Blood Pressure Management in the Presence of Pain

Physicians are not likely to intensify antihypertensive medications when patients have an elevated blood pressure (BP) in the setting of pain, according to the results of a recent study.¹

An observational study was conducted to examine the associations of an elevated BP and medication intensification at a patient’s initial visit and BP at a subsequent visit. Included in the study were 56,322 participants who reported various levels of pain.

Despite a lack of medication intensification, patients with an elevated BP during their initial visit were not more likely to have an elevated BP at a follow-up visit.

Consultant360 reached out to study author Elizabeth Pfoh, PhD, MPH, who is a researcher in the internal medicine and geriatrics departments at the Cleveland Clinic in Cleveland, Ohio, to gain more insight on the associations between BP, pain, and medication intensification as observed in this study.

Consultant360: Your study examined how physicians managed BP medication in patients who reported pain. How did this research objective come about?

Elizabeth Pfoh: This study came about through a combination of teamwork, opportunity, and clinical insight. It is common medical knowledge that BP rises when an individual is in severe pain, and physicians often do not treat elevated BP in the presence of pain. We wanted to know the impact of that clinical decision. Fortunately, we had 2 separate datasets from previously conducted studies: one with pain scores and one with BP measurements. The dataset that contained the pain measurements was originally collected by Alex Chaitoff, MD, who was a medical student at the time. He not only shared his dataset but also was a big proponent of answering this question. A really delightful part of this study was the opportunity to work with him and the other members of this team to answer this question.

C360: Your team found that, while health care providers were less likely to intensify antihypertensive treatment when patients reported pain during their initial visit, patients were not more likely to have an elevated BP at subsequent visits. Why is this finding significant?

EP: This finding is significant because it is known that physicians delay treating patients’ elevated BP when they are in pain. Now we know that the delay is not associated with harm in the following 6 months. 

C360: Was this a result that surprised you, or did you anticipate this?

EP: Our results were surprising to us. We hypothesized that pain would not be associated with elevated BP, but reporting pain would be associated with delayed treatment and subsequent elevated BP. We undertook this study because we thought patients might be unnecessarily living with elevated BP due to delayed treatment. We were pleased to find out that that was not the case. Instead, physicians’ inertia in prescribing antihypertensive medications when the patient had elevated BP and reported pain was not associated with harm.

C360: What are the key takeaway messages of this study for health care providers?

EP: The key takeaway message is that clinicians should not take pain into account when deciding to intensify medication for hypertension unless the patient is in severe pain. 

Reference:

1. Pfoh ER, Chaitoff AM, Martinez K, Keenan K, Rothberg MB. Association between pain, blood pressure and medication intensification in primary care: an observational study. J Intern Med. 2020;35:3549-3555. doi:10.1007/s11606-020-06208-z