Introduction: Hypertensive emergencies are a critical subset of emergency department (ED) visits, but diagnostic and admission criteria for asymptomatic patients remain unclear. We hypothesized that these patients would have high admission rates due to concern for end-organ damage. This study analyzes a national dataset to describe the demographics, diagnostic testing, and disposition outcomes of adult ED patients with initial systolic blood pressure (SBP) ≥200 mmHg. Methods: We conducted a retrospective analysis of the National Hospital Ambulatory Medical Care Survey from 2016 to 2022, focusing on ED visits involving adult patients with SBP ≥200 mmHg. Demographics, comorbidities, diagnostic testing, and admission rates were assessed descriptively. Diagnostic utilization between admitted and non-admitted patients was compared using chi-square analysis. Results: From 2016–2022, 12,673,716 adult ED visits with SBP ≥200 mmHg were recorded, showing a decline through 2018, a 2019 peak (2.1 million visits), a COVID-related dip, and a rebound to over 2 million visits in 2022. The mean age was 63.5 years (±16), 64% were female, and 59.6% were white. The mean SBP was 215.1 (±13.8) mmHg. Comorbid hypertension (HTN) was present in 81.8% of cases, while chronic kidney disease, coronary artery disease, congestive heart failure, and end-stage renal disease were present in 13.8%, 15.6%, 10.3%, and 6.1%, respectively. Imaging was obtained in 69.2%, including CT in 36.3%. Among the 9.7 million patients with repeat BP documentation, SBP declined to 169.2 (±26.6) mmHg. Most patients were triaged as ESI level 2 (34.8%) or 3 (52.3%), and 25.1% arrived by EMS. Medicare-covered 52%, 64.3% were referred for outpatient follow-up, and the ED mortality rate was 0.016%. Of all visits, 78.4% resulted in discharge. Admitted patients (21.6%) had markedly higher diagnostic testing rates, including more frequent EKGs (82.5% vs. 47.8%), CT scans (53.3% vs. 31.6%), CT head (37.8% vs. 17.3%), CT chest (6.2% vs. 3.5%), CT abdomen (11.2% vs. 9.8%), and use of intravenous contrast during CT (27.9% vs. 23.7%). Overall, 4.2% of patients had visited the same ED within the prior 72 hours, while 9.6% had a return visit documented. Conclusion: Despite severely elevated blood pressure, most patients were discharged, raising concerns about clinical decision-making, high resource use, and unclear admission criteria. Findings highlight the need for evidence-based disposition guidelines in patients with severe HTN.
Pichardo et al. (Mon,) studied this question.
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