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Emergency Department-Provided Home Blood Pressure Devices Can Help Detect Undiagnosed Hypertension

  • Elizabeth M. GoldbergEmail author
  • Taneisha Wilson
  • Bianca Jambhekar
  • Sarah J. Marks
  • Michael Boyajian
  • Roland C. Merchant
Original Article

Abstract

Introduction

Emergency departments (EDs) are critical sites for hypertension (HTN) screening. Home blood pressure (BP) monitoring (HBPM) is used routinely in outpatient settings, yet its utility after the ED visit for those with elevated BP in the ED is unclear.

Aim

In this pilot study, we assessed if HBPM could detect HTN in patients with elevated in-ED BP.

Methods

From September 2014 to July 2017, we recruited adult patients at an urban, academic ED with a triage BP ≥ 120/80 mmHg and no history of HTN into this prospective cohort observational study. After their ED visit, participants obtained BP measurements for two weeks using a validated HBPM. HTN was considered probable if the average HBPM BP was ≥ 135/85 mmHg. We calculated the proportion of participants whose ED BP measurement accurately predicted HTN using HBPM after discharge.

Results

Of 136 participants enrolled, 93 (68%) returned the HBPM with at least four home BP measurements [mean number of measurements obtained: 29 (SD: 17, range 4–59)]. Participants’ median age was 40 years-old (IQR 34–48); 55% were female, 19% were black, and 58% were white. Forty-six percent of participants with elevated in-ED BP had HTN in follow-up.

Conclusions

For patients with elevated BP in the ED, HBPM could be valuable for determining which patients have HTN and require expedient follow-up.

Keywords

Hypertension Quality measurement Guidelines Cardiovascular disease Blood pressure 

Notes

Acknowledgements

We have received funding for this work from the Agency for Healthcare Research and Quality (T32 HS000011), Brown Emergency Medicine; and the Rhode Island Foundation.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

40292_2019_300_MOESM1_ESM.docx (13 kb)
Supplementary material 1 (DOCX 13 kb)

References

  1. 1.
    CDC/National Center for Health Statistics. Vital signs: awareness and treatment of uncontrolled hypertension among adults–United States, 2003–2010. MMWR Morb Mortal Wkly Rep. 2012;61:703–9.Google Scholar
  2. 2.
    McNaughton CD, Self WH, Zhu Y, Janke AT, Storrow AB, Levy P. Incidence of hypertension-related emergency department visits in the United States, 2006 to 2012. Am J Cardiol. 2015;116(11):1717–23.Google Scholar
  3. 3.
    Lebby T, Paloucek F, Dela Cruz F, Leikin JB. Blood pressure decrease prior to initiating pharmacological therapy in nonemergent hypertension. Am J Emerg Med. 1990;8(1):27–9.Google Scholar
  4. 4.
    Karras DJ, Kruus LK, Cienki JJ, et al. Evaluation and treatment of patients with severely elevated blood pressure in academic emergency departments: a multicenter study. Ann Emerg Med. 2006;47(3):230–6.Google Scholar
  5. 5.
    Karras DJ, Ufberg JW, Heilpern KL, et al. Elevated blood pressure in urban emergency department patients. Acad Emerg Med. 2005;12(9):835–43.Google Scholar
  6. 6.
    Backer HD, Decker L, Ackerson L. Reproducibility of increased blood pressure during an emergency department or urgent care visit. Ann Emerg Med. 2003;41(4):507–12.Google Scholar
  7. 7.
    Tanabe P, Persell SD, Adams JG, McCormick JC, Martinovich Z, Baker DW. Increased blood pressure in the emergency department: pain, anxiety, or undiagnosed hypertension? Ann Emerg Med. 2008;51(3):221–9.Google Scholar
  8. 8.
  9. 9.
    Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM. Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013;62(1):59–68.Google Scholar
  10. 10.
    Levy PD, Cline D. Asymptomatic hypertension in the emergency department: a matter of critical public health importance. Acad Emerg Med. 2009;16(11):1251–7.Google Scholar
  11. 11.
    McNaughton CD, Self WH, Levy PD, Barrett TW. High-risk patients with hypertension: clinical management options. Clin Med Rev Vasc Health. 2013;2012(4):65–71.Google Scholar
  12. 12.
    Brody A, Rahman T, Reed B, et al. Safety and efficacy of antihypertensive prescription at emergency department discharge. Acad Emerg Med. 2015;22(5):632–5.Google Scholar
  13. 13.
    Goldberg EM, Shah K, Shayne P. An evidence-based approach to managing asymptomatic elevated blood pressure in the emergency department. Emerg Med Pract. 2015;17(2):1–20 (quiz 21).Google Scholar
  14. 14.
    Baumann BM, Cline DM, Cienki JJ, Egging D, Lehrmann JF, Tanabe P. Provider Self-report and practice: reassessment and referral of emergency department patients with elevated blood pressure. Am J Hypertens. 2009;22(6):604–10.Google Scholar
  15. 15.
    Goldberg EM, Levy PD. New approaches to evaluating and monitoring blood pressure. Curr Hypertens Rep. 2016;18(6):49.Google Scholar
  16. 16.
    Parati G, Stergiou GS, Asmar R, et al. European Society of Hypertension practice guidelines for home blood pressure monitoring. J Hum Hypertens. 2010;24(12):779–85.Google Scholar
  17. 17.
    Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2005;45(1):142–61.Google Scholar
  18. 18.
    Nasothimiou EG, Tzamouranis D, Rarra V, Roussias LG, Stergiou GS. Diagnostic accuracy of home vs. ambulatory blood pressure monitoring in untreated and treated hypertension. Hypertens Res. 2012;35(7):750–5.Google Scholar
  19. 19.
    Niiranen TJ, Hanninen MR, Johansson J, Reunanen A, Jula AM. Home-measured blood pressure is a stronger predictor of cardiovascular risk than office blood pressure: the Finn-Home study. Hypertension. 2010;55(6):1346–51.Google Scholar
  20. 20.
    Siu AL. Screening for high blood pressure in adults: U.S. preventive services task force recommendation statement. Ann Intern Med. 2015;163(10):778–86.Google Scholar
  21. 21.
    Parati G, Stergiou GS, Asmar R, et al. European Society of Hypertension guidelines for blood pressure monitoring at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring. J Hypertens. 2008;26(8):1505–26.Google Scholar
  22. 22.
    Agarwal R, Bills JE, Hecht TJ, Light RP. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension. 2011;57(1):29–38.Google Scholar
  23. 23.
    Breaux-Shropshire TL, Judd E, Vucovich LA, Shropshire TS, Singh S. Does home blood pressure monitoring improve patient outcomes? A systematic review comparing home and ambulatory blood pressure monitoring on blood pressure control and patient outcomes. Integr Blood Press Control. 2015;8:43–9.Google Scholar
  24. 24.
    Chou SC, Deng Y, Smart J, Parwani V, Bernstein SL, Venkatesh AK. Insurance status and access to urgent primary care follow-up after an emergency department visit in 2016. Ann Emerg Med. 2018;71(4):487–496.e481.Google Scholar
  25. 25.
    Baumann BM, Abate NL, Cowan RM, Chansky ME, Rosa K, Boudreaux ED. Characteristics and referral of emergency department patients with elevated blood pressure. Acad Emerg Med. 2007;14(9):779–84.Google Scholar
  26. 26.
    Beckett L, Godwin M. The BpTRU automatic blood pressure monitor compared to 24 hour ambulatory blood pressure monitoring in the assessment of blood pressure in patients with hypertension. BMC Cardiovasc Disord. 2005;5(1):18.Google Scholar
  27. 27.
  28. 28.
    Dabl Educational Trust. 2016. http://www.dableducational.org. Accessed 17 July 2018.
  29. 29.
    Omron. Omron 7 series blood pressure monitor instruction manual. https://omronhealthcare.com/wp-content/uploads/BP760N-IM.pdf. Accessed 3 Aug 2018.
  30. 30.
    Shimamoto K, Ando K, Fujita T, et al. The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2014). Hypertens Res. 2014;37(4):253–390.Google Scholar
  31. 31.
    Almeida AE, Stein R, Gus M, et al. Improved diagnostic accuracy of a 3-day protocol of home blood pressure monitoring for the diagnosis of arterial hypertension. Blood Press Monit. 2013;18(2):119–26.Google Scholar
  32. 32.
    Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure—the JNC 7 report. Jama J Am Med Assoc. 2003;289(19):2560–72.Google Scholar
  33. 33.
    Dieterle T, Schuurmans MM, Strobel W, Battegay EJ, Martina B. Moderate-to-severe blood pressure elevation at ED entry: hypertension or normotension? Am J Emerg Med. 2005;23(4):474–9.Google Scholar
  34. 34.
    Huang Y, Cai X, Li Y, Su L, Mai W, Wang S, Hu Y, Wu Y, Xu D. Prehypertension and the risk of stroke: a meta-analysis. Neurology. 2014;82(13):1153–6.Google Scholar
  35. 35.
    Hsia J, Margolis KL, Eaton CB, et al. Prehypertension and cardiovascular disease risk in the Women’s Health Initiative. Circulation. 2007;115(7):855–60.Google Scholar
  36. 36.
    Goldberg EM, Wilson T, Saucier C, et al. Achieving the BpTRUth: emergency department hypertension screening and the Centers for Medicare & Medicaid Services quality measure. J Am Soc Hypertens. 2017;11(5):290–4.Google Scholar
  37. 37.
    Vasan RS, Larson MG, Leip EP, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med. 2001;345(18):1291–7.Google Scholar
  38. 38.
    DeLia D, Tong J, Gaboda D, Casalino LP. Post-discharge follow-up visits and hospital utilization by Medicare patients, 2007–2010. Medicare Medicaid Res Rev. 2014.  https://doi.org/10.5600/mmrr.004.02.a01.Google Scholar
  39. 39.
    McGillicuddy JW, Gregoski MJ, Weiland AK, et al. Mobile health medication adherence and blood pressure control in renal transplant recipients: a proof-of-concept randomized controlled trial. JMIR Res Protoc. 2013;2(2):e32.Google Scholar
  40. 40.
    Magid DJ, Olson KL, Billups SJ, Wagner NM, Lyons EE, Kroner BA. A pharmacist-led, American Heart Association Heart360 Web-enabled home blood pressure monitoring program. Circ Cardiovasc Qual Outcomes. 2013;6(2):157–63.Google Scholar
  41. 41.
    Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021–104.Google Scholar
  42. 42.
    Brody AM, Sharma VK, Singh A, Kumar VA, Goldberg EM, Millis SR, Levy PD. Barriers to emergency physician diagnosis and treatment of uncontrolled chronic hypertension. Am J Emerg Med. 2016;34(11):2241–2.Google Scholar
  43. 43.
    Shayne P. Against routine initiation of antihypertensive therapy in the emergency department. Ann Emerg Med. 2009;54(6):792–3.Google Scholar
  44. 44.
    Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC Jr, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol. 2018;71(19):2199–269.Google Scholar
  45. 45.
    Ntineri A, Nasothimiou E, Kollias A, Roussias L, Achimastos A, Stergiou GS. 3C.05: diagnostic Agreement of the European Society of Hypertension Home Blood Pressure Monitoring Schedule with Ambulatory Blood Pressure Monitoring in Untreated and Treated Subjects. J Hypertens. 2015;33(Suppl 1):e38.Google Scholar
  46. 46.
    Niiranen TJ, Rissanen H, Johansson JK, Jula AM. Overall cardiovascular prognosis of isolated systolic hypertension, isolated diastolic hypertension and pulse pressure defined with home measurements: the Finn-home study. J Hypertens. 2014;32(3):518–24.Google Scholar
  47. 47.
    Setia S, Subramaniam K, Teo BW, Tay JC. Ambulatory and home blood pressure monitoring: gaps between clinical guidelines and clinical practice in Singapore. Int J Gen Med. 2017;10:189–97.Google Scholar
  48. 48.
    Logan AG, Dunai A, McIsaac WJ, Irvine MJ, Tisler A. Attitudes of primary care physicians and their patients about home blood pressure monitoring in Ontario. J Hypertens. 2008;26(3):446–52.Google Scholar

Copyright information

© Italian Society of Hypertension 2019

Authors and Affiliations

  1. 1.Department of Emergency MedicineBrown UniversityProvidenceUSA
  2. 2.Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceUSA
  3. 3.New York Medical CollegeValhallaUSA
  4. 4.Department of Emergency MedicineBrigham and Women’s HospitalBostonUSA
  5. 5.Alpert Medical School of Brown UniversityProvidenceUSA

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