SGEM#499: Under Pressure – To Start Antihypertensives in Hypertensive ED Patients at Discharge

Date: December 23, 2025 Reference: Todd et al. Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients. J Am Coll Emerg Physicians Open. 2024 Guest Skeptic: Dr. Mike Pallaci is a Professor of Emergency Medicine at Northeast Ohio Medical University and a Clinical Professor of Emergency Medicine at Ohio University Heritage College of Osteopathic Medicine. He currently serves as Core Faculty for the USACS EM Residency at Summa Health System in Akron, OH where he is also Medical Director for the Virtual Care Simulation Lab, Director for the Simulation Medicine Fellowship and Vice Chair for Faculty and Resident Development. Over the course of his 24-year career in EM (15 in academics), he has worked in EDs with volumes ranging from 6,000 to 85,000 per year in urban and rural areas, in community and academic institutions, and has served as Program Director for two EM residencies. He has given lectures and published podcasts and articles in all areas of Emergency Medicine, including at the ACOEP Scientific Assembly, on the EM:RAP platform and right here on the SGEM. Prior research has resulted in book chapters, journal publications and presentations at multiple regional, national and international conferences on numerous topics including medical education, chest pain, pain management, gender bias, documentation, wellness, medicolegal issues, emergency ultrasound, hypertension and others. Case: A 47-year-old male presents to the emergency department (ED) with an ankle sprain. Admitting vital signs include a blood pressure of 210/130, which is similar on repeat measurements. He has no complaints except for ankle pain. He is in good health, has no known medical history, and has a primary care doctor whom he hasn't seen in about 6 or 7 years. Background: Hypertension is one of the most common “incidental” findings in the ED. In the US, there are over 900,000 annual ED visits with elevated blood pressure, and that number is climbing each year. Up to a third of these patients have no prior diagnosis of hypertension. Chronic uncontrolled blood pressure is strongly associated with myocardial infarction, stroke, heart failure, renal failure, and death, so these “incidental” readings are not benign. Standard outpatient care focuses on confirming the diagnosis with repeated measurements and then starting long-term therapy (lifestyle plus medications) to reduce cardiovascular events and mortality over the years, with randomized trial and meta-analytic evidence that treating hypertension reduces composite cardiovascular events and death. The ED, however, sits at an awkward intersection between chronic disease and acute care. Many patients we see with elevated blood pressure are asymptomatic or have nonspecific complaints, with no clear end-organ damage. Guidelines generally allow ED physicians considerable discretion about whether to initiate oral antihypertensives at discharge versus simply arranging follow-up. In 2025, the American College of Emergency Physicians (ACEP) published an updated policy regarding patients with asymptomatic markedly elevated blood pressure. They asked whether ED medical intervention reduces rates of adverse outcomes. They provided a Level C Recommendation that said: In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required. In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control. [Consensus recommendation] Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up. [Consensus recommendation] Previous work suggests that starting antihypertensives from the ED is safe and improves short-term blood pressure control in high-risk populations. Still, there has been very little evidence about patient-oriented short-term outcomes (myocardial infarction, stroke, heart failure, death, and ED revisits). Clinical Question: Among adult ED patients discharged with a diagnosis of hypertension and not on antihypertensive therapy, is an ED discharge prescription for an oral antihypertensive medication associated with a lower 30-day risk of severe hypertension-related adverse events, death, or ED revisits? Reference: Todd et al. Antihypertensive prescription is associated with improved 30-day outcomes for discharged hypertensive emergency department patients. J Am Coll Emerg Physicians Open. 2024 Population: Adult patients (≥18 years) seen and discharged from an ED within a single hospital system with a primary or secondary ED discharge diagnosis of essential (primary) hypertension and hypertensive urgency without prior treatment for hypertension during the previous 18 months. Excluded: Patients admitted to the hospital or to ED observation. Those who died in the ED. Patients without documented elevated blood pressure (BP <140/90). Pregnant patients. ED stay >48 hours. Anyone prescribed an antihypertensive in the 18 months prior. Patients with a severe adverse event (AE) that were already present at ED discharge. Visits with missing gender or race data. Exposure: Receiving a prescription for an oral antihypertensive medication at ED discharge. Comparison: Discharged hypertensive ED patients meeting the same inclusion/exclusion criteria who did not receive an antihypertensive prescription at ED discharge. Outcome: Primary Outcome: Severe composite adverse events from hypertension within 30 days of ED discharge (Acute aortic catastrophe, Acute heart failure, Myocardial infarction, Hemorrhagic stroke, Ischemic stroke or Hypertensive encephalopathy) Secondary Outcomes: All-cause death within 30 days of ED discharge and ED revisit within 30 days of ED discharge. Type of Study: Retrospective observational cohort study Authors’ Conclusions: “Prescription antihypertensive therapy for discharged ED patients is associated with a 30-day decrease in severe adverse events and ED revisit rate.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? YES Did the authors use an appropriate method to answer their question? YES Was the cohort recruited in an acceptable way? YES Was the exposure accurately measured to minimize bias? UNSURE Was the outcome accurately measured to minimize bias? UNSURE Have the authors identified all important confounding factors? NO Was the follow-up of the subjects sufficient? UNSURE How precise are the results? YES Do you believe the results? YES Can the results be applied to the local population? YES Do the results fit with other available evidence? YES Who funded the trial? The study is explicitly described as unfunded research. Did the authors declare any conflicts of interest? NO Results: After applying the inclusion and exclusion criteria, they had 93,512 ED visits with a discharge diagnosis of hypertension. The mean age was 59 years, 57% female, 59% white, 10% received antihypertensive treatment in the ED before discharge, and 5% received an antihypertensive prescription at ED discharge. Patients prescribed antihypertensives at discharge were younger, more often male and Black, had higher systolic and diastolic blood pressure, lower comorbidity burden, were more likely to have received antihypertensives in the ED, and less likely to have prior heart failure. Key Result: One in 20 hypertensive ED patients received an antihypertensive prescription at discharge; among those who did, the adjusted odds of severe 30-day adverse events and ED revisits were substantially lower, with no difference in 30-day mortality compared with those who did not receive a prescription. Primary Outcome: Severe adverse events within 30 days 0.7% untreated vs 0.2% treated aOR 0.224 (95% CI; 0.106 to 0.416, p<0.001) Number needed to treat (NNT) 183 (95% CI; 161 to 247) to prevent one adverse event. Secondary Outcomes All cause death at 30 days: No statistical difference between groups (5 deaths in treated vs 105 untreated, aOR 1.445, 95% CI; 0.476–3.583, p=0.467). ED revisit within 30 days: Fewer in the treated group (10% vs 16%). Adjusted aOR 0.610 (95% CI; 0.547 to 0.678, p<0.001). NNT 18 (95% CI 16 to 23) to prevent one ED revisit. Individual Adverse Events: Antihypertensive therapy was significantly associated with decreased odds of acute heart failure (aOR 0.183, 95% CI; 0.056 to 0.441). No statistical difference in aortic catastrophe, MI, ischemic stroke, hemorrhagic stroke, and hypertensive encephalopathy, with some components having zero events in the treated group. 1. Residual Confounding: This is an observational treatment study, not a randomized trial, so the decision to prescribe is influenced by physician judgment and patient factors. Treated patients were younger, had less comorbidity, and were more likely to have received antihypertensives in the ED and to get follow-up prescriptions later. This suggests that they differed systematically from untreated patients. Even with multivariable adjustment and inverse probability weighting, unmeasured factors such as medication adherence, health literacy, or clinician concern could both drive the decision to treat and influence the likelihood of good outcomes. 2. Composite Endpoint: Death, severe adverse event or....ED revisit. That's kind of like a composite endpoint of you die, you have a myocardial infarction, or you sprain your ankle. As you would expect, the vast majority of patients who met one of these criteria (14,208 out of 14,978, almost 95%) had repeat ED visits. There was no significant difference in deaths. While there was a statistically significant difference in severe adverse events, the NNT to prevent one was 183,