Profile of patients with hypertensive urgency and emergency presenting to an urban emergency department of a tertiary referral hospital in Tanzania

Exploring the prevalence, clinical spectrum, and determinants of uncontrolled hypertension in the emergency department: Insights from a hospital-based study in Somalia

BACKGROUND

Uncontrolled hypertension (UH) is a significant public health issue in both developed and developing countries. This study aimed to analyze the clinical spectrum and degrees of severity of hypertension, antihypertensive use, and factors associated with UH.

METHOD

Hospital-based cross-sectional study was conducted at the emergency-department of Mogadishu Somali Turkey Training and Research Hospital from September 2021 to August 2022. A total of 278 hypertensive patients were selected using a convenient sampling technique. Data was entered into and cleaned by Excel and exported to SPSS version-26.0 for analysis. A binary logistic regression model (AOR, 95 % CI and p-value<0.05) was used to determine the predictors of UH.

RESULTS

The prevalence of UH was 62 %(n = 172). Of the total respondents, 144(51.8 %) were males. The predominance of the respondents(n = 147, 52.9 %) were in the age group 40-69years. Almost 65.8 %(n = 183) of the participants were married. 112(40.3 %) of the participants had no formal education. The majority of the participants (n = 192, 69.1 % %) were unemployed. 225(81 %) patients had at least one or more coexisting diseases. Diabetes was the most common comorbid(47.4 %). The most common clinical manifestations observed in the study group were headache(21 %). According to the stages of hypertension, most of the patients have a Hypertensive crisis(20.9 %). Among the participants, 50 % were on calcium channel blockers(CCBs). Additionally, the majority (53.2 %) were receiving monotherapy. Patients who have no comorbidity (AOR = 0.178, 95 % CI:0.066-0.447), not performed diet control (AOR = 15.475, 95 % CI:6.666-35.929), and non-adherence to physical-activity (AOR = 5.585, 95 % CI:2.834-12.792) are independent predictors of UH.

CONCLUSION

The prevalence of UH among patients with hypertension in Somalia was high. Unhealthy lifestyles and non-adherence to physical activity were the major modifiable risk factors for UH. Regular health education during follow-up visits by nurses and physicians is crucial in preventing the issue by providing continuous information on lifestyle practices and the potential complications associated with hypertension.

An Assessment of the Prevalence and Risk Factors of Hypertensive Crisis in Patients Who Visited the Emergency Outpatient Department (EOPD) at Adama Hospital Medical College, Adama, Oromia, Ethiopia: A 6-Month Prospective Study

Background

Over 1 billion people worldwide suffer from the common chronic medical condition of hypertension. A hypertensive crisis occurs when blood pressure exceeds 180/110 mmHg. Depending on whether the target organ is harmed, the situation may be presented as a hypertensive emergency or urgency.

Objective

To assess the prevalence and risk factors of patients with hypertensive crises who visited the Emergency Outpatient Department (EOPD) at Adama Hospital Medical College in Adama, Oromia, Ethiopia, between January 01 and August 31, 2021, G.C. Methodology. A cross-sectional, prospective study on the hypertensive crisis was conducted at Adama Hospital Medical College from January 01 to August 31, 2021, G.C. The data were collected using a standardized questionnaire, validated for completeness, and analyzed using SPSS. The findings were tabulated, and conclusions and recommendations were conveyed.

Result

Out of 9,082 patients who visited the EOPD during the six-month period, 444 individuals with hypertensive crises were identified, representing a prevalence of 4.9%. Of these, 56.8% were men, resulting in a M : F ratio of 1.31 : 1. Those between the ages of 66 and 75 were the most affected. At presentation, 91.0% of the study participants were known hypertensive patients. Among the known hypertensive patients, the majority (34.9%) were known to have been hypertensive for 5-10 years. Of the known hypertensive patients, 48.6% were found to be adherent. Hypertensive urgency was discovered to be far more common than hypertensive emergencies (63.5% vs. 36.5%). Headache was the most common presenting symptom, and most patients (36.5%) presented to the health setup in less than 24 hours. The main risk variables identified were drug discontinuation, family history of hypertension, salt consumption, and alcohol usage. The main excuse for the lack of adherence was the cost of the medications. More than half of the patients do not have any additional comorbidities, and of those who do, diabetes mellitus is the most prevalent. A stroke was identified as a major complication. Conclusions and Recommendations. Hypertensive crises are one of the most prevalent reasons for EOPD admission and are linked to significant consequences. At presentation, most of the study subjects were known hypertension patients. Diabetes mellitus was discovered to be a comorbid condition in one-quarter of them. Although more than half of the patients had improved, the death rate still remained high. Infrastructure and capacity building to provide hospitals with the requisite baseline investigations are among the government's recommendations. Health practitioners are expected to make improvements, such as by educating the public about the need for lifestyle changes and evaluating and managing any hypertension problems.

Prevalence, trends, and factors associated with hypertensive crisis among Peruvian adults

There are few studies focused on the epidemiology of hypertensive crisis at the population level in resource-constrained settings. This study aimed to determine the prevalence and trends over time of hypertensive crisis, as well as the factors associated with this condition among adults. A secondary data analysis was carried out using the Peruvian Demographic and Family Health Survey (ENDES). Hypertensive crisis was defined based on the presence of systolic (≥ 180mmHg) or diastolic (≥ 110mmHg) blood pressure, regardless of previous diagnosis or medication use. The factors associated with our outcome were evaluated using multinomial logistic regression, and the trend of hypertensive crisis was evaluated using the Cochrane-Armitage test. Data from 260,167 participants were analyzed, with a mean age of 44.2 (SD: 16.9) years and 55.5% were women. Hypertension prevalence was 23% (95%CI: 22.7-23.4) and, among them, 5.7% (95%CI: 5.4-5.9) had hypertensive crisis, with an overall prevalence of 1.5% (95%CI: 1.4-1.6). From 2014 to 2022, a significant decrease in the prevalence of hypertensive crisis was observed, from 1.7% in 2014 to 1.4% in 2022 (p = 0.001). In the multivariable model, males, increasing age, living in urban areas, high body mass index, and self-reported type 2 diabetes were positively associated with hypertensive crisis, whereas higher educational level, socioeconomic status, and high altitude were inversely associated. There is a need to improve strategies for the diagnosis, treatment, and control of hypertension, especially hypertensive crisis.

Determinants of hypertensive crisis among hypertensive patients at adult emergency departments of public hospitals in Addis Ababa, Ethiopia, 2021: a case-control study

BACKGROUND

Hypertension (HTN) is a major global health problem that affects approximately 1.13 billion people worldwide, and 1-2% of this population has hypertensive crisis. Hypertensive crisis is becoming a major health issue in low-income countries. However, few studies have been conducted in developing countries such as Ethiopia. This study aimed to assess the determinants of hypertensive crisis among patients visiting adult emergency departments of public hospitals in Addis Ababa.

METHOD

A hospital-based unmatched case-control study was conducted among 85 cases with a hypertensive crisis and 170 controls with hypertension without a hypertensive crisis in the adult emergency departments of public hospitals in Addis Ababa from March 15 to May 15, 2021. Data were collected using a structured questionnaire and analyzed using SPSS version 26. Binary logistic regression and multivariable logistic regression were performed. Finally, a statistically significant level was declared at a p value of less than 0.05. The result was summarized and presented in text, tables, and graph.

RESULT

The odds of having hypertensive crisis were 3.6 times (AOR = 3.621) higher among participants with a history of hypertension compared to those without a history of hypertension. There was also 4 times increased risk of hypertensive crisis among participants who presented with diabetes mellitus than participants who presented without it (AOR = 4.179). Similarly, participants who presented with stroke had 7 times higher odds of having hypertensive crisis (AOR = 7.174) than participants without stroke.

CONCLUSION

This study demonstrated a statistically significant association between unemployment, diabetes mellitus, stroke, heart failure, history of hypertension, family history of hypertension, and regular follow-up with a hypertensive crisis. The Ethiopian Ministry of Health, Ababa City Administration Health Bureau, and hospitals shall give due attention to the HTN crisis. Health care workers, hospital managers, and other stakeholders shall work towards the early detection and management of HTN-crisis to prevent related morbidity, disability, and mortality.

The burden and management strategies of hypertensive crisis in adult patients presenting to emergency departments of district and regional hospitals in Sub-Saharan Africa

BACKGROUND

Hypertensive crisis is among the causes of morbidity and mortality in adult patients with hypertension in Sub-Saharan Africa. We aimed to determine the burden, risk factors and describe the management strategies of hypertensive crisis among adult patients seen at emergency departments of district and regional hospitals in Tanzania.

METHODS

This was a prospective multicenter longitudinal study which included all 162 district and regional hospitals in Tanzania. It was part of the Tanzania Emergency Care Capacity Survey (TECCS), a large assessment of burden of acute illness and emergency care capacity in Tanzania. Adult patients who presented to emergency departments with blood pressure ≥ 180/110mmHg were enrolled. Demographics, clinical presentation, management, and 24-hours outcomes were recorded using a structured case report form. Descriptive statistics were summarized in frequency and median, while logistic regression was used to evaluate the association between risk factors and presence of hypertensive crisis.

RESULTS

We screened 2700 patients and enrolled 169 adults, henceforth proportion of adult patients with hypertensive crisis was 63 per 1000. Median age was 62 years (IQR 50-70 years) and predominantly females, 112 (66.3%). Majority 151(89.3%) were self-referred with two-wheel motorcycle being the commonest 46 (27.2%) mode of arrival to the hospital. Hypertensive emergency was found in over half 96 (56.8%) of the patients with hypertensive crisis, with oral medications administered in more than half of them, 71 (74%) as means to control the high blood pressure, and one-third 33 (34.4%) were discharged home. On multivariate analysis increasing age (AOR 4.53, p < 0.001), use of illicit drug (AOR 4.14, p-0.04) and pre-existing hypertension (AOR 8.1, p < 0.001) were independent risk factors for hypertensive crisis occurrence.

CONCLUSION

Hypertensive crisis among adult patients attending district and regional hospitals is common (63 patients per every 1000 patients). Increasing age, use of illicit drug and pre-existing hypertension are independent associated factors for developing hypertensive crisis.

Use of hospital services by patients with chronic conditions in sub-Saharan Africa: a systematic review and meta-analysis

Objective

To estimate the prevalence of individual chronic conditions and multimorbidity among adults admitted to hospital in countries in sub-Saharan Africa.

Methods

We systematically searched MEDLINE®, Embase®, Global Index Medicus, Global Health and SciELO for publications reporting on patient cohorts recruited between 1 January 2010 and 12 May 2023. We included articles reporting prevalence of pre-specified chronic diseases within unselected acute care services (emergency departments or medical inpatient settings). No language restrictions were applied. We generated prevalence estimates using random-effects meta-analysis alongside 95% confidence intervals, 95% prediction intervals and I2 statistics for heterogeneity. To explore associations with age, sex, country-level income status, geographical region and risk of bias, we conducted pre-specified meta-regression, sub-group and sensitivity analyses.

Findings

Of 6976 identified studies, 61 met the inclusion criteria, comprising data from 20 countries and 376 676 people. None directly reported multimorbidity, but instead reported prevalence for individual conditions. Among medical admissions, the highest prevalence was human immunodeficiency virus infection (36.4%; 95% CI: 31.3-41.8); hypertension (24.4%; 95% CI: 16.7-34.2); diabetes (11.9%; 95% CI: 9.9-14.3); heart failure (8.2%; 95% CI: 5.6-11.9); chronic kidney disease (7.7%; 95% CI: 3.9-14.7); and stroke (6.8%; 95% CI: 4.7-9.6).

Conclusion

Among patients seeking hospital care in sub-Saharan Africa, multimorbidity remains poorly described despite high burdens of individual chronic diseases. Prospective public health studies of multimorbidity burden are needed to generate integrated and context-specific health system interventions that act to maximize patient survival and well-being.

Clinical Outcomes in Hypertensive Emergency: A Systematic Review and Meta-Analysis

Background To study the prevalence and types of hypertension-mediated organ damage and the prognosis of patients presenting to the emergency department (ED) with hypertensive emergencies. Methods and Results PubMed was queried from inception through November 30, 2021. Studies were included if they reported the prevalence or prognosis of hypertensive emergencies in patients presenting to the ED. Studies reporting data on hypertensive emergencies in other departments were excluded. The extracted data were arcsine transformed and pooled using a random-effects model. Fifteen studies (n=4370 patients) were included. Pooled analysis demonstrates that the prevalence of hypertensive emergencies was 0.5% (95% CI, 0.40%-0.70%) in all patients presenting to ED and 35.9% (95% CI, 26.7%-45.5%) among patients presenting in ED with hypertensive crisis. Ischemic stroke (28.1% [95% CI, 18.7%-38.6%]) was the most prevalent hypertension-mediated organ damage, followed by pulmonary edema/acute heart failure (24.1% [95% CI, 19.0%-29.7%]), hemorrhagic stroke (14.6% [95% CI, 9.9%-20.0%]), acute coronary syndrome (10.8% [95% CI, 7.3%-14.8%]), renal failure (8.0% [95% CI, 2.9%-15.5%]), subarachnoid hemorrhage (6.9% [95% CI, 3.9%-10.7%]), encephalopathy (6.1% [95% CI, 1.9%-12.4%]), and the least prevalent was aortic dissection (1.8% [95% CI, 1.1%-2.8%]). Prevalence of in-hospital mortality among patients with hypertensive emergency was 9.9% (95% CI, 1.4%-24.6%). Conclusions Our findings demonstrate a pattern of hypertension-mediated organ damage primarily affecting the brain and heart, substantial cardiovascular renal morbidity and mortality, as well as subsequent hospitalization in patients with hypertensive emergencies presenting to the ED.

A Systematic Review and Meta-analysis of the Clinical and Epidemiological Characteristics of Patients with Hypertensive Emergencies: Implication for Risk Stratification

INTRODUCTION

Acute severe elevation of blood pressure (BP) is a common clinical event, that can present as hypertensive emergency (HTNE) and hypertensive urgency (HTNU). HTNE results in life-threatening target organ damage, including myocardial infarction, pulmonary edema, stroke, and acute kidney injury. It is associated with high utilization of healthcare and increased cost. HTNU is high BP without acute serious complications.

AIM

The purpose of this review was to examine the clinical-epidemiological characteristics of patients with HTNE and propose a risk stratification framework to differentiate between the two conditions, since prognosis, setting of therapy and treatment is vastly different.

METHODS

Systematic review.

RESULTS

Fourteen full-text studies were included in this review. In comparison with HTNU, patients with HTNE had higher mean systolic (mean difference 2.413, 95% CI 0.477, 4.350) and diastolic BP (mean difference 2.043, 95% CI 0.624, 3.461). HTNE were more prevalent in men (OR 1.390, 95% CI 1.207, 1.601), older adults (mean difference 5.282, 95% CI 3.229, 7.335) and those with diabetes (OR 1.723, 95% CI 1.485, 2.000). Non-adherence to BP medications (OR 0.939, 95% CI 0.647, 1.363) and unawareness of hypertension diagnosis (OR 0.807, 95% CI 0.564, 1.154) did not elevate the risk of HTNE.

CONCLUSIONS

Systolic and diastolic BP are marginally higher in patients with HTNE. Given that these differences are not clinically significant, other epidemiological and medical characteristics (older age, male sex, cardiometabolic comorbidities) as well as patient's presentation should be considered to differentiate between HTNU and HTNE.

Hypertensive Urgency and Anterior Epistaxis Caused by Antihypertensive Medication Noncompliance: A Case Report

Background and Aims

A sudden increase in blood pressure without serious, life-threatening symptoms or indications of immediate target organ damage is referred to as "hypertensive urgency." This case study revealed the rare direct cause of epistaxis and the direct cause of hypertensive urgency in an elderly man due to antihypertensive medication noncompliance.

Case Presentation

A black male farmer, age 63, was brought to the emergency room on June 1st, 2022, with chief complaints of breathing difficulties, epistaxis, and disorientation. The patient was hospitalized after exhibiting symptoms of breathlessness, malaise, nausea, and vomiting. Magnetic resonance imaging, an echocardiogram, and a computed tomography scan of the brain are all clear. For the treatment of epistaxis, he received 1g of tranexamic acid intravenously three times a day for two days. He received intravenous labetalol, which was effective in treating his hypertensive urgency and rebound hypertension, utilizing repeated dosages of 5-20 mg. The patient's intravenous labetalol and previous enalapril were switched to captopril 25 mg orally three times a day for one month after starting drugs per os.

Discussion

The patient's hypertensive urgency is directly caused by forgetting to take his blood pressure medication and by not adhering to his previous antihypertensive drugs as prescribed. In this study, the patient's hypertension had been uncontrolled for the previous six months despite his treatment plan. Unaware that he had missed two doses of his antihypertensive medication, he was admitted to the emergency room with progressive anterior nose bleeding that persisted for four hours. The patient's elevated arterial blood pressure is what's causing the patient's nose to bleed.

Clinico-epidemiological profile and risk factors of hypertensive crisis among patients attended at a tertiary care hospital in Somalia

Hypertensive crisis (HC) is a life-threatening clinical condition in which an abrupt rise in arterial blood pressure can lead to acute damage to vital organs. The main objective of our study is to determine the epidemiological profile, clinical characteristics, and risk factors of hypertensive crisis patients in Somalia. This study was a prospective cross-sectional study conducted on HC patients attended at Mogadishu Somali Turkish Training and Research Hospital in Mogadishu, Somalia, from November 2020 to April 2021. A total of 6239 patients were screened during the study period. The prevalence of HC was 2.1% (128/6239). Of them, 76 (59.4%) were males. The mean (SD) age of the participants was 56.5 (± 16.9) years (range: 24-98 years). 54.7% (70/128) met the criteria for a hypertensive emergency, while 45.3% (58/128) met the criteria of hypertensive urgency. Most patients (55.5%) took a single antihypertensive medicine, with calcium channel blockers being the most frequently used (57.8%). Headache and palpitation were the most often reported symptoms upon admission (39.1% and 25%). The most often prescribed antihypertensive drugs for the initial therapy included Intravenous furosemide (35.2%), Sublingual captopril (25.8%), intravenous nitroglycerin (23.4%), and intravenous labetalol (20%). Among the forms or patterns of end-organ damage of HE, we most frequently observed acute heart failure (45.7%), acute pulmonary edema (29.9%), and acute renal injury (25.7%). Infrequent medical checkups, poor compliance with medications, poor compliance with exercise, positive family history of hypertension, and being male gender were significant predictors of HC, AOR = 20.312; p < 0.000, AOR = 7.021; p < 0.008, AOR = 6.158; p < 0.017, AOR = 3.545; p < 0.032, and AOR = 2.144; p = 0.001, respectively. In Somalia, the hypertensive crisis is common in this clinic population. Infrequent medical checkups, poor compliance with medications and exercise, positive family history of hypertension, and being male gender were significant predictors of HC.

Treatment Outcome and Associated Factors Among Patients Admitted with Hypertensive Crisis in Public Hospitals at Harar Town, Eastern Ethiopia: A Cross-Sectional Study

BACKGROUND

Hypertensive crisis is a significant global health issue that raises the costs to healthcare systems and requires specific attention to improve clinical outcome. There is scarce information on hypertensive crisis cases treatment outcome in the study setting.

OBJECTIVE

This study aimed to assess treatment outcome and associated factors among patients admitted with hypertensive crisis at Public Hospitals in Harar Town, Eastern Ethiopia.

METHODS

A cross-sectional study was conducted among 369 hypertensive crisis patients who had been admitted to the emergency department of Hiwot Fana Comprehensive Specialized Hospital and Jugol General Hospital from May 1, 2017, to May 1, 2022. All hypertensive crisis patients who fulfilled the inclusion criteria were included. The data were extracted from medical records using a data abstraction format. The collected data were analyzed using Statistical Package for Social Sciences version 22. Binary logistics regression model using bivariate and multivariable analysis with 95% confidence intervals and P-values were used to determine the association between variables.

RESULTS

The medical records of 369 patients in total were reviewed. Of these, the medical records of 363 patients contained all the necessary information and were used in the study. More than half of the patients (238; 65.6%) were males. Among 363 patients admitted with hypertensive crisis, 98 (27.0%, 95% Confidence Interval (CI):22.5%-31.9%) of them had poor treatment outcome of hypertensive crisis. Being female (Adjusted Odds Ratio (AOR)=3.4; 95% CI=1.7-7.9), residing in rural areas (AOR=2.4; 95% CI=2.7-5.1), taking captopril during admission (AOR=5.6; 95% CI=2.4-7.9), taking antihypertensive treatment before admission (AOR=0.5; 95% CI=0.2-0.9), and being non compliant to treatment (AOR=2.7; 95% CI=1.4-3.5) had statistically significant associations with poor treatment outcome of hypertensive crisis compared to their counterparts.

CONCLUSION

The magnitude of poor treatment outcome of hypertensive crisis was high. Sex, residence, non-compliance, and type of emergency drug administered during admission were substantially related with poor treatment outcome of hypertensive crisis. Health professionals should put great emphasis on emergency drugs administered during admission to achieve the desired outcome.

Effect of a one-time financial incentive on linkage to chronic hypertension care in Kenya and Uganda: A randomized controlled trial

Background

Fewer than 10% of people with hypertension in sub-Saharan Africa are diagnosed, linked to care, and achieve hypertension control. We hypothesized that a one-time financial incentive and phone call reminder for missed appointments would increase linkage to hypertension care following community-based screening in rural Uganda and Kenya.

Methods

In a randomized controlled trial, we conducted community-based hypertension screening and enrolled adults ≥25 years with blood pressure ≥140/90 mmHg on three measures; we excluded participants with known hypertension or hypertensive emergency. The intervention was transportation reimbursement upon linkage (~$5 USD) and up to three reminder phone calls for those not linking within seven days. Control participants received a clinic referral only. Outcomes were linkage to hypertension care within 30 days (primary) and hypertension control <140/90 mmHg measured in all participants at 90 days (secondary). We used targeted minimum loss-based estimation to compute adjusted risk ratios (aRR).

Results

We screened 1,998 participants, identifying 370 (18.5%) with uncontrolled hypertension and enrolling 199 (100 control, 99 intervention). Reasons for non-enrollment included prior hypertension diagnosis (n = 108) and hypertensive emergency (n = 32). Participants were 60% female, median age 56 (range 27–99); 10% were HIV-positive and 42% had baseline blood pressure ≥160/100 mmHg. Linkage to care within 30 days was 96% in intervention and 66% in control (aRR 1.45, 95%CI 1.25–1.68). Hypertension control at 90 days was 51% intervention and 41% control (aRR 1.22, 95%CI 0.92–1.66).

Conclusion

A one-time financial incentive and reminder call for missed visits resulted in a 30% absolute increase in linkage to hypertension care following community-based screening. Financial incentives can improve the critical step of linkage to care for people newly diagnosed with hypertension in the community.

In‐hospital outcomes of patients with a hypertensive emergency at a medical center, Ethiopia: A prospective observational study

Background

Hypertensive emergency is associated with substantial complications and loss of life across the world. Early identification and treatment of hypertensive emergency complications are critical to prevent or avoid any consequences. Despite this, in Ethiopia, studies addressing mortality rate and its predictors as well as complications of hypertensive emergency are limited.

Aims

This study aim to evaluate in‐hospital mortality of patients admitted with a hypertensive emergency at the emergency ward of Jimma Medical Center.

Methods

A consecutive sample of 140 adult (≥18 years of age) patients with a hypertensive emergency were recruited from September 1, 2020 to February 25, 2021 at Jimma Medical Center, Ethiopia and were followed up from admission to discharge/death. Patients who declined to participate and readmitted during the study period were excluded. To assess factors associated with in‐hospital mortality, bivariate and multivariate Cox regression analyses were performed. A p value of less than 0.05 was used to declare the statistical significance.

Results

Over three‐fourths of the study participants, that is, 108 (77.1%), were males with a mean (±standard deviation) age of 52.8 ± 13.6 years. Hemorrhagic stroke, 53 (38.0%), and acute kidney injury, 38 (27.1%), were the most common complications of hypertensive emergency. The average (±standard deviation) length of stay in the hospital was 8.53 ± 3.61 days. During in‐hospital follow‐up, 16 patients (11.4%, 95% confidence interval: 6.7–17.9) died. Multivariate Cox regression analysis showed that there was a significant relationship between patients not doing regular physical exercise before the current admission (adjusted hazard ratio = 4.629, 95% confidence interval: 1.171–18.294, p = 0.015) and in‐hospital mortality.

Conclusion

More than one‐tenth of patients with hypertensive emergency death was recorded at Jimma Medical Center. The frequent complications of hypertensive emergency were hemorrhagic stroke and acute renal injury. Not doing regular physical exercise before the current admission raises the likelihood of in‐hospital death. Therefore, strengthening and encouraging patients to perform regular physical exercise is imperative.

The capacity of primary health care centers in Jordan to manage hypertension: areas for improvement

The assessment of the capacity of Primary Health Care (PHC) settings for the management of hypertension is essential to identify areas for improving management outcomes. This study aimed to assess the capacity of PHC centers in Jordan to manage hypertension including the assessment of human resources, equipment, and infrastructure. All comprehensive PHC centers located in Irbid and Mafraq governorates in north of Jordan (n = 23) were assessed. An assessment tool from HEARTS Technical Package was adapted and used for assessment. All centers have general practitioners and half of the centers (n = 11, 47.8%) had at least one family doctor working full time. In only one center, all doctors, nurses, and other health workers were trained on the management of hypertension. All centers, except one, had at least one functional automatic blood pressure measuring devices (BPMDs). Almost two thirds of centers (43.5%) had no measuring tapes. ECG machines were present in all centers except two. One third (n = 8, 34.8%) of centers had no functional glucometers. The majority of health centres carry out the laboratory investigations. Educational materials on physical activity, hypertension, and diabetes were seen in four (17.4%) centers only. Necessary medications were always available in the majority of health centers. In conclusion, this assessment revealed many areas for improvement in human resources, equipment, infrastructures, and other resources, such as developing an updated guideline/protocol of hypertension management, training the PHC staff on these guidelines, providing PHC centers with the necessary equipment, and establishing e-registry to improve documentation of data.

Hypertension in the South African public healthcare system: a cost-of-illness and burden of disease study

OBJECTIVES

To quantify the health and economic burden of hypertension in the South African public healthcare system.

SETTING

All inpatient, outpatient and rehabilitative care received in the national public healthcare system.

PARTICIPANTS

Adults, aged ≥20 years, who receive care in the public healthcare system.

OUTCOMES

Worksheet-based models synthesised data from multiple sources to estimate the burden of disease, direct healthcare costs, and societal costs associated with hypertension. Results were disaggregated by sex.

RESULTS

Approximately 8.22 million (30.8%, 95% CI 29.5% to 32.1%) South African adults with no private health insurance have hypertension. Hypertension was estimated to cause 14 000 (95% CI 11 100 to 17 200) ischaemic heart disease events, 13 300 (95% CI 10 600 to 16 300) strokes and 6100 (95% CI 4970 to 7460) cases of chronic kidney disease annually. Rates of hypertension, hypertension-related stroke and hypertension-related chronic kidney disease were greater for women compared with men.The direct healthcare costs associated with hypertension were estimated to be ZAR 10.1 billion (95% CI 8.98 to 11.3 billion) or US$0.711 billion (95% CI 0.633 to 0.793 billion). Societal costs were estimated to be ZAR 29.4 billion (95% CI 26.0 to 33.2 billion) or US$2.08 billion (95% CI 1.83 to 2.34 billion). Direct healthcare costs were greater for women (ZAR 6.11 billion or US$0.431 billion) compared with men (ZAR 3.97 billion or US$0.280 billion). Conversely, societal costs were lower for women (ZAR 10.5 billion or US$0.743 billion) compared with men (ZAR 18.9 billion or US$1.33 billion).

CONCLUSION

Hypertension exerts a heavy health and economic burden on South Africa. Establishing cost-effective best practice guidelines for hypertension treatment requires further research. Such research will be essential if South Africa is to make progress in its efforts to implement universal healthcare.

Pathophysiologically based antihypertensive pharmacotherapeutics rationality, efficacy and safety in Sub Saharan African Nations – A review

Background

Hypertension (HT) prevalence, Uncontrolled Blood Pressure (UBP), morbidity and mortality are highest in Sub-Saharan Africa (SSA). Correlating pathophysiology of HT to pharmaco-therapy with antihypertensive drugs (AHD) may bring amelioration. Aims:To review peculiarities of HT in SSA, UBP causes, diagnostic modalities, AHD use, rationality and efficacy.

Methods and results

14 published therapeutic audits in 4 SSA nations on Google Scholar or PUBMED, (total n = 6496 patients) were evaluated. Calcium Channel blockers (CCB) amlodipine, and thiazide diuretics (TD), hydrochlorothiazide (HCTZ) were the commonest AHD. Thiazide Like Diuretics (TLD) were underutilized. The % of patients on AHD were: 1 drug 5.4–55%; 2 drugs 37–82%; >/ = 3 drugs 6–50.3%. 2-drug combinations were: ACEI/ARB + TD (42%); CCB + TD (36.8%); ACEI + CCB (15.8%) of studies. Triple/quadruple therapy included Methyldopa (MTD) with ACEI + CCB or TD. The (%) attaining BP < 140/< 90 mmHg, ranged from 29 to 53.6%, median, 44%. The co-morbidities, range and median were: Diabetes Mellitus (DM): 9.8–64%, 19.2%; Chronic Kidney Disease (CKD): 5.7–7.5%, 6.9%, and Coronary artery Disease (CAD): 0.9–2.6%, 2.3%. ACEI + CCB ± TD were the preferred AHD for comorbidities.

Conclusions

Therapeutic inertia; Non-compliance; co-morbidities; refractory HT; ignorance; substandard AHD; contribute to UBP. Studies relating 24 hour ABPM to complications and mortality in SSA hypertensives; and impact of different AHD classes on ABPM, are needed. Study of ACEI + alpha-₁ blockers + TLD on 24 hour ABPM and personalized care, are required.

Low serum corin levels predict end-organ damage in patients with hypertensive crisis

OBJECTIVE

The study aimed to investigate the predictive power of serum corin levels for distinguishing between hypertensive urgency (HU) and hypertensive emergency (HE) in patients with hypertensive crisis (HC) admitted to the emergency department.

METHODS

A total of 120 consecutive consenting adult patients diagnosed with HC and 55 age- and sex-matched healthy controls were enrolled. Blood pressure measurements [(systolic, diastolic, and mean arterial pressure (MAP)] and the evidence of end-organ damage at the first admission were recorded. Patients with HC were classified as patients with HE or HU according to the presence or absence of acute end-organ damage. Serum corin levels were compared between the 2 groups.

RESULTS

The mean serum corin level was significantly lower in the HC group than in the control group; it was also lower in the HE group than in the HU group (p<0.001 for all). In the HE group, clinical features associated with end-organ damage included ST-elevation myocardial infarction (n=28, 46.7%), hemorrhagic stroke (n=11, 18.3%), ischemic stroke (n=11, 18.3%), and non-ST-elevation myocardial infarction (n=10, 16.7%). The receiving operator characteristic (ROC) analysis identified a serum corin cutoff value of 45 pg/mL for distinguishing patients with HE from patients with HU with 98.3% sensitivity and 95% specificity.

CONCLUSION

Our findings suggest that serum corin levels play an important role in regulating blood pressure and are involved in the pathogenesis of HC. Low serum corin levels may predict end-organ damage and serve as a guide for diagnostic decision making in patients with HC.

Risk factors for hypertensive crisis in adult patients: a systematic review

OBJECTIVE

The objective of this review was to examine the best available evidence on the risk factors for hypertensive crisis in adult patients with hypertension.

INTRODUCTION

Hypertensive crisis is an acute severe elevation in blood pressure, which can present as hypertensive urgency or emergency. In contrast to hypertensive urgency, which is a markedly elevated blood pressure without acute target organ damage, hypertensive emergency is associated with equally high blood pressure in the presence of potentially life-threatening target organ damage, such as myocardial infarction, stroke, pulmonary edema, or acute kidney injury. Hypertensive crisis results in adverse clinical outcomes and high utilization of health care.

INCLUSION CRITERIA

This review considered studies of non-modifiable factors (age, sex, ethnicity) and modifiable factors such as socioeconomic factors (lack of medical insurance, lack of access to medical care), adherence to medical therapies, presence of comorbidities (diabetes, hyperlipidemia, coronary artery disease, history of stroke, chronic kidney disease, congestive heart failure), and substance abuse in persons of either sex, older than 18 years with a diagnosis of hypertension.

METHODS

A search of four databases, seven gray literature sites, and relevant organizational websites revealed 11,387 titles. After duplicates were removed, 9183 studies were screened by the title and abstract for eligibility. Forty full-text articles were retrieved, and each was assessed for eligibility. Twenty-one articles were excluded. The remaining 19 full-text studies were critically appraised and included in this review.

RESULTS

The risk of hypertensive crisis was higher in patients with a history of comorbid cardiovascular conditions, such as chronic kidney disease (odds ratio [OR] 2.899, 95% confidence interval [CI] 1.32, 6.364), coronary artery disease (OR 1.654, 95% CI 1.232, 2.222), or stroke (OR 1.769, 95% CI 1.218, 2.571). Patients with hypertensive emergency had higher mean systolic blood pressure (mean difference [MD] 2.413, 95% CI 0.477, 4.350) and diastolic blood pressure (MD 2.043, 95% CI 0.624, 3.461). Hypertensive emergency was more common in men (OR 1.390, 95% CI 1.207,1.601), older patients (MD 5.282, 95% CI 3.229, 7.335), and those with diabetes (OR 1.723, 95% CI 1.485, 2.000) and hyperlipidemia (OR 2.028, 95% CI 1.642, 2.505). Non-adherence to antihypertensive medications (OR 0.939, 95% CI 0.647,1.363) and hypertensive diagnosis unawareness (OR 0.807, 95% CI 0.564, 1.154) did not increase the risk of hypertensive emergency.

CONCLUSIONS

Comorbid cardiac, renal, and cerebral comorbidities (coronary artery disease, congestive heart failure, cerebrovascular disease, and chronic kidney disease) increase the risk of hypertensive crisis. The risk of hypertensive crisis is higher in patients with unhealthy alcohol and recreational drug use. Systolic and diastolic blood pressure are marginally higher in patients with hypertensive emergency compared to patients with hypertensive urgency. Since these differences are small and not clinically significant, clinicians should rely on other symptoms and signs to differentiate between hypertensive urgency and hypertensive emergency. The risk of hypertensive emergency is higher in older adults. The coexistence of diabetes, hyperlipidemia, and chronic kidney disease increases the risk of hypertensive emergency.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO (CRD42019140093).

Management of hypertensive emergencies: a practical approach

Background: Acute increases of high blood pressure values, usually described as 'hypertensive crises', 'hypertensive urgencies' or 'hypertensive emergencies', are common causes of patients' presentation to emergency departments. Owing to the lack of ad hoc randomized clinical trials, current recommendations/suggestions for treatment of these patients are not evidenced-based and, therefore, the management of acute increases of blood pressure values represent a clinical challenge. However, an improved understanding of the underlying pathophysiology has changed radically the approach to management of the patients presenting with these conditions in recent years. Accordingly, it has been proposed to abandon the terms 'hypertensive crises' and 'hypertensive urgencies', and restrict the focus to 'hypertensive emergencies'. Aims and Methods: Starting from these premises, we aimed at systematically review all available studies (years 2010-2020) to garner information on the current management of hypertensive emergencies, in order to develop a novel symptoms- and evidence-based streamlined algorithm for the assessment and treatment of these patients.Results and Conclusions: In this educational review we proposed the BARKH-based algorithm for a quick identification of hypertensive emergencies and associated acute organ damage, to allow the patients with hypertensive emergencies to receive immediate treatment in a proper setting.

Beyond severe acute maternal morbidity: a mixed-methods study on the long-term consequences of (severe pre-)eclampsia in rural Tanzania

OBJECTIVES

To explore the long-term (perceived) consequences of (severe pre-)eclampsia in rural Tanzania.

METHODS

Women were traced for this mixed-methods study 6-7 years after the diagnosis of (severe pre-)eclampsia. Demographic and obstetric characteristics were noted, and blood pressure was recorded. Questionnaires were used to assess physical and mental health. The qualitative part consisted of semi-structured interviews (SSI). A reference group consisted of women without hypertensive disorders of pregnancy.

RESULTS

Of 74 patients, 25 (34%) were available for follow-up, and 24 were included. Five (20%) had suffered from (pre-)eclampsia twice. Hypertension was more common after (pre-)eclampsia than in the reference group (29% vs. 13%). Thirteen women (56%) had feelings of anxiety and depression, compared to 30% in the reference group. In SSIs, experiences during the index pregnancy were explored, as well as body functions, reproductive life course and limitations in daily functioning, which were shown to be long-lasting.

CONCLUSIONS

Women who suffered from (severe pre-)eclampsia may experience long-term sequelae, including hypertension, depression and anxiety. Women lack information about their condition, and some are worried to conceive again. To address their specific needs, a strategy along the continuum of care is needed for women following a complicated pregnancy, starting with a late postnatal care visit 6 weeks after giving birth.

Prevalence of Hypertensive Emergency and Associated Factors Among Hospitalized Patients with Hypertensive Crisis: A Retrospective Cross-Sectional Study

Background

Hypertensive emergency (HE) is an acute stage of uncontrolled blood pressure which poses a substantial cardiovascular morbidity and mortality in developing countries. In our setting, the prevalence of HE and the characteristics of patients with a hypertensive crisis are not certainly known yet.

Objective

The study assessed the prevalence of hypertensive emergency and associated factors among hospitalized patients with hypertensive crisis.

Methods

A retrospective cross-sectional study was conducted by reviewing records of patients having a diagnosis of hypertensive crisis with systolic/diastolic blood pressure raised to more than 180/120 mmHg admitted to Ayder Comprehensive Specialized Hospital (ACSH) from September 2018 to August 2019. Patients' medical records with complete information were enrolled consecutively. Socio-demographic, clinical characteristics, and other related variables were collected using a structured data collection tool from patient medical records. Data were entered and analyzed using SPSS version 20. Logistic regression was employed to determine factors associated with HE.

Results

A total of 141 patients' records with a diagnosis of a hypertensive crisis were enrolled in the study; the majority were females 77 (54.6%) and residing in the urban setting 104 (73.8%). The mean age of the participants was 58.8 years. HE was found in 42 (29.8%) of patients. Intravenous Hydralazine 39 (27.7%) and oral calcium channel blocker 102 (72.3%) were the prescribed drugs for acute blood pressure reduction in the emergency setting. Surprisingly, patients who had no history of hypertension (adjusted odds ratio (AOR)=2.469; 95% confidence interval (CI): 0.176‒0.933) and female sex (AOR=2.494; 95% CI: 1.111‒5.596) were found to be independently associated factors with HE.

Conclusion

The prevalence of HE was found to account a significant proportion of patients. Hence, hypertensive patients should be strictly managed accordingly, and promoting screening programs could reduce the risk of target organ damage.

Clinical value of multiorgan damage in hypertensive crises: A prospective follow-up study

Hypertensive crises are associated with high rates of target organ complications and poor outcomes. A recent shift from the definition of malignant hypertension to hypertension-multiorgan damage (MOD) contributes to the diagnosis and management of hypertensive crises. Here, we prospectively included 166 adult (≥18 years old) patients with hypertensive crises (blood pressure >180/120 mm Hg). Target organs and causes of hypertension were assessed. Patients who were diagnosed with malignant hypertensive retinopathy, the absence of malignant hypertensive retinopathy but the presence of damage to at least 3 organs, and the absence of both retinopathy and MOD were classified as the malignant hypertension (n = 48), hypertension-MOD (n = 42), and hypertension without MOD (n = 76) groups, respectively. Patients were followed to evaluate renal and cardiovascular prognoses. At baseline, patients with malignant hypertension had worse renal function, higher level of albuminuria, and more severe microvascular damage than those with hypertension-MOD. Both had similar proportions of malignant arteriolar nephrosclerosis (83% vs 64%), left ventricular hypertrophy (90% vs 88%), abnormal repolarization (71% vs 60%), and left ventricular dysfunction (12% vs 21%). At the twenty months of follow-up, both the malignant hypertension and hypertension-MOD groups had similar blood pressure control rates and proteinuria. Both groups had worse renal outcomes than the hypertension without MOD group (P = .002). Patients with hypertension-MOD (HR = 0.67, [95% CI: 0.30-1.46], P = .31) had similar renal event-free survival than patients with MHT after adjustments of age, sex, blood pressure, and proteinuria control. These results suggest that in hypertensive crises, both malignant hypertension and hypertension-MOD have impact on adverse renal outcomes.

The Burden of Hypertension and Diabetes in an Emergency Department in Northern Tanzania

Introduction

Little is known about the burden of hypertension and diabetes on emergency department (ED) utilization and hospitalizations in sub-Saharan Africa.

Methods

A retrospective review of adult ED patients in northern Tanzania was performed from September 2017 through March 2018. Hypertension was defined as documented diagnosis of hypertension or blood pressure ≥ 140/90 mm Hg. Diabetes was defined as documented diagnosis of diabetes mellitus or random glucose ≥ 200 mg/dL.

Results

Of 3961 adult ED patients, 1359 (34.3%) had hypertension, 518 (13.1%) had diabetes, and 273 (6.9%) had both. Both hypertension (OR 1.42, 95% CI 1.23-1.63, P<.001) and diabetes (OR 2.05, 95% CI 1.66-2.54, P<.001) were associated with increased odds of admission. Of 2418 hospital admissions, 694 (28.7%) were for complications of hypertension or diabetes. Of 499 patients admitted for hypertensive complications, the most common admission diagnoses were: heart failure (163 patients, 32.7%); stroke (147 patients, 29.5%); and severe hypertension (139 patients, 27.9%). Of 278 patients admitted for diabetic complications, the most common admission diagnoses were: hyperglycemia (158 patients, 56.9%); infection (60 patients, 21.6%); and stroke (28 patients, 10.1%).

Conclusions

The burden of hypertension and diabetes in a Tanzanian ED is high, and the ED may serve as an opportune location for case identification and linkage-to-care interventions. Given the large proportion of Africans with undiagnosed hypertension and diabetes, an ED-based screening program would likely identify many new cases of these diseases. The high burden of hypertension- and diabetes-related hospitalizations highlights the urgent need for improvements in primary preventative care in Tanzania.

Hypertensive crises in sub-Saharan Africa: Clinical profile and short-term outcome in the medical emergencies department of a national referral hospital in Burkina Faso

BACKGROUND

Data on hypertensive crises (HC) are limited in sub-Saharan Africa (SSA). We aimed to characterize the pattern and short-term mortality of hypertensive emergencies (HE) and urgencies (HU).

METHODS

This was a prospective cohort study. Consecutive patients with acute and severely elevated blood pressure (systolic>180mmHg and/or diastolic >120mmHg) with or without acute target-organs damage attending the emergency department (ED) of the Teaching Hospital of Yalgado Ouedraogo, Ouagadougou, Burkina Faso were included with a one-month follow-up.

RESULTS

One hundred and sixty-six of 1254 patients presenting to the ED (January to march 2016) had HC (13.2%) and 113 of them (68.1%) had HE. The mean age was 50.9±15.9 years and males were 63.3% (n=105). Younger age (<45 years) accounted for 55% of the cases. History of known HTN was reported in 101 patients (60.8%). Among patients with HE, 62.8% had brain-related events, 30.1% had cardiac involvement and 31% had acute renal impairment. The overall survival rate was 89% within the first 72hours and 81% at fourteen days follow-up. At one-month follow-up, 36 patients died with a survival rate of 77.8%. Factors independently associated with death were history of known hypertension, acute brain-related damage and renal dysfunction and not being transferred to a specialized department.

CONCLUSION

HC are not rare in SSA and are associated with higher morbidity and mortality in HE. Further studies are needed to determine factors that promote HC in African patients in order to better address the prevention and management strategies of such hypertensive entity.