Utility of Routine Testing in Asymptomatic Markedly Elevated Blood Pressure in the Emergency Department: A Prospective Cohort Study.

BACKGROUND: Routine diagnostic testing for asymptomatic adults with markedly elevated blood pressure (BP) in the emergency department (ED) imposes a substantial operational burden despite uncertain clinical benefit. OBJECTIVES: This study aimed to evaluate the prevalence and clinical significance of routine test abnormalities, identify predictors of actionable findings, and assess short-term clinical outcomes in this population. METHODS: We conducted a prospective observational cohort study from May 2025 to February 2026. Asymptomatic adults (>18 years) with significantly elevated BP (systolic >180 mmHg or diastolic >110 mmHg) were enrolled. Acute target-organ damage (TOD) was ruled out using a structured symptom checklist. Primary outcomes were clinically meaningful test abnormalities and 7-day adverse clinical events. RESULTS: Among 210 enrolled patients (median presenting BP 199/118 mmHg), repeat measurement after >30 min showed a significant spontaneous median systolic reduction of 24 mmHg without acute intervention. While 13.3% of patients had clinically meaningful abnormalities, only 3.3% necessitated hospital admission and 3.3% required immediate treatment modification. Most abnormalities (10.9%) triggered process-driven outcomes, such as specialist consultations, without altering ED disposition. Chronic kidney disease (CKD) was the sole independent predictor of actionable findings (aOR = 8.28, (95% CI: 2.09-32.82; p = 0.003). The 7-day adverse event rate was low (1.9%), with no deaths or events occurring in patients without meaningful ED-based abnormalities. CONCLUSIONS: Routine screening for asymptomatic severe hypertension is low-yield and often identifies subacute conditions rather than emergencies. Validating 2025 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines, a risk-stratified approach prioritizing CKD screening and rapid outpatient follow-up ensures safety while optimizing emergency resources.