Untreated Hypertension and Diabetes in the Chest Pain Observation Unit

Hypertension and diabetes are common cardiovascular disease risk factors among emergency department observation unit (EDOU) patients evaluated for acute coronary syndrome (ACS). Our primary aim was to determine rates of untreated hypertension and diabetes in the EDOU. Our secondary aim was to identify rates of glycemic control assessment among patients with diabetes.

We conducted a retrospective, observational cohort study of patients ≥ 18 years old evaluated for ACS in a tertiary care center EDOU from March 3, 2019-February 28, 2020. Known diagnoses prior to EDOU encounter and new outpatient diagnoses within one year for hypertension and diabetes were identified by health record data. We defined untreated hypertension and diabetes as no antihypertensive or antihyperglycemic prescriptions or diabetes counseling within one year. We calculated treatment rates with exact 95% confidence intervals (CI). Multivariable logistic regression adjusting for age, sex, and race compared treatment rates among men vs women and White vs non-White patients. Rates of glycemic control assessment were defined by the proportion of patients with known diabetes who received hemoglobin A1c (HbA1c) measurement within one year.

Among 649 EDOU patients, 59.5% (386/649) were female and 43.8% (284/649) were non-White with a mean age of 59 ± 12 years. Of these, 76.9% (499/649) had known hypertension and 31.3% (203/649) had known diabetes. Within one year, 3.1% (20/649) had newly diagnosed hypertension and 3.2% (21/649) had newly diagnosed diabetes. Among those with known or newly diagnosed hypertension, untreated hypertension occurred in 36.4% (189/519; 95% CI 32.3 - 40.7). Hypertension treatment rates were similar in men vs women (aOR [adjusted odds ratio] 0.82, 95% CI 0.57 - 1.19) and White vs non-White patients (aOR 0.95, 95% CI 0.66 - 1.38). Among those with known or newly diagnosed diabetes, untreated diabetes occurred in 25.0% (56/224; 95% CI 18.5 - 31.2). Diabetes treatment rates were similar in men vs women (aOR 1.41, 95% CI 0.72 - 2.74) and White vs. non-White patients (aOR 1.05, 95% CI 0.56 - 1.97). At one year, just 32.0% (65/203) of patients with diabetes had HbA1c testing.

Given that many patients evaluated for acute coronary syndrome in the ED observation unit do not receive treatment for hypertension and diabetes within one year of presentation, clinicians should consider initiating EDOU-based preventive cardiovascular care for these conditions.