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….
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:
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.