Episode Details

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 outc