time). It was something like 237/130. But it was mostly the headache, not the number, that made me go to one of those strip mall emergency places and, when they failed to control my blood pressure with clonidine, to the ER.

At the ER, the doctor did what you say she shouldn't have done, which is give me another dose of clonidine and recheck my BP until she saw a "safe" number. In fact, she did even more: ordered a brain scan, blood tests, and put some other medicine in my IV (though I forget what it was). After checking to make sure that the strip mall doctor had given me at least a 30 day prescription of lisinopril, she finally sent me home.

My point is that from my perspective as the patient, the wonderful thing is that she got rid of my debilitating headache. Three days out, it hasn't returned. That made the huge bill I'm going to get at least somewhat worth it. She was also kind enough to recommend a place where I can access a PCP that would monitor my blood pressure and issue prescriptions on a regular basis. Some other doctor would have just told me to "go to my primary physician," without acknowledging my predicament or helping me resolve it. Nope, she actually referred me to a place where I could seek long term care.

In any case, I don't know whether, in my case, you would have done what she did. Would the headache have made a difference to you? Sending me home without addressing it by lowering my BP would have been cruel.

This is why this forum is not for personal medical advice.