To treat or not to treat: that is the question

In a study from Israel, Ayalon-Dangur and colleagues1 evaluated the outcome of patients with hypertension who visited emergency departments (ED) over an 18-month period. They included all patients with hypertension attending an ED who had no target organ damage. Hypertension was defined as systolic blood pressure (BP) >140 mm Hg and diastolic BP >90 mm Hg. From a composite of 150 000 patients who visited the ED between 2012 and 2015, 410 patients (205 cases and 205 controls) were included in the study. Baseline characteristics except for history of chronic renal failure were similar between the two groups. Approximately 70 patients in each group already had a history of hypertension. The composite end point included all-cause mortality, acute coronary syndrome, cerebrovascular accident/transient ischemic attack, or hospitalization for heart failure. The analysis revealed that while most composite end points remained unchanged for both groups, patients with elevated BP during the ED visit were more commonly hospitalized for heart failure compared with those presenting with normal BP. This study has limitations that should be noted. First, the investigation was underpowered to assess the difference in mortality or cardiovascular events. Second, it had a short study duration and small study population. Third, there were also significantly more cases of patients with shortness of breath and cardiac causes of ED visits compared with controls. Last, history of congestive heart failure in participants was not known. Nonetheless, the study addresses a clinically relevant question. Several studies have suggested a correlation between BP during ED visits and actual BP at home. In one study of 156 patients with increased ED BP and no history of hypertension, persistently increased BP at home was present in 79 of 156 patients (51%).2 Yet, the reasons for the difference between home and ED systolic BPs in the other 40% was not obvious, as the study found no association between anxiety or pain and elevated BP. Hence, it remains unknown which groups of patients would benefit from BP control. Currently, most patients receive no further adjustment of their BP medications or are not treated for high BP if they have no history of hypertension. In fact, based on guidelines issued by the American College of Emergency Physicians (ACEP), ED physicians are not required to initiate treatment for hypertension. This clinical policy of the ACEP for evaluation and management of adult patients with asymptomatic elevated BP in the ED is based on a review of the literature by a writing subcommittee to derive evidence-based recommendations for clinicians. The key questions addressed by the writing subcommittee were whether screening for target organ injury in the ED in patients with asymptomatic elevated BP reduces the rates of adverse outcomes and whether medical intervention in such patients reduces the rates of adverse outcomes. The recommendations were made based on the strength of the evidence in the medical literature. Based on the statement made by the ACEP, routine medical intervention for elevated BP in the ED is not required.3 The ACEP, however, made room for individualized decisions such as initiation of treatment for selected patients, such as those with poor compliance. The ACEP, however, acknowledges the benefit of long-term BP control for the prevention of target organ damage, morbidity, and mortality and underscores the need for outpatient follow-up, whether treatment is started. ACEP also shows concern for the potential harm in rapid lowering of BP in asymptomatic patients. Overall, ACEP issued two consensus recommendations as follows: Given the state of the current literature, the policy adopted by the ACEP appears rational. While acute treatment of patients with markedly elevated BP in the presence of target organ injury has a scientific basis,4 there is insufficient evidence to support treatment of asymptomatic elevated BP as shown by randomized controlled trials.5 There are even fewer data available for BP treatment in emergency settings in patients with elevated diastolic BP. The available data support treatment of diastolic hypertension to prevent end organ damage. In the Veterans Administration Cooperative Study Group on Antihypertensive Agents trial,6 143 men with a first-time measured diastolic BP of 115 mm Hg to 129 mm Hg were randomized to placebo or antihypertensive medications (hydrochlorothiazide plus reserpine plus hydralazine hydrochloride). There were significantly more complications in those treated with placebo vs those treated with antihypertensive drugs (39% vs 3; absolute risk reduction 36% and number needed to treat = 3). Based on the results from 17 controlled trials of mild to moderate diastolic hypertension in patients younger than 65 years, treatment with antihypertensive medications reduces the number of cardiovascular and cerebrovascular events.7 Most of these patients, however, had concomitant systolic hypertension, which complicated the analysis. Currently, the advantages of initiating antihypertension medication in the ED are unclear. In this relationship, it would be useful if the investigators could compare the hospitalization rate for heart failure between those treated for hypertension and those who were untreated. Randomized controlled trials are notoriously underpowered in determining the benefit of medical intervention, particularly in different subgroups of patients. In the era of precision medicine, it is critical to identify subcategories of patients with asymptomatic hypertension who should be treated for elevated BP in the ED. Thus, it would be advantageous if the investigators would conduct a randomized trial to determine whether the initiation of antihypertensive therapy in certain subgroups, such as those with shortness of breath or cardiovascular disease, would reduce future admission for heart failure. The author reports no conflicts of interest.