ORIGINAL PAPER

Diagnosis, Treatment, and Referral of Hypertension or Prehypertensionin an Emergency Department After an Educational Program: Preliminary

Results

Tushar Shah, MD;1 Wilbert S. Aronow, MD;2 Stephen J. Peterson, MD;1 David Goldwag, DO3

From the Department of Medicine, General Medicine;1 the Division of Cardiology;2 and the Department of Emergency Medicine, New York

Medical College, Valhalla, NY3

The authors prospectively audited 602 randomly selectedcharts of patients seen in an academic emergency depart-ment (ED) for prevalence of hypertension and its manage-ment after an educational program (EP) because of resultsfound in auditing 500 charts before the EP. Blood pressurewas not measured in 11 of 500 patients (2.2%) before theEP and in 1 of 602 patients (0.2%) after the EP (P<.005).Hypertension was treated in the ED in 14 of 187 patients(8%) before the EP and in 29 of 282 patients (10%) afterthe EP (P=not significant). Of 187 patients with hyperten-sion before the EP, 99 (53%) were referred to a physician

or clinic for follow-up of hypertension, and 281 of 282patients (99.6%) with hypertension were referred to a phy-sician or clinic for follow-up of hypertension after the EP(P<.001). These data show that an EP administered to thestaff of an academic ED significantly increased measure-ment of blood pressure in the ED, significantly increasedobtaining a history of hypertension and of its treatment inED patients, and significantly increased referral of patientswith hypertension to a physician or clinic for follow-up ofhypertension. J Clin Hypertens (Greenwich). 2011;13:413–415. �2011 Wiley Periodicals, Inc.

Hypertension is a major risk factor for coronaryevents,1–6 stroke,1,2,6–9 congestive heart failure,1,2,10,11

and peripheral arterial disease.12–16 Emergency depart-ment (ED) physicians have done a poor job in recog-nizing, treating, and referring patients withhypertension for follow-up care.17–21 In addition,many patients being seen for medical care in the EDdo not have a primary care physician or access to pri-mary care.

In March 2006, the American College of EmergencyPhysicians (ACEP) Clinical Policies Subcommittee rec-ommended that patients with hypertension should bereferred for follow-up of hypertension and treat-ment.22 We previously reported in a prospective studyfrom the ED of a university medical center that 11 of500 patients (2.2%) seen in the ED did not have theirblood pressure (BP) measured.23 Of the 489 patientswho had their BP measured, 187 patients (38%) hadhypertension diagnosed. Of the 187 patients withhypertension, 14 (8%) were treated for hypertensionin the ED and 99 (53%) were referred to a physicianor clinic for follow-up of their hypertension.23

These data were discussed with the medical directorof the ED and with the medical staff of the ED. Aneducational program about the importance of diagnos-ing hypertension, treating it, and referring patientswith hypertension for follow-up care was then given

to the medical staff of the ED and a grand rounds onthis topic given to the medical staff. The medical staffwas also taught to obtain follow-up BPs in the ED ifthe BP was elevated.

After this educational program, a prospective studywas then repeated during a 7-month period in 602patients seen in the ED to determine whether the edu-cational program had an effect on the prevalence ofmeasuring BP, the prevalence of treatment of hyper-tension in the ED, and the prevalence of referringpatients with hypertension for follow-up care of theirhypertension.

METHODSAn educational program was administered to the med-ical staff of the ED about the importance of diagnos-ing hypertension, treating it, and referring patientswith hypertension for follow-up care of their hyperten-sion. After administration of this educational programfor 6 months, we audited in a prospective study 602randomly selected charts of patients seen during a 7-month period (November 2009 through May 2010) inthe ED of Westchester Medical Center ⁄ New YorkMedical College for the prevalence of hypertensionand how it was managed. There were no inclusion orexclusion criteria for selection of these patients. Therewas no control population involved. The age, sex,race, and BP taken in the ED of each patient wererecorded. Hypertension was diagnosed if systolic BPwas �140 mm Hg or diastolic BP was �90 mm Hg.The last BP value recorded in the chart prior to treat-ment was used. Since this was a study of patients withuncontrolled hypertension, patients with normal BPswhile taking medication were not classified as havinghypertension.

Address for correspondence: Wilbert S. Aronow, MD, Division ofCardiology, New York Medical College, Macy Pavilion, Room 138,Valhalla, NY 10595E-mail: wsaronow@aol.comPresented at the Annual Meeting of the American Heart Association,Chicago, Illinois on November 17, 2010.

Manuscript received: October 7, 2010; Revised: December 9, 2010;Accepted: December 10, 2010DOI: 10.1111/j.1751-7176.2010.00423.x

Official Journal of the American Society of Hypertension, Inc. The Journal of Clinical Hypertension Vol 13 | No 6 | June 2011 413

In the patients with hypertension, a history ofhypertension, current therapy for hypertension, athero-sclerotic vascular disease, diabetes mellitus, congestiveheart failure, and chronic kidney disease wererecorded. Whether the hypertension was treated in theED and whether the patient was referred to a physi-cian or clinic for follow-up of their hypertension werealso recorded. The physicians and nurses in the EDwere aware that this study was being performed.

Student t tests were used to analyze continuous vari-ables. Chi-square tests were used to analyze dichoto-mous variables.

This study was approved by the New York MedicalCollege institutional review board and by the institu-tional review board of Westchester Medical Center.

RESULTSThe 602 patients included 311 men and 291 women,with a mean age of 53�14 years. Of the 602 patients,313 (52%) were white and 289 (48%) were nonwhite.The BP was not measured in 11 of 500 patients (2.2%)before the educational program and in 1 of 602 patients(0.2%) after the educational program (P<.005).

Of the 601 patients in whom BP was measured, 282(47%) had hypertension. Systolic and diastolic hyper-tension were present in 166 of 601 patients (28%),isolated systolic hypertension in 114 of 601 patients(19%), and isolated diastolic hypertension in 2 of 601patients (<1%). A history of hypertension wasobtained in 103 of 187 patients (55%) with hyperten-sion before the educational program and in 209 of282 patients (74%) with hypertension after the educa-tional program (P<.001). A history of treatment forhypertension was obtained in 73 of 187 patients(39%) with hypertension before the educational pro-gram and in 189 of 282 patients (67%) with hyperten-sion after the educational program (P<.001).

Of 282 patients with hypertension, 62 (22%) had ahistory of coronary artery disease, 85 (30%) had a his-tory of diabetes mellitus, 27 (10%) had a history of

stroke or transient ischemic attack, 22 (8%) had a his-tory of peripheral arterial disease, 23 (8%) had a his-tory of chronic renal disease, and 25 (9%) had ahistory of congestive heart failure. Table I shows theprevalence of different levels of systolic and diastolichypertension in the 601 patients in whom BP wasmeasured in the ED. Table II shows the baseline char-acteristics of the 282 patients with hypertension.

Hypertension was treated in the ED in 14 of 187patients (8%) before the educational program and in29 of 282 patients (10%) after the educational pro-gram (P=not significant). Of the 187 patients withhypertension before the educational program, 99(53%) were referred to a physician or clinic for fol-low-up of their hypertension, and 281 of 282 patients(99.6%) with hypertension were referred to a physi-cian or clinic for follow-up of their hypertension afterthe educational program (P<.001).

DISCUSSIONHypertension should be treated to decrease cardiovascu-lar events and mortality.1,24–26 ED physicians have donea poor job in recognizing, treating, and referring patientswith hypertension for follow-up care.17–21 In an ED of atertiary care teaching hospital, 1574 patients had hyper-tension.17 Of these 1574 patients, a discharge diagnosisof hypertension was made in 93 patients (6%), antihy-pertensive treatment was given in the ED to 38 patients(2%), discharge instructions for follow-up of BP weregiven to 82 patients (5%), and a prescription for antihy-pertensive drugs was given to 33 patients (2%).17

Of 137 patients seen in a university ED who neededreferral for hypertension management, 5 (4%) werereferred.18 Of 37 patients with hypertension seen inthe ED of an academic medical center, 27 (73%) didnot have their BP rechecked and were not referred forfollow-up of their hypertension.19 Of 269 patientswith a BP �180 ⁄ 110 mm Hg seen in the ED of an

TABLE I. Prevalence of Different Levels of Systolicand Diastolic Hypertension in 601 Patients in WhomBlood Pressure (BP) Was Measured in theEmergency Department

BP, mm Hg No (%)

Systolic BP �200 6 (1)

Systolic BP �190 13 (2)

Systolic BP �180 28 (5)

Systolic BP �170 41 (7)

Systolic BP �160 103 (17)

Systolic BP �150 156 (26)

Systolic BP �140 280 (47)

Diastolic BP �120 4 (1)

Diastolic BP �110 20 (3)

Diastolic BP �100 66 (11)

Diastolic BP �90 168 (28)

TABLE II. Baseline Characteristics of 282 PatientsWith Hypertension Diagnosed in the EmergencyDepartment

Variable No. (%)

Men 146 (52)

Women 136 (48)

Age, y 55�14

Whites 135 (48)

Nonwhites 147 (52)

History of hypertension 209 (74)

Treatment for hypertension 189 (67)

Coronary artery disease 62 (22)

Diabetes mellitus 85 (30)

Stroke or transient ischemic attack 27 (10)

Peripheral arterial disease 22 (8)

Chronic renal disease 23 (8)

History of heart failure 25 (9)

414 The Journal of Clinical Hypertension Vol 13 | No 6 | June 2011 Official Journal of the American Society of Hypertension, Inc.

Hypertension and Management | Shah et al.

academic medical center, 56 patients (21%) receivedantihypertensive treatment.20

A survey of 306 physicians and nurses in 4 EDs inacademic medical centers found that both physiciansand nurses considered hypertension a low priority.21

On the basis of the available data, the ACEP ClinicalPolicies Subcommitttee recommended in March 2006that patients with hypertension should be referred forfollow-up of hypertension and treatment.22

The present prospective study showed that BP wasnot measured in patients seen in the ED in 2.2% ofpatients before the educational program vs 0.2% ofpatients after the educational program (P<.005). A his-tory of hypertension was obtained in 103 of 187patients (55%) with hypertension before the educationalprogram and in 209 of 282 patients (74%) with hyper-tension after the educational program (P<.001). A his-tory of treating hypertension was obtained in 73 of 187patients (39%) with hypertension before the educationalprogram and in 189 of 282 patients (67%) with hyper-tension after the educational program (P<.001). Hyper-tension was treated in the ED in 14 of 187 patients (8%)before the educational program and in 29 of 282patients (10%) after the educational program (P=notsignificant). Of 187 patients with hypertension beforethe educational program, 99 (53%) were referred to aphysician or clinic for follow-up of hypertension, and281 of 282 patients (99.6%) with hypertension werereferred to a physician or clinic for follow-up of hyper-tension after the educational program (P<.001).

Some of the patients with hypertension may havehad acutely elevated BPs due to their presenting com-plaint. These patients may have prehypertension andneed follow-up care.

The physician director of our ED is interested inimproving the quality of medical care provided in theED. He will use their current electronic medical systemand enhance this system with an Allscripts program(Allscripts Healthcare Solutions, Inc, Chicago, IL) inwhich abnormal BP values will be addressed.

CONCLUSIONSAn educational program with the support of the medi-cal director of the ED is valuable in the identificationof hypertension with several BP measurements madein the ED, treatment of hypertension in the ED if indi-cated, and referral of patients to a physician or clinicfor follow-up of their hypertension.

Disclosures: None of the authors have any conflict of interest pertaining tothis paper.

References1. 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.2003;289:2560–2572.

2. Aronow WS, Ahn C, Kronzon I, et al. Congestive heart failure, cor-onary events and atherothrombotic brain infarction in elderly blacksand whites with systemic hypertension and with and without echo-

cardiographic and electrocardiographic evidence of left ventricularhypertrophy. Am J Cardiol. 1991;67:295–299.

3. Aronow WS, Ahn C. Risk factors for new coronary events in a largecohort of very elderly patients with and without coronary artery dis-ease. Am J Cardiol. 1996;77:864–866.

4. Vokonas PS, Kannel WB. Epidemiology of coronary heart disease inthe elderly. In: Aronow WS, Fleg JL, Rich MW, eds. CardiovascularDisease in the Elderly, 4th ed. New York, NY: Informa Healthcare;2008:215–241.

5. Franklin SS, Larson MG, Khan SA, et al. Does the relation of bloodpressure to coronary heart disease risk change with aging? The Fra-mingham Heart Study. Circulation. 2001;103:1245–1249.

6. Psaty BM, Furberg CD, Kuller LH, et al. Association between bloodpressure level and the risk of myocardial infarction, stroke, and totalmortality: the cardiovascular health study. Arch Intern Med.2001;161:1183–1192.

7. Aronow WS, Ahn C, Gutstein H. Risk factors for new atherothrom-botic brain infarction in 664 older men and 1,488 older women.Am J Cardiol. 1996;77:1381–1383.

8. Aronow WS, Frishman WH. Treatment of hypertension and preven-tion of ischemic stroke. Curr Cardiol Rep. 2004;6:124–129.

9. Wolf PA. Cerebrovascular disease in the elderly. In: Tresch DD,Aronow WS, eds. Cardiovascular Disease in the Elderly Patient.New York, NY: Marcel Dekker, Inc.; 1994:125–147.

10. Aronow WS, Ahn C, Kronzon I. Comparison of incidences of con-gestive heart failure in older African-Americans, Hispanics, andwhites. Am J Cardiol. 1999; 84:611–612.

11. Levy D, Larson MG, Vasan RS, et al. The progression from hyper-tension to congestive heart failure. JAMA. 1996;275:1557–1562.

12. Stokes J III, Kannel WB, Wolf PA, et al. The relative importance ofselected risk factors for various manifestations of cardiovasculardisease among men and women from 35 to 64 years old: 30 years offollow-up in the Framingham Study. Circulation. 1987;75(suppl V):V-65–V-73.

13. Aronow WS, Sales FF, Etienne F, et al. Prevalence of peripheralarterial disease and its correlation with risk factors for peripheralarterial disease in elderly patients in a long-term health care facility.Am J Cardiol. 1988;62:644–646.

14. Ness J, Aronow WS, Ahn C. Risk factors for peripheral arterial dis-ease in an academic hospital-based geriatrics practice. J Am GeriatrSoc. 2000;48:312–314.

15. Ness J, Aronow WS, Newkirk E, et al. Prevalence of symptomaticperipheral arterial disease, modifiable risk factors, and appropriateuse of drugs in the treatment of peripheral arterial disease in olderpersons seen in a university general medicine clinic. J Gerontol: MedSci. 2005;60A: M255–M257.

16. Aronow WS, Ahmed MI, Ekundayo OJ, et al. A propensity-matchedstudy of the association of peripheral arterial disease with cardiovas-cular outcomes in community-dwelling older adults. Am J Cardiol.2009;103:130–135.

17. Tilman K, DeLashaw M, Lowe S, et al. Recognizing asymptomaticelevated blood pressure in ED patients: how good (bad) are we? AmJ Emerg Med. 2007;25:313–317.

18. Nerlinger J, Jubanyik K. Quantifying the problem: undiagnosed hyper-tension in the emergency department and failure to refer for bloodpressure recheck (abstract). Acad Emerg Med. 2006;13(suppl 1):S54.

19. Tanabe P, Steinmann R, Kippenhan M, et al. Undiagnosed hyperten-sion in the ED setting—an unrecognized opportunity by emergencynurses. J Emerg Nurs. 2004;30:225–229.

20. Chiang WK, Jamshahi B. Asymptomatic hypertension in the ED.Am J Emerg Med. 1998;16:701–704.

21. Lehrmann JF, Baumann BM, Cienki JJ, et al. Physician and nurseself-reported blood pressure (BP) reassessment practices and percep-tions of barriers to BP reassessment. Acad Emerg Med. 2006;13(sup-pl 1):S54–S55.

22. Decker WW, Godwin SA, Hess EP, et al. Clinical policy: criticalissues in the evaluation and management of adult patients withasymptomatic hypertension in the emergency department. AnnEmerg Med. 2006;47:237–249.

23. Shah T, Aronow WS, Peterson SJ. Diagnosis, treatment, and referralof hypertension in an emergency department. Prev Cardiol. 2009;12:173–175.

24. Sethi A, Arora RR. Ambulatory blood pressure as a predictor of car-diovascular risk. Arch Med Sci. 2009;5:3–9.

25. Ramezani MA, Dastanpour M, Eshaghi SR, et al. Determinants ofawareness, treatment and control of hypertension in Isfahan, CentralIran. Arch Med Sci. 2009;5:523–530.

26. Amsterdam EA. JNC 7: a moving guideline responds to a movingtarget. Prev Cardiol. 2003;6:177–178.

Official Journal of the American Society of Hypertension, Inc. The Journal of Clinical Hypertension Vol 13 | No 6 | June 2011 415

Hypertension and Management | Shah et al.