PODCAST: 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:

1. In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required.
2. 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]
3. 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:

1. Did the study address a clearly focused issue? YES
2. Did the authors use an appropriate method to answer their question? YES
3. Was the cohort recruited in an acceptable way? YES
4. Was the exposure accurately measured to minimize bias? UNSURE
5. Was the outcome accurately measured to minimize bias? UNSURE
6. Have the authors identified all important confounding factors? NO
7. Was the follow-up of the subjects sufficient? UNSURE
8. How precise are the results? YES
9. Do you believe the results? YES
10. Can the results be applied to the local population? YES
11. Do the results fit with other available evidence? YES
12. Who funded the trial? The study is explicitly described as unfunded research.
13. 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, and the patients who did not receive a prescription had a severe adverse event rate of 0.7%. No change in mortality, with an adverse event rate of 0.7%, should be the headline of the study. So, this didn’t really prove that we could prevent bad outcomes in a meaningful way. It proved that we could reduce repeat ED visits (NNT 18).

3. Statistical Fragility: Despite the large cohort, severe adverse events were rare (0.7% overall), with only nine events in the treated group. This leads to wide confidence intervals for some components, raising concerns about statistical fragility. The loss or gain of a few events could meaningfully change the effect estimate. The NNT of 183 to prevent one AE sounds precise but rests on small absolute differences.

4. Selection Bias: Including only patients with one of two ICD-10 codes (essential [primary] hypertension and hypertensive urgency) as either their primary or secondary diagnosis introduces selection bias. How many had it but weren’t given the diagnosis, or had it listed further down? Those were probably patients in whom the treating provider was less concerned and might have lower event rates. In addition, people who received treatment were healthier, younger, and at lower risk, and may (probably?) have had better outcomes because of that, as opposed to getting the prescription. Even with the deck stacked, the differences in significant outcomes were tiny.

5. Exposure Misclassification and Lack of Adherence Data or Harms: The exposure is “prescription given at ED discharge,” captured via electronic medical record orders, which is appropriate for studying prescribing behaviour but only a proxy for actual medication use. The authors note that patients who received antihypertensives outside the health system would be misclassified as untreated, and they had no data on prescription filling or medication adherence. There was also no data on the potential harms of taking the medication (allergic reactions, angioedema, hypotension leading to falls, etc). Hare to know the net impact of an intervention if you don’t collect data on the potential harms.

Comment on the Authors’ Conclusion Compared to the SGEM’s Conclusion: The major difference between the authors’ interpretation of these results and ours lies in how they are framed. Are the authors factually incorrect? No. They are technically correct in their presentation of their findings. But how clinically meaningful is it? The take-home point for us is that the baseline adverse event rate is well below 1%, which is our usual target. That’s the headline, which confirms our priors. So yes, in this cohort there was a decrease in short-term adverse event rates, but it was from a level we were already very happy with to a level that we should be a little bit happier with – not from bad to good,

SGEM Bottom Line: For discharged ED patients with untreated hypertension, giving an oral antihypertensive prescription at discharge is associated with reduced 30-day severe hypertensive events and ED revisits, but the observational design means we should be skeptical of the tiny potential benefit.

Case Resolution: Ankle X-ray is negative. The patient remains asymptomatic, aside from his ankle pain. He wants to know if we need to do anything about his blood pressure.

Clinical Application: This study reinforces the very low short-term risk of patients with elevated blood pressure without evidence of acute end-organ damage in the ED, with a 30-day severe adverse event rate of 0.7% when treatment was not provided. The authors suggest that this very low short-term risk may be further reduced by initiating antihypertensive therapy at discharge. This study shouldn’t be read as a mandate to treat every elevated blood pressure, but rather as supportive evidence when you’re on the fence about starting therapy at discharge.

Dr. Mike Pallaci

What Do I Tell the Patient? You engage in some shared decision-making with the patient. Emphasize the importance of management of blood pressure (even in the absence of symptoms) to prevent long-term complications such as heart attack, stroke, kidney failure and others, while also stressing that these are long-term risks, not short-term risks. “The likelihood of something bad happening in the next 30 days is significantly less than 1% no matter what we do. I can start a prescription here, which is unlikely to cause significant problems and may make that even less likely. We could wait until you follow up with your PCP and start it then, or I could call him/her to see if they have a preference. It’s a low-stakes decision; the likelihood of something bad happening either way is very low. What do you think?”

Keener Kontest: Last week’s winner was Dr. Casey Parker, a rural physician from Broome, Australia. He knew Andromeda was a princess of Ethiopia, Perseus’ wife and the daughter of Cepheus. She was apparently so beautiful that her father boasted she was more beautiful than the sea nymphs. Poseidon did not like that at all.

Listen to this week’s episode to hear the keener question. If you think you know the answer, send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a shoutout on the next SGEM episode.