Why We Do What We Do: Routine ECGs for Hypertension

You are working at Jacobi, screening a huge number of patients when the nurse hands you an EKG. “Who is this for?” She replies, “It’s for a new patient, Mr. Jones.” “What’s his complaint?” She responds, “He has high blood pressure, but he is here for his knee pain.” It seems to be routine for our institution to fetch EKGs on all hypertensive patients even when they don’t have symptoms related to cardiac issues. Having worked at Jacobi a number of years I resorted to the thought…there must be some reason we do this…so I sign the EKG and keep moving. There are some things to consider in this situation. First and foremost, if there is an abnormality on the EKG will it effect your management when it has nothing to do with the reason the patient came to the ER? Secondly, as responsible physicians, we need to consider the cost of an ECG interpretation in an already expensive healthcare arena. With this on my mind, I decided to go digging in the archives and uncovered this nugget….

Routine Chest Roentgenograms and Electrocardiograms – Usefulness in the Hypertensive Workup – Arch Intern Med 1978

The article, although old, does a pretty nice job reviewing a decent cohort of patient charts (109) with asymptomatic hypertension to see in the clinic if a routine ECG made any difference in their management. Arguments were made that LVH or cardiac enlargement may be identified on the ECG as they are difficult findings on physical exam. However, when considering how identifying LVH (which has questionable reliability on ECG as it is) effects the management of patients with asymptomatic hypertension in the ER, you might start thinking the ECG is kind of silly. History and physical exam (there you go Ciorciari) should be relied on in the setting of asymptomatic hypertension to determine if an ECG or other studies are required in a patient with asymptomatic hypertension. Ultimately, according to ACEP guidelines, asymptomatic hypertension usually only requires referral for follow-up….while we are on a roll check that policy out if you get a chance below:

Clinical Policy – Critical Issues in the Evaluation and Management of Adult Patients With Asymptomatic Hypertension in the Emergency Department – AEM 2006

After reviewing the evidence, the Jacobi-ism of routine ECGs for hypertension may need to come to an end. I’d like to know your thoughts…leave a post for me.

2 Comments on "Why We Do What We Do: Routine ECGs for Hypertension"

  • Fairly recent (2 weeks ago)… ACEP updated their clinical guidelines on asymptomatic hypertension… pretty much don’t do anything.. http://www.acep.org/Clinical—Practice-Management/Clinical-Policy–Critical-Issues-in-the-Evaluation-and-Management-of-Adult-Patients-in-the-Emergency-Department-With-Asymptomatic-Elevated-Blood-Pressure/

    ***EXCEPT for patients with poor follow up. which is most of my patients, and I’m assuming, jacobi’s and even monte’s as well.

    173 1. In ED patients with asymptomatic elevated blood pressure, does screening for target organ injury reduce
    174 rates of adverse outcomes?
    176 Patient Management Recommendations
    177 Level A recommendations. None specified.
    178 Level B recommendations. None specified.
    179 Level C recommendations. (1) In ED patients with asymptomatic markedly elevated blood pressure,
    180 routine screening for acute target organ injury (eg, serum creatinine, urinalysis, ECG) is not required.
    181 (2) In select patient populations (eg, poor follow-up), screening for an elevated serum creatinine may
    182 identify kidney injury that affects disposition (eg, hospital admission).

  • by the way, just a refresher.. level C recommendation is not that robust. it’s consensus recommendation/expert opinion, but not backed by great research. still better than my opinion though =)

    122 Level A recommendations. Generally accepted principles for patient management that reflect a high
    123 degree of clinical certainty (ie, based on strength of evidence Class I or overwhelming evidence from strength of
    124 evidence Class II studies that directly address all of the issues).
    125 Level B recommendations. Recommendations for patient management that may identify a particular
    126 strategy or range of management strategies that reflect moderate clinical certainty (ie, based on strength of
    127 evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or
    128 strong consensus of strength of evidence Class III studies).
    129 Level C recommendations. Other strategies for patient management that are based on Class III studies or,
    130 in the absence of any adequate published literature, based on panel consensus. In instances in which consensus
    131 recommendations are made, this is specifically indicated next to the recommendation.

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