Hospital admissions for hypertensive crisis in the emergency departments: a large multicenter Italian study

[Clinical acute and emergency medicine curriculum-focus on internal medicine : Recommendations for advanced training in internal medicine in the emergency department]

In Germany, physicians qualify for emergency medicine by combining a specialty medical training-e.g. internal medicine-with advanced training in emergency medicine according to the statutes of the State Chambers of Physicians largely based upon the Guideline Regulations on Specialty Training of the German Medical Association. Internal medicine and their associated subspecialities represent an important column of emergency medicine. For the internal medicine aspects of emergency medicine, this curriculum presents an overview of knowledge, skills (competence levels I-III) as well as behaviours and attitudes allowing for the best treatment of patients. These include general aspects (structure and process quality, primary diagnostics and therapy as well as indication for subsequent treatment; resuscitation room management; diagnostics and monitoring; general therapeutic measures; hygiene measures; and pharmacotherapy) and also specific aspects concerning angiology, endocrinology, diabetology and metabolism, gastroenterology, geriatric medicine, hematology and oncology, infectiology, cardiology, nephrology, palliative care, pneumology, rheumatology and toxicology. Publications focussing on contents of advanced training are quoted in order to support this concept. The curriculum has primarily been written for internists for their advanced emergency training, but it may generally show practising emergency physicians the broad spectrum of internal medicine diseases or comorbidities presented by patients attending the emergency department.

The diagnostic approach and management of hypertension in the emergency department

Hypertension urgency and emergency represents a challenging condition in which clinicians should determine the assessment and/or treatment of these patients. Whether the elevation of blood pressure (BP) levels is temporary, in need of treatment, or reflects a chronic hypertensive state is not always easy to unravel. Unfortunately, current guidelines provide few recommendations concerning the diagnostic approach and treatment of emergency department patients presenting with severe hypertension. Target organ damage determines: the timeframe in which BP should be lowered, target BP levels as well as the drug of choice to use. It's important to distinguish hypertensive emergency from hypertensive urgency, usually a benign condition that requires more likely an outpatient visit and treatment.

Slow on the Draw-ED Management of Elevated BP in Older Adults

PURPOSE OF REVIEW

The purpose of this study is to review data surrounding the emergency department management of elevated blood pressure in older adults, including the management of hypertensive crisis and outpatient management of markedly elevated blood pressure.

RECENT FINDINGS

Acute lowering of blood pressure in older adults with markedly elevated blood pressure may lead to serious complications without improvements in hospital length of stay, return visits, or mortality. Older adults presenting with elevated blood pressures without evidence of end-organ damage should be referred for outpatient management of their blood pressure. Treatment of hypertensive emergency should follow standard guidelines with additional considerations for aging physiology. Acute lowering of elevated blood pressure in older adults without evidence of end-organ damage has the potential for harm. If the emergency physician opts to acutely treat, they should consider the increased risk of side effects in older adults and avoid Beers list medications including short-acting nifedipine and clonidine.

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.

One-year outcomes following a hypertensive urgency or emergency

There are scarce data on the comparative prognosis between patients with hypertensive emergencies (HE), urgencies (HU), and those without HU or HE (HP). Our study aimed to compare cardiovascular (CV) outcomes of HE, HU, and HP during a 12-month follow-up period. The population consisted of 353 consecutive patients presenting with HE or HU in a third-care emergency department and subsequently referred to our hypertension center for follow-up. After both groups completed scheduled follow-up visits, patients with HU were matched one-to-one by age, sex, and hypertension history with HP who attended our hypertension center during the same period. Primary outcomes were 1) a recurrent hypertensive HU or HE event and 2) non-fatal CV events (coronary heart disease, stroke, heart failure, or CV interventions), while secondary outcomes were 1) all-cause death, 2) CV death, 3) non-CV death, and 4) any-cause hospitalization. Events were prospectively registered for all three groups. During the study period, 81 patients were excluded for not completing follow-up. Among eligible patients(HE = 94; HU = 178), a total of 90 hospitalizations and 14 deaths were recorded; HE registered greater CV morbidity when compared with HU (29 vs. 9, HR 3.43, 95 % CI 1.7-6.9, p = 0.001), and increased CV mortality (8 vs. 1, HR 13.2, 95 % CI 1.57-110.8, p = 0.017). When opposing HU to HP, events did not differ substantially. Cox regression models were adjusted for age, sex, CV and chronic kidney disease, diabetes mellitus, and smoking. During 1-year follow-up, the prognosis of HU was better than HE but not different compared to HP. These results highlight the need for improved care of HU and HE.

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 emergencies and urgencies: a preliminary report of the ongoing Italian multicentric study ERIDANO

Hypertensive urgencies (HU) and hypertensive emergencies (HE) are challenges for the Emergency Department (ED). A prospective multicentre study is ongoing to characterize patients with acute hypertensive disorders, prevalence of subclinical hypertension-mediated organ damage (HMOD), short- and long-term prognosis; this is a preliminary report. Patients admitted to the ED with symptomatic blood pressure (BP) ≥180/110 mmHg were enrolled. They were managed by ED personnel according to their clinical presentations. Subsequently they underwent clinical evaluation and subclinical HMOD assessment at a Hypertension Centre within 72 h from enrolment. 122 patients were included in this report. Mean age was 60.7±13.9 years, 52.5% were females. 18 (14.8%) patients were diagnosed with HE, 108 (88.5%) with HU. There were no differences in gender, BMI, and cardiovascular comorbidities between groups. At ED discharge, 66.7% and 93.6% (p = 0.003) of HE and HU patients, respectively, had BP < 180/110 mmHg. After 72 h, 34.4% of patients resulted normotensive; 35.2%, 22.1%, and 8.2% had hypertension grade 1, 2, and 3, respectively. Patients with uncontrolled BP at office evaluation had higher vascular HMOD (49.1 vs. 25.9%, p = 0.045). Cardiac (60 vs. 34%, p = 0.049), renal (27.8 vs. 9.6%, p = 0.010) and cerebral (100 vs. 21%, p < 0.001) HMOD was more frequent in HE compared to HU group. HE showed greater cardiac, renal, and cerebral subclinical HMOD, compared to HU. 72-hours BP control is not associated with different HMOD, except for vascular HMOD; therefore, proper comprehensive examination after discharge from the ED could provide added value in cardiovascular risk stratification of such patients. One third of patients with acute blood pressure rise evaluated to the ED resulted normotensive at office evaluation (<72 hours after discharge). Patients with hypertensive emergency showed greater cardiac, renal, and cerebral subclinical HMOD, compared to the patients with hypertensive urgency. BP: blood pressure; HMOD: hypertension-mediated organ damage; y.o.: years old; mo.: months.

The effect of combining therapeutic drug monitoring of antihypertensive drugs with personalised feedback on adherence and resistant hypertension: the (RHYME-RCT) trial protocol of a multi-centre randomised controlled trial

BACKGROUND

Adherence to antihypertensive drugs (AHDs) is important for adequate blood pressure control. Not taking these drugs as prescribed is one of the main underlying causes for resistant hypertension (RH), which in turn leads to an increased risk of cardiovascular events, stroke and kidney damage. Therefore, correct identification of patients that are non-adherent to AHDs is crucial to improve clinical outcome. For this goal, therapeutic drug monitoring is the most reliable method. The primary objective of this trial is to investigate whether monitoring of drug concentrations with a dried blood spot (DBS) sampling method combined with personalised feedback leads to a decrease in prevalence of RH after 12 months due to an increase in adherence. Secondary objectives include the difference over time in the number of required AHDs as well as the defined daily dose (DDD). Lastly, the cost-utility of SoC versus the intervention in RH is determined.

METHODS

This is a multi-centre single-blinded randomised controlled trial (RHYME-RCT). First, at an eligibility visit, DBS sampling, to monitor drug concentrations in blood, and a 24-h ambulatory blood pressure measurement (24-h ABPM) are performed simultaneously. Patients with a daytime systolic blood pressure (SBP) > 135 and/or diastolic blood pressure (DBP) > 85 mmHg are randomised to SoC or intervention + SoC. The intervention is performed by the treating physician and includes information on drug concentrations and a comprehensive personalised feedback conversation with the use of a communication tool. The follow-up period is one year with visits at 3, 6 and 12 months randomisation and includes 24-h ABPM and DBS sampling.

DISCUSSION

This will be the first trial that focusses specifically on patients with RH without taking into account suspicion of non-adherence and it combines monitoring of AHD concentrations to identify non-adherence to AHDs with a comprehensive feedback to improve non-adherence. Furthermore, if this trial shows positive outcomes for the intervention it can be directly implemented in clinical practice, which would be a great improvement in the treatment of RH.

TRIAL REGISTRATION

RHYME-RCT is registered in the Dutch Trial Register on 27/12/2017 (NTR6914) and can be found in the International Clinical Trials Registry Platform.

Prevalence of neurological complaints among emergency department patients with severe hypertension

OBJECTIVE

Severe hypertension can accompany neurological symptoms without obvious signs of target organ damage. However, acute cerebrovascular events can also be a cause and consequence of severe hypertension. We therefore use US population-level data to determine prevalence and clinical characteristics of patients with severe hypertension and neurological complaints.

METHODS

We used nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected in 2016-2019 to identify adult ED patients with severely elevated blood pressure (BP) defined as systolic BP ≥ 180 mmHg and/or diastolic BP ≥120 mmHg. We used ED reason for visit data fields to define neurological complaints and used diagnosis data fields to define acute target organ damage. We applied survey visit weights to obtain national estimates.

RESULTS

Based on 5083 observations, an estimated 40.4 million patients (95% CI: 37.5-43.0 million) in EDs nationwide from 2016 to 2019 had severe hypertension, equating to 6.1% (95% CI: 5.7-6.5%) of all ED visits. Only 2.8% (95% CI: 2.0-3.9%) of ED patients with severe hypertension were diagnosed with acute cerebrovascular disease; hypertensive urgency was diagnosed in 92.0% (95% CI: 90.3-93.4%). Neurological complaints were frequent in both patients with (75.6%) and without (19.9%) cerebrovascular diagnoses. Hypertensive urgency patients with neurological complaints were more often older, female, had prior stroke/TIA, and had neuroimaging than patients without these complaints. Non-migraine headache and vertigo were the most common neurological complaints recorded.

CONCLUSION

In a nationally representative survey, one-in-sixteen ED patients had severely elevated BP and one-fifth of those patients had neurological complaints.

Clinical Profile of Patients with Hypertensive Emergency Referred to a Tertiary Hospital in the Western Cape Province of South Africa

BACKGROUND

Despite advances in managing hypertension, hypertensive emergencies remain a common indication for emergency room visits. Our study aimed to determine the clinical profile of patients referred with hypertensive emergencies.

METHODS

We conducted an observational study involving patients aged ≥18 years referred with hypertensive crisis. A diagnosis of hypertensive emergencies was based on a systolic blood pressure (BP) ≥180 mmHg and/or a diastolic BP ≥110 mmHg, with acute hypertension-mediated organ damage (aHMOD). Patients without evidence of aHMOD were considered hypertensive urgencies. Hypertensive disorders of pregnancy and unconscious patients were excluded from the study.

RESULTS

Eighty-two patients were included, comprising 66 (80.5%) with hypertensive emergencies and 16 (19.5%) with hypertensive urgencies. The mean age of patients with hypertensive emergencies was 47.9 (13.2) years, and 66.7% were males. Age, systolic BP, and duration of hypertension were similar in the hypertensive crisis cohort. Most patients with hypertensive emergencies reported nonadherence to medication (78%) or presented de novo without a prior diagnosis of hypertension (36%). Cardiac aHMOD (acute pulmonary edema and myocardial infarction) occurred in 66%, while neurological emergencies (intracranial hemorrhage, ischemic stroke, and hypertensive encephalopathy) occurred in 33.3%. Lactate dehydrogenase (LDH) (P < 0.001), NT-proBNP (P=0.024), and cardiac troponin (P<0.001) were higher in hypertensive emergencies compared to urgencies. LDH did not differ in the subtypes of hypertensive emergencies.

CONCLUSION

Cardiovascular and neurological emergencies are the most common hypertensive emergencies. Most patients reported nonadherence to medication or presented de novo without a prior diagnosis of hypertension.

Medication Adherence in Patients With Uncontrolled Hypertension & Hypertensive Crisis Presenting to a Hospital Setting in Karachi, Pakistan

BACKGROUND

Hypertension is an established risk factor for cardiovascular disease. Non-adherence to antihypertensive medications contributes to poorly controlled hypertension while also increasing the risk of hypertensive crisis. The aim of our study was thus to estimate the frequency of adherence to antihypertensive medications in our population and also see if an association exists between adherence and the development of a hypertensive crisis.

METHODS

This cross-sectional study was undertaken on patients admitted to Aga Khan University Hospital, Karachi, Pakistan, between July 2020 and March 2022. All patients with uncontrolled hypertension with systolic blood pressure >140 and diastolic blood pressure >90 who were admitted through the emergency department were included. A systolic blood pressure over 180mmHg or diastolic blood pressure over 120mmHg, with or without end-organ damage was used to define a hypertensive crisis. Adherence to medications was assessed using the 4-item Morisky Green Levine (MGL) scale. Each item was scored as 1 and then added together to get a final score out of 4 with a score of ≥3 signifying adherence while a cumulative score of 0, 1, or 2 was classified as non-adherence.

RESULTS

We found that 64% of the cohort were adherent to their medications while 93 (36%) were non-adherent. The most common comorbid condition was found to be diabetes mellitus (54.8%). Around 146 (64.6%) patients were on a single anti-hypertensive agent. Depression as calculated according to the hospital anxiety and depression scale (HADS) was seen in 133 (51.2%) of our cohort while 147 (56.5%) had anxiety. Similar rates of adherence were seen amongst males (49.1%) and females (50.9%). The highest level of adherence was seen in the 61 to 75 years age group (34.9%) and in those with university-level education (30.6%). We also found a statistically significant association between adherence to antihypertensive medications with anxiety (p-value=0.048). Moreover, in the hypertensive crisis group, 40.7% of the patients were adherent to their antihypertensive medications while 54.8% were found to be non-adherent, with the p-value reaching statistical significance (p-value=0.028).

CONCLUSION

We found a higher rate of adherence (64%) in this inpatient hypertensive population as compared to previous studies in our population. We also found that non-adherence is a risk factor for the development of a hypertensive crisis. Therefore, at clinic visits, physicians should assess their patient's adherence to antihypertensive medications to prevent the development of a hypertensive crisis.

Prevalence of Myocardial Injury and Myocardial Infarction in Patients with a Hypertensive Emergency: A Systematic Review

Myocardial injury and myocardial infarction can complicate a hypertensive emergency, and both are associated with poor prognosis. However, little is known about the prevalence of myocardial injury and the different subtypes of myocardial infarction in patients with hypertensive emergencies. This systematic review aims to determine the prevalence of myocardial infarction and its subtypes, and the prevalence of myocardial injury in patients with hypertensive emergencies following the PRISMA guideline. A systematic search of PubMed, Web of Science, and EBSCOHost (MEDLINE) databases was carried out from inception to identify relevant articles. A total of 18 studies involving 7545 patients with a hypertensive emergency were included. Fifteen (83.3%) studies reported on the prevalence of myocardial infarction ranging from 3.6% to 59.6%, but only two studies specifically indicated the prevalence of ST-elevation and non-ST-elevation myocardial infarction. The prevalence of myocardial injury was obtained in three studies (16.7%) and ranged from 15% to 63%. Despite being common, very few studies reported myocardial injury and the subtypes of myocardial infarction among patients presenting with a hypertensive emergency, highlighting the need for more research in this area which will provide pertinent data to guide patient management and identify those at increased risk of major adverse cardiovascular events.

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.

Inflammatory cytokines are associated to lower glomerular filtration rate in patients with hypertensive crisis

Introduction

Hypertension and kidney function are closely related. However, there are few studies on renal function during acute elevation of blood pressure (BP), denominated hypertensive crisis (HC).

Objectives

To evaluate the relationship between renal function and inflammatory cytokines in HC, subdivided into hypertensive urgency (HUrg) and emergency (HEmerg).

Materials and methods

This cross-sectional study was carried out in 74 normotensive (NT) and 74 controlled hypertensive individuals (ContrHT) followed up in outpatient care. Additionally, 78 subjects with hypertensive emergency (HEmerg) and 50 in hypertensive urgency (HUrg), attended in emergency room, were also evaluated. Hypertensive crisis was classified into HEmerg, defined by systolic blood pressure (BP) ≥ 180 mmHg and/or diastolic BP ≥ 120 mmHg in presence of target-organ damage (TOD), and HypUrg, clinical situation with BP elevation without TOD. The glomerular filtration rate (eGFR) was estimated, and cytokine levels were measured. Statistical analysis was performed using the Kruskal-Wallis or Mann-Whitney test and Spearman’s correlation, with significant differences p-value &lt; 0.05.

Results

The median age was 53.5 years in the NT group (52 female), 61 years in the ContrHT group (52 female), and 62.5 years in the HC group (63 female) (p-value &lt; 0.0001). The median BP was 118.5/75 mmHg for NT, 113.5/71 for ContrHT, and 198.5/120 mmHg for HC, respectively (p-value &lt; 0.0001 among groups). BP and heart rate levels were significantly higher in the HC group compared to the NT and ContrHT groups (P &lt; 0.001 for all). The eGFR was significantly lower in HC group compared to the NT and ContrHT groups. The cytokine levels were higher in the HEmerg and HUrg groups compared to ContrHT group (P &lt; 0.0001, except for IL-1β in HUrg vs. ContrHT), without difference between the acute elevation of BP groups. Thus, all cytokines were significantly elevated in patients with HC compared to the control groups (NT and ContrHT). There was a negative correlation between eGFR and the cytokines (IL-1β, IL-6, IL-8, IL-10, and TNF-α) in the HC group.

Conclusion

Elevated inflammatory cytokines are associated with reduced eGFR in individuals with HC compared to control groups, suggesting that the inflammatory process participates in the pathogenesis of acute elevations of BP.

Epidemiology and outcomes of hypertensive crisis in patients with chronic kidney disease: a nationwide analysis

BACKGROUND

The epidemiology and outcomes of hypertensive crisis (HTN-C) in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) have not been well studied. The objective of our study is to describe the incidence, clinical characteristics, and outcomes of emergency department (ED) visits for HTN-C in patients with CKD and ESRD.

METHODS

We performed a secondary analysis of Nationwide Emergency Department Sample databases for years 2016-2018 by identifying adult patients presenting to ED with hypertension related conditions as primary diagnosis using appropriate diagnosis codes.

RESULTS

There were 348 million adult ED visits during the study period. Of these, 680 333 (0.2%) ED visits were for HTN-C. Out of these, majority were in patients without renal dysfunction (82%), with 11.4 and 6.6% were in patients with CKD and ESRD, respectively. The CKD and ESRD groups had significantly higher percentages of hypertensive emergency (HTN-E) presentation than in the No-CKD group (38.9, 34.2 and 22.4%, respectively; P  < 0.001). ED visits for HTN-C frequently resulted in hospital admission and these were significantly higher in patients with CKD and ESRD than in No-CKD (78.3 vs. 72.6 vs. 44.7%; P  < 0.0001). In-hospital mortality was overall low but was higher in CKD and ESRD than in No-CKD group (0.3 vs. 0.2 vs. 0.1%; P  < 0.0001), as was cost of care (USD 28 534, USD 29 465 and USD 26 394, respectively; P  < 0.001).

CONCLUSION

HTN-C constitutes a significant burden on patients with CKD and ESRD compared with those without CKD with a higher proportion of ED visits, incidence of HTN-E, hospitalization rate, in-hospital mortality and cost of care.

GRAPHICAL ABSTRACT

http://links.lww.com/HJH/C22.

Differences in Diagnosis and Management of Hypertensive Urgencies and Emergencies According to Italian Doctors from Different Departments Who Deal With Acute Increase in Blood Pressure-Data from Gear (Gestione Dell'emergenza e Urgenza in ARea Critica) Study

Background: Diagnosis and treatment of hypertension emergency (HE) and urgency (HU) may vary according to the physicians involved and the setting of the treatment. The aim of this study was to investigate differences in management of HE and HU according to the work setting of the physicians. Methods: The young investigators of the Italian Society of Hypertension developed a 23-item questionnaire spread by email invitation to the members of Italian Scientific societies involved in the field of emergency medicine and hypertension. Results: Six-hundred and sixty-five questionnaires were collected. No differences emerged for the correct definitions of HE and HU or for the investigation of possible drugs that may be responsible for an acute increase in BP. The techniques used to assess BP values (p < 0.004) and the sizes of cuffs available were different according to the setting. Cardiologists more frequently defined epistaxis (55.2% p = 0.012) and conjunctival hemorrhages (70.7%, p < 0.0001) as possible presentation of HE, and rarely considered dyspnea (67.2% p = 0.014) or chest pain (72.4%, p = 0.001). Intensive care (IC) unit doctors were more familiar with lung ultrasound (50% p = 0.004). With regard to therapy, cardiologists reported the lowest prescription of i.v. labetalol (39.6%, p = 0.003) and the highest of s.l. nifedipine (43.1% p < 0.001). After discharge, almost all categories of physicians required home BP assessment or referral to a general practitioner, whereas hypertensive center evaluation or ambulatory BP monitoring were less frequently suggested. Conclusion: Management and treatment of HE and HU may be different according to the doctor’s specialty. Educational initiatives should be done to standardize treatment protocols and to improve medical knowledge.

Cardiovascular prognosis in patients admitted to an emergency department with hypertensive emergencies and urgencies

BACKGROUND

At present, few data are available on the prognosis of hypertensive emergencies and urgencies admitted to emergency departments.

AIM

The aim of our study was to evaluate the incidence of total and cardiovascular events during follow-up in hypertensive patients admitted to the emergency departments of Brescia Hospital (Northern Italy) with hypertensive emergencies or urgencies from 1 January to 31 December 2015.

METHODS

Medical records of patients aged more than 18 years, admitted to the emergency department with SBP values at least 180 mmHg (SBP) and/or DBP values at least 120 mmHg (DBP) were collected and analysed (18% of patients were classified as 'hypertensive emergency' and 82% as 'hypertensive urgency'). Data in 895 patients (385 men and 510 women, mean age 70. 5 ± 15 years) were analysed; the mean duration of follow-up after admission to the emergency department was 12 ± 5 months.

RESULTS

During the follow-up, 96 cardiovascular events (28 fatal) occurred (20 cardiac events, 30 cerebrovascular events, 26 hospital admission for heart failure, 20 cases of new onset kidney disease). In 40 patients (4.5%), a new episode of acute blood pressure rise with referral to the emergency department was recorded. Cardiovascular mortality and morbidity were greater in patients with a previous hypertensive emergency (14.5 vs. 4.5% in patients with hypertensive emergency and urgency, respectively, chi-square, P < 0.0001). Similar results were obtained when the occurrence of cerebrovascular or renal events were considered separately.

CONCLUSION

Admission to the emergency department for hypertensive emergencies and urgencies identifies hypertensive patients at increased risk for fatal and nonfatal cardiovascular events. Our findings add some new finding suggesting that further research in this field should be improved aiming to define, prevent, treat and follow hypertensive urgencies and emergencies.

Clinical characteristics, practice patterns, and outcomes of patients with acute severe hypertension visiting the emergency department

OBJECTIVES

Data regarding acute severe hypertension, a life-threatening condition encountered in the emergency department, are limited. We aimed to identify the characteristics, practice patterns, and outcomes of patients with acute severe hypertension in the emergency department.

METHODS

This cross-sectional study at a tertiary referral centre included patients aged at least 18 years who were admitted to the emergency department between January 2016 and December 2019 for acute severe hypertension, which was defined as SBP at least 180 mmHg and/or DBP at least 100 mmHg.

RESULTS

Of 172 105 patients who visited the emergency department, 10 219 (5.9%) had acute severe hypertension. Of them, 2506 (24.5%) patients had acute hypertension-mediated organ damage (HMOD), and these patients had more cardiovascular risk factors than did patients without HMOD. Additionally, 4137 (40.5%) patients were admitted, and nine (0.1%) died in the emergency department. The overall 3-month, 1-year, and 3-year mortality rates were 4.8, 8.8, and 13.9%, respectively. In patients with HMOD, the 1-year mortality rate was 26.9%, and patients lost to follow-up had a significantly higher 1-year mortality rate than those who were followed up (21.3 vs. 10.5%, respectively, P < 0.001).

CONCLUSION

The mortality rate in patients with acute severe hypertension in the emergency department is high, especially in patients with HMOD. Evaluation of HMOD, investigating the underlying causes, and adequate follow-up are mandatory to improve the outcomes in these patients. This study emphasizes the need for disease-specific guidelines that include detailed acute treatment strategies and follow-up management for acute severe hypertension.

Profile and management of hypertensive urgencies and emergencies in the emergency cardiology department of a tertiary hospital: a 12-month registry

AIMS

Currently there are scarce epidemiological data regarding prevalence, clinical phenotype, and therapy of hypertensive urgencies (HU) and emergencies (HE). The aim of this article was to record the prevalence, clinical characteristics, and management of patients with HU and HE assessed in an emergency department (ED) of a tertiary hospital.

METHODS AND RESULTS

The population consisted of patients presenting with HE and HU in the ED (acute increase in systolic blood pressure (BP) ≥ 180 mmHg and/or diastolic BP ≥120 mmHg with and without acute target organ damage, respectively). Of the 38 589 patients assessed in the ED during a 12-month period, 353 (0.91%) had HU and HE. There were 256 (72.5%) cases presented as HU and 97 (27.5%) as HE. Primary causes for both HU and HE were stress/anxiety (44.9%), increased salt intake (33.9%), and non-adherence to medication (16.2%). Patients with HU reported mainly dizziness/headache (46.8%) and chest pain (27.4%), whereas those with HE presented dyspnoea (67%), chest pain (30.2%), dizziness/headache (10.3%), and neurological disorders (8.2%). In HE, the underlying associated conditions were pulmonary oedema (58%), acute coronary syndrome (22.6%), and neurological disorders/stroke (7.2%). All HE cases were hospitalized and received intensive healthcare, including dialysis.

CONCLUSION

This 1-year single-centre registry demonstrates a reasonable prevalence of HU and HE contributing to the high volume of visits to the ED. Stress, increased salt intake and non-adherence were main triggers of HE and HU. Dizziness and headache were the prevalent symptoms of HU patients while heart failure was the most common underlying disease in patients with HE.

Impact of Intravenous Antihypertensives on Outcomes Among Hospitalized Patients

BACKGROUND

Many hospitalized patients with acute elevations in blood pressure (BP) are treated with intravenous (IV) antihypertensive medications without evidence of benefit. This study investigated the effects of IV as-needed (PRN) antihypertensives on BP, hospital length of stay, and mortality.

METHODS

We included hospitalized patients with an order for an IV PRN antihypertensive medication. We excluded patients with target organ damage. We performed multivariate analysis to assess whether the medication was independently associated with outcomes.

RESULTS

1,784 out of 5,680 patients (31%) had an administration of the PRN medication. Patients who received the medication had a longer hospital stay compared with patients with an order for the medication who did not receive it (4.9 ± 6.1 vs. 3.1 ± 4.1 days, P < 0.001). This remained statistically significant after adjusting for covariates. In-hospital mortality was higher in the group that received the medication (3.3% vs. 1.6%, P < 0.001), but this was not statistically significant on multivariate analysis. IV hydralazine caused the most significant reduction in BP and led to a shorter length of stay when compared with enalapril and labetalol. A total of 62% of patients received the medication for a systolic BP lower than 180 mm Hg.

CONCLUSIONS

Treating hypertension in the in-patient setting remains complex. Rapid lowering of BP can cause harm to patients, and this study showed that antihypertensive medication increased hospital length of stay. Once assuring no target organ damage, a strategic approach should be to treat modifiable factors and gradually reduce BP.

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.

Guide de Pratique Clinique. Prise en charge de l’hypertension artérielle chez l’adulte en Tunisie

Ce document a été réalisé dans le cadre d'une collaboration entre l'Instance Nationale de l’Évaluation et de l'Accréditation en Santé (INEAS), la Société Tunisienne de Cardiologie et de Chirurgie Cardiovasculaire (STCCCV) et la Caisse Nationale d’Assurance Maladie (CNAM).

Hypertensive crisis in patients with obstructive sleep apnea-induced hypertension

Background

Hypertensive crisis is an urgent/emergency condition. Although obstructive sleep apnea (OSA) in resistant hypertension has been thoroughly examined, information regarding the risk factors and prevalence of hypertensive crisis in co-existing OSA and hypertension is limited. This study thus aimed to determine prevalence of and risk factors for hypertensive crisis in patients with hypertension caused by OSA.

Methods

The inclusion criteria were age of 18 years or over and diagnosis of co-existing OSA and hypertension. Those patients with other causes of secondary hypertension were excluded. Patients were categorized by occurrence of hypertensive crisis. Factors associated with hypertensive crisis were calculated using multivariate logistic regression analysis.

Results

There were 121 patients met the study criteria. Of those, 19 patients (15.70%) had history of hypertensive crisis. Those patients in hypertensive crisis group had significant higher systolic and diastolic blood pressure at regular follow-ups than those without hypertensive crisis patients (177 vs. 141 mmHg and 108 vs. 85 mmHg; p value < 0.001 for both factors). After adjusted for age, sex, and Mallampati classification, only systolic blood pressure was independently associated with hypertensive crisis with adjusted odds ratio (95% CI) of 1.046 (1.012, 1.080).

Conclusions

The prevalence of hypertensive crisis in co-existing OSA and hypertension was 15.70% and high systolic blood pressure or uncontrolled blood pressure associated with hypertensive crisis in patients with OSA-associated hypertension.

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).

Hypertensive emergencies and urgencies in emergency departments: a systematic review and meta-analysis

OBJECTIVES

The prevalence of hypertensive emergencies and urgencies and of acute hypertension-mediated organ damage (aHMOD) in emergency departments is unknown. Moreover, the predictive value of symptoms, blood pressure (BP) levels and cardiovascular risk factors to suspect the presence of aHMOD is still unclear. The aim of this study was to investigate the prevalence of hypertensive emergencies and hypertensive urgencies in emergency departments and of the relative frequency of subtypes of aHMOD, as well as to assess the clinical variables associated with aHMOD.

METHODS

We conducted a systematic literature search on PubMed, OVID, and Web of Science from their inception to 22 August 2019. Two independent investigators extracted study-level data for a random-effects meta-analysis.

RESULTS

Eight studies were analysed, including 1970 hypertensive emergencies and 4983 hypertensive urgencies. The prevalence of hypertensive emergencies and hypertensive urgencies was 0.3 and 0.9%, respectively [odds ratio for hypertensive urgencies vs. hypertensive emergencies 2.5 (1.4-4.3)]. Pulmonary oedema/heart failure was the most frequent subtype of aHMOD (32%), followed by ischemic stroke (29%), acute coronary syndrome (18%), haemorrhagic stroke (11%), acute aortic syndrome (2%) and hypertensive encephalopathy (2%). No clinically meaningful difference was found for BP levels at presentations. Hypertensive urgency patients were younger than hypertensive emergency patients by 5.4 years and more often complained of nonspecific symptoms and/or headache, whereas specific symptoms were more frequent among hypertensive emergency patients.

CONCLUSION

Hypertensive emergencies and hypertensive urgencies are a frequent cause of access to emergency departments, with hypertensive urgencies being significantly more common. BP levels alone do not reliably predict the presence of aHMOD, which should be suspected according to the presenting signs and symptoms.

Funduscopy: Yes or no? Hypertensive emergencies and retinopathy in the emergency care setting; a retrospective cohort study

According to international guidelines, patients with a suspected hypertensive emergency (HE) admitted to the emergency department (ED) should undergo comprehensive evaluation including funduscopic examination. However, funduscopy is not always readily available and little is known about the prevalence of retinopathy among these patients in the ED setting. In order to characterize patients who should undergo funduscopy, we studied the prevalence, characteristics and clinical outcome in patients with a suspected HE and retinopathy grade III/IV. We conducted a retrospective cohort study of consecutive patients with severe elevation of blood pressure (BP) admitted to the ED between 2012 and 2015. Patients with a systolic blood pressure (SBP) ≥180 mm Hg or diastolic blood pressure (DBP) ≥120 mm Hg at time of presentation were included. A total of 271 patients were included, of whom 18 (6.6%; 95%CI 3.9‐10.5) had a HE. In 121 patients (44.6%; 95%CI 37.1‐53.3), funduscopy was performed, of whom 17 (14.0%; 95%CI 8.2‐22.5) had retinopathy grade III/IV. Mean SBP and DBP were significantly higher in patients with retinopathy (P < .001). However, retinopathy was also seen in patients with lower BP (SBP < 200 mm Hg and DBP < 120 mm Hg). No differences in other clinical characteristics, including visual disturbances, were found. One patient with retinopathy suffered an ischemic stroke after taking oral medication. The prevalence of retinopathy is high among examined patients. Except for higher BP, no clinical signs or symptoms are associated with the presence of retinopathy grade III/IV. We therefore conclude that funduscopic examination should be performed in every patient with a suspected HE.

Characteristics, treatment, and outcome of patients with hypertensive crisis admitted to University of Gondar Specialized Hospital, northwest Ethiopia: A cross-sectional study

Despite major public health initiatives are working in the control of hypertension, hypertensive crisis remains an important clinical problem. This study aimed at examining the characteristics, treatment and outcome of patients with hypertensive crisis admitted to the University of Gondar Specialized Hospital, Ethiopia. A cross-sectional study was conducted on patient medical records (n = 304) between January 01, 2013 and December 31, 2017. Data were analyzed using Statistical Package for Social Sciences version21. A total of 252 patient medical records were included in the analysis. The mean age of the entire patients was 54 ± 17 years. Two hundred and nineteen (86.9%) patients have a documented history of hypertension and on antihypertensive drugs (n = 166, 65.9%). The majority of cases (n = 166, 65.9%) were hypertensive urgencies. In more than one-third of the patients (n = 98, 38.9%), the cause of the illness was attributed to non-compliance to therapy. The most common presenting signs and symptoms at admission were headache (n = 170, 67.5%), dyspnea (n = 36, 14.3%), and vomiting (n = 33, 13.1%). Of 852 tests ordered, the results of one-third (n = 298,34.9%) were abnormal. Nearly two-thirds (n = 336, 59.2%) of prescriptions documented were for hypertensive urgency. Captopril (n = 136, 23.9%) and hydralazine (n = 43, 7.6%) were the most commonly prescribed oral and intravenous drugs respectively. Ten patients died during 55 hours of hospital stay. All hospital mortalities were documented for a hypertensive emergency. The median decrement of diastolic blood pressure among patients with no history of previous admission and hypertensive urgency was significantly higher than those patients with a previous history of admission (P = .005) and hypertensive emergency (P = .010). These findings justify better treatment and follow-up for these patients. Most importantly, to improve compliance with treatment health professionals should provide education to the patients.

[The hypertensive emergency situation : Recommendations for initial drug therapy management]

The hypertensive emergency situation is characterized by an acute-mostly life-threatening-blood pressure derailment with the risk of acute end organ damage. It is an acute manifestation of arterial hypertension, which manifests in a variety of symptoms. The etiology is in most cases long-term (chronic) hypertension as a result of low compliance or inadequate antihypertensive therapy. It can also occur as a first manifestation of arterial hypertension. It requires timely antihypertensive drug therapy, which should be initiated in an intensive or intermediate care unit. The choice of antihypertensive therapy regimen should be based on the underlying end organ damage. Fast-acting, easily controllable and intravenously administered substances should be preferred. The most commonly used substances (groups) are urapidil, nitroglycerin, beta blockers and short-acting calcium channel blockers. With a few exceptions, a deliberate, rapid reduction in blood pressure of no more than 20-25% of the initial value is sufficient for extracerebral causes. A subsequent systolic blood pressure target of 160/100 mm Hg should be aimed for within the next 2-6 h. An overly rapid drop in blood pressure can lead to reduced blood flow to the central nervous system due to changes in autoregulation. Exceptions to this rule are acute aortic dissection and flash pulmonary edema-in these cases, prompt blood pressure normalization should be achieved. The initial acute therapy should be followed by a more detailed investigation of the cause and a long-term therapy setting based on this.

Retinal and Choroidal Capillary Perfusion Are Reduced in Hypertensive Crisis Irrespective of Retinopathy

Purpose

Hypertensive crisis causes end-organ damage through small-vessel damage as described histologically. Noninvasive optical coherence tomography angiography (OCTA) makes it possible to image retinal and choroidal capillaries on a microscopic level in vivo. We quantified eye vessel perfusion changes in hypertensive crisis using OCTA.

Methods

Patients with hypertensive crisis (systolic blood pressure ≥180 mm Hg and/or diastolic blood pressure ≥110 mm Hg) and age-matched healthy controls were included in the study. OCTA en face 3 × 3-mm images of the superficial and deep retinal layers and the choriocapillaris were acquired. Outcome parameters included vessel density (VD) and vessel skeleton density (VSD) of the superficial and deep retinal layers, as well as flow voids of the choriocapillaris.

Results

Twenty-eight eyes of 17 patients and 31 age-matched control eyes of 18 healthy subjects were included. VD and VSD of the deep retinal layer were significantly reduced in hypertensive crisis (P ≤ 0.004). Choriocapillaris signal intensity was more heterogeneous in patients, and flow voids exhibited confluence with a larger average area and a lower absolute count (P ≤ 0.045). These changes were independent of time since onset of hypertensive crisis and of the presence and extent of retinopathy. Deep retinal changes were associated with renal end-organ failure (P = 0.045).

Conclusions

Hypertensive crisis is associated with a significant reduction in retinal and choroidal capillary perfusion based on OCTA findings. These alterations are independent of retinopathy and related to end-organ damage.

Translational Relevance

OCTA might help distinguish hypertensive urgency from hypertensive emergency earlier than currently possible.

Accuracy of a Symptom-Based Approach to Identify Hypertensive Emergencies in the Emergency Department

BACKGROUND

A hierarchical symptoms-based diagnostic strategy relying on the presence of five main symptoms (chest pain, acute dyspnea, neurological symptoms, headache, visual impairment) was recently proposed to diagnose patients with hypertensive emergency. However, poor scientific evidence is available about the role of symptoms in both diagnosis and management of acute hypertensive disorders.

METHODS

Data from 718 patients presenting to the emergency department of the "Città della Salute e della Scienza" Hospital of Turin with systolic blood pressure > 180 and/or diastolic blood pressure > 110 mm/Hg were retrospectively analyzed. The accuracy of the typical symptoms for identification of hypertensive emergencies was assessed.

RESULTS

A total of 79 (11%) out of 718 patients were diagnosed with hypertensive emergencies (51% had cardiovascular and 49% neurovascular acute organ damage). Patients with hypertensive emergencies were older and with higher prevalence of coronary artery disease and chronic heart failure than patients with uncontrolled hypertension. Typical symptoms could discriminate true hypertensive emergency from uncontrolled hypertension with 64% accuracy, 94% sensitivity, and 60% specificity.

CONCLUSION

Typical symptoms might be used as a simple screening test (99% negative predictive value) in the emergency department to select for further evaluations of patients with suspected hypertensive emergencies among those with acute hypertensive disorders.

Drug nonadherence is a common but often overlooked cause of hypertensive urgency and emergency at the emergency department

OBJECTIVES

Over 70% of patients who visit the emergency department with a hypertensive emergency or a hypertensive urgency have previously been diagnosed with hypertension. Drug nonadherence is assumed to play an important role in development of hypertensive urgency and hypertensive emergency, but exact numbers are lacking. We aimed to retrospectively compare characteristics of patients with hypertensive urgency and hypertensive emergency and to prospectively quantify the attribution of drug nonadherence.

METHODS

We retrospectively analysed clinical data including information on nonadherence obtained by treating physicians of patients with SBP at least 180 mmHg and DBP at least 110 mmHg visiting the emergency department between 2012 and 2015. We prospectively studied drug adherence among patients admitted to the emergency department with severely elevated BP by measuring plasma drug levels using liquid chromatography tandem mass spectrometry from September 2016 to March 2017.

RESULTS

Of the 1163 patients retrospectively analysed, 257 (22.0%) met the criteria for hypertensive urgency and 356 (30.6%) for hypertensive emergency. Mean SBP (SD) was 203 (19) mmHg and mean DBP 121 (12) mmHg. Mean age was 60.1 (14.6) years; 55.1% were men. In 6.3% of patients with hypertensive urgency or hypertensive emergency, nonadherence was recorded as an attributing factor. Of the 59 patients prospectively analysed, 18 (30.5%) were nonadherent for at least one of the prescribed antihypertensive drugs.

CONCLUSION

Hypertensive urgency and hypertensive emergency are common health problems resulting in frequent emergency department admissions. Workup of patients with a hypertensive urgency or hypertensive emergency should include an assessment of drug adherence to optimize treatment strategy.

[Hypertensive Crisis in the Elderly Patients]

A hypertensive crisis is a sudden increase in blood pressure (BP) to an individually high level associated with clinical symptoms and target organ damage, in which BP must be reduced immediately. Since 2018 in Europe and since 2020 in Russia, an uncomplicated hypertensive crisis is recommended to be considered as a part of malignant (uncontrolled) arterial hypertension. The clinical picture of increased BP in elderly patients is characterized by nonspecific symptoms even in target organ damage. Management of this group of patients requires a physician to know the patient's comorbidities and the drugs taken on a regular basis to minimize development of side effects of the administered drugs and their undesirable interaction with the chronic therapy.

Arterial hypertension in adults. Clinical guidelines 2020

Arterial hypertension in adults. Clinical guidelines 2020

Hypertension Urgencies and Emergencies: The GEAR Project

Acute elevations in blood pressure (BP), usually defined as ≥ 180/110 mmHg, may present with highly heterogeneous profiles ranging from absence of symptoms to life-threatening target organ damage. In most recent years the diagnostic approach and the treatment of hypertension have gained interest by patients and physicians. The GEAR project (Gestione delle Emergenze e urgenze in ARea critica, management of hypertensive emergencies and hypertensive urgencies in the emergency setting) was proposed by the group of Young Investigators of the Italian Society of Hypertension as a survey aimed to evaluate the awareness, diagnosis and treatment of hypertensive emergencies and urgencies in Italy.

Pharmacological management of malignant hypertension

INTRODUCTION

According to current guidelines, malignant hypertension is one of the emergencies in hypertension. The definition requires the presence of bilateral retinal hemorrhages or exudates, with or without papilledema, acute heart failure and acute deterioration in renal function in severe hypertension. Patients with malignant hypertension are characterized by pronounced target organ damage, including structural and functional cardiac abnormalities and renal insufficiency.

AREAS COVERED

Knowledge of the available treatment options is extremely important as we know that we only have a limited time to reduce blood pressure. There are only four drugs dedicated to immediate blood pressure lowering in patients with malignant hypertension, including 'first-line' and alternative drugs. Our review aims to discuss all those drugs and gives practical suggestions on how to properly use them.

EXPERT COMMENTARY

The decision of which drug to use depends on numerous factors including the clinical indications, pharmacokinetics, toxicity and drug interactions. Furthermore, frequently, more than one of the recommended drugs is required for the successful lowering of the patient's blood pressure.

Modern Management of Hypertensive Emergencies

Hypertensive emergencies (HE) represent critical conditions in which extremely high blood pressure values are accompanied by acute hypertension-mediated organ damage. In this clinical setting, the main therapeutic goal is represented by the immediate reduction of blood pressure, in order to limit the extension or promote the regression of target organ damage. At present, HE are classified according to the condition or target organ involved, into: (1) malignant hypertension with or without thrombotic microangiopathy; (2) coronary ischemia or acute cardiogenic pulmonary edema; (3) acute stroke or hypertensive encephalopathy; (4) acute aortic dissection or aneurysm; and (5) eclampsia or severe preeclampsia/HELLP syndrome. The management of these conditions is different in relation to the complex pathophysiology involved in each of these types. This mini-review presents the main characteristics and management strategy for different forms of HE, revealing the particularities of management strategy for each of them.

Diagnosis and treatment of hypertensive emergencies and urgencies among Italian emergency and intensive care departments. Results from an Italian survey: Progetto GEAR (Gestione dell'Emergenza e urgenza in ARea critica)

Hypertensive emergencies (HE) and urgencies (HU) are frequent causes of patients referral to Emergency Department (ED) and the approach may be different according to local clinical practice. Our aim was to explore awareness, management, treatment and counselling after discharge of HE and HU in Italy, by mean of an on-line survey. The young investigator research group of the Italian Society of Hypertension developed a 23-item questionnaire spread by e-mail invitation to the members of Italian Scientific societies in the field of Hypertension. 665 questionnaires were collected from EDs, Emergency and Urgency Medicine, Cardiology or Coronary Units, Internal Medicines, Intensive care, Stroke units. Symptoms considered suspicious of acute organ damage were: chest pain (89.0%), visual disturbances (89.8%), dyspnoea (82.7%), headache (82.1%), dizziness (52.0%), conjunctival haemorrhages (41.5%), tinnitus (38.2%) and epistaxis (34.4%). Exams more frequent prescribed were: electrocardiogram (97.2%), serum creatinine (91.4%), markers of cardiomyocyte necrosis (66.2%), echocardiography (65.1%). The use of intravenous or oral medications to treat HEs was 94.7% and 3.5%, while for HUs 24.4% and 70.8% respectively. Of note, a surprisingly high percentage of physicians (22 % overall, 24.5% in North Italy) used to prescribe sublingual nifedipine. After discharge, home blood pressure monitoring and general practitioner re-evaluation were more frequently suggested, while ambulatory blood pressure monitoring and hypertension specialist examination were less prescribed. The differences observed across the different macro-areas, regarded prescription of diagnostic test and drug administration. This survey depicts a complex situation of shades and lights in the real-life management of HE and HU in Italy.

Österreichischer Blutdruckkonsens 2019

Erhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.