Clinical presentation and management of patients with uncontrolled, severe hypertension: results from a public teaching hospital

CONTEXT

There is relatively little data available on the management of patients with severe, uncomplicated hypertension and severe hypertension with stable hypertensive complications.

OBJECTIVE

To determine the incidence, clinical features, acute management, and clinical course of severe, uncomplicated hypertension and severe hypertension with stable hypertensive complications presenting for emergency department care in a large public teaching hospital.

DESIGN

Chart survey of consecutive emergency department visits.

PATIENTS

Ninety-one of 2898 consecutive visits to a public teaching hospital emergency department were specifically for severe, uncomplicated hypertension.

RESULTS

Of 2898 consecutive medical emergency department visits, there were 142 (4.9%) patient visits specifically for systolic blood pressure (SBP) > or =220 mm Hg or diastolic blood pressure (DBP) > or =120 mm Hg. Ninety-one of the 142 patient visits were for severe hypertension in the absence of acute target organ impact or neuroretinopathy. Eighty-nine patients received acute drug therapy. Twenty-nine patients received two drugs, and 15 received three drugs. Sixty-eight patients (75%) received clonidine, and 15 (16.5%) received short-acting nifedipine despite widely published concerns about the safety of this practice. We found a wide variability of blood pressure response to treatment. The average decline in SBP was 50+/-31 mm Hg and the average decline of DBP was 34+/-20 mm Hg over 4.2+/-2.9 h. Forty-two patients (46%) had the SBP reduced to less than 160 mm Hg, and 46 patients (50%) the DBP to less than 100 mm Hg. Long-term management and follow-up were suboptimal. Of 74 patients discharged from the emergency room, 22 patients (30%) returned because of uncontrolled hypertension within an average of 33+/-28 days, 10 patients with hypertensive complications.

CONCLUSIONS

Severe hypertension continues to present an important and common problem. Physicians appear to place a strong emphasis on acute lowering of the blood pressure to near-normal levels. Patients are frequently lost to follow-up and have a very high rate of recurrent emergency department visits and hypertensive complications. This study points to a need for detailed, specific practice guidelines and comprehensive disease management protocols for severe, uncomplicated hypertension.