Hypertensive Emergency

Short-Term Mortality Associated With Hypertensive Emergencies: A Prospective Observational Cohort Study From South India

Background and aims Hypertensive emergencies are caused by acutely occurring massive elevations in blood pressure with features suggestive of acute end-organ damage and are a common complication of hypertension. About 1-2% of all patients with hypertension develop this complication in their lifetime. This study was undertaken to assess short-term outcomes associated with hypertensive emergencies in a tertiary care center. Methods We conducted a prospective cohort study and recruited 66 consenting adults with a hypertensive emergency. Sociodemographic details, clinical characteristics, blood pressure readings at different intervals, in-hospital course, and diagnosis of end-organ damage were recorded. The in-hospital outcome was noted as dead or alive. After four weeks, patients were followed up through telephonic interviews and the patient's status was then reviewed and recorded. Multiple logistic regression determined the predictors of death. Data were analyzed in SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Results A total of 66 patients were enrolled, with a mean age of 54.57 (±38.18) years and a male predominance of 44 (66.35%) patients. The majority of patients were known hypertensives (n=55, 83.35%). Of the known hypertensives, 41 (74.54%) patients had discontinued their anti-hypertensive medications prior to admission. The median duration of hospitalization was 10 (7-14) days. The most common presenting complaints were dyspnea (n=35, 53.03%), pedal edema (n=29, 43.94%) and headache (n=25, 37.87%). Forty-one (62.12%) patients required ICU care, and 39 (59.09%) required ventilator support. The most common end-organ damage was acute-on-chronic kidney disease (n=21, 31.81%). The short-term mortality documented at the end of one month was 24 (36.36%). Of these, seven (10.6%) patients died in the hospital, and 17 (25.75) patients died within one month of getting discharged from the hospital. The factors that were associated with high mortality were newly-diagnosed hypertension and in-hospital hypotension. Conclusion We found high mortality associated with hypertensive emergencies. At one month follow-up, we found that more than one-third of the patients had died. Post-hospitalisation mortality was higher than in-hospital mortality. Most patients had discontinued their anti-hypertensive medication before admission. The most frequently encountered end-organ damage was acute-on-chronic kidney disease. The factors associated with high mortality were newly-diagnosed hypertension and in-hospital hypotension.

Differentiating between severe hypertension and thrombocytopenic purpura as the cause of thrombotic microangiopathy in a patient with Castleman disease: a case report and literature review

Thrombotic microangiopathy (TMA) is a syndrome characterized by thrombosis in capillaries and arterioles, resulting in microangiopathic hemolytic anemia, thrombocytopenia and target organ injury. In TMA presenting with severe hypertension, it is difficult to determine whether the TMA is primary and due to thrombotic thrombocytopenic purpura (TTP) or secondary to severe hypertension. The response to antihypertensive medication favors the diagnosis of severe hypertension as the cause of TMA. Comorbid inflammatory disease supports the diagnosis of TTP-induced TMA. This case describes a 75-year-old woman with Castleman disease who presented with severe hypertension and TMA. She improved with hypertension therapy. However, ADAMST13 showed zero activity, and the diagnosis was TTP. In cases of TMA accompanied by severe hypertension, it is challenging to diagnose the cause of TMA. Even when there is a pronounced clinical response to lowering blood pressure, the diagnosis of TTP should be considered, particularly when an inflammatory disease is present.

Current U.S. Guideline-Based Management Strategies for Special Clinical Situations Involving Hypertensive Crises: A Narrative Review of the Literature

Hypertensive crises, although somewhat rare in hypertensive patients, might become an increasingly relevant issue in the future as the number of adults living with hypertension in the United States increases. Many of the current U.S. clinical guidelines for the treatment and management of a variety of medical conditions do not factor hypertensive crises into their recommendations or only consider them in a limited fashion in the context of other medical conditions. This review article summarizes the definitions of hypertensive crises/urgent hypertension/emergent hypertension, the epidemiological profile and outcomes of patients, current U.S. clinical guidelines' recommendations for the general treatment of hypertensive crises, and current U.S. clinical guidelines' recommendations for the treatment of acute kidney injuries, acute ischemic stroke, aortic dissection, and acute heart failure in relation to hypertensive crises. All physicians who manage hypertensive patients, but particularly physicians who work in intensive care units, emergency departments and in U.S. hospitals, should review hypertensive crises guidelines and relevant treatments, and understand current recommendations.

CE: Hypertensive Emergencies: A Review

ABSTRACT

While acute blood pressure elevations are commonly seen in the ED, not all require emergency treatment. True hypertensive emergencies are characterized by a rapid elevation in blood pressure to a level above 180/120 mmHg and are associated with acute target organ damage, which requires immediate hospitalization for close hemodynamic monitoring and IV pharmacotherapy. Recognizing the clinical signs and symptoms of hypertensive emergency, which may vary widely depending on the target organ involved, is critical. High blood pressure levels that produce no signs or symptoms of target organ damage may be treated without hospitalization through an increase in or reestablishment of previously prescribed oral antihypertensive medication. However, all patients presenting with blood pressure this high should undergo evaluation to confirm or rule out impending target organ damage, which differentiates hypertensive emergency from other hypertensive crises and is vital in facilitating appropriate emergency treatment. Drug therapy for hypertensive emergency is influenced by end-organ involvement, pharmacokinetics, potential adverse drug effects, and patient comorbidities. Frequent nursing intervention and close monitoring are crucial to recuperation. Here, the authors define the spectrum of uncontrolled hypertension; discuss the importance of distinguishing hypertensive emergencies from hypertensive urgencies; and describe the pathophysiology, clinical manifestations, and management of hypertensive emergencies.

Relationship between the presence of dedicated doctors in rapid response systems and patient outcome: a multicenter retrospective cohort study

BACKGROUND

Rapid response systems (RRSs) improve patients' safety, but the role of dedicated doctors within these systems remains controversial. We aimed to evaluate patient survival rates and differences in types of interventions performed depending on the presence of dedicated doctors in the RRS.

METHODS

Patients managed by the RRSs of 9 centers in South Korea from January 1, 2016, through December 31, 2017, were included retrospectively. We used propensity score-matched analysis to balance patients according to the presence of dedicated doctors in the RRS. The primary outcome was in-hospital survival. The secondary outcomes were the incidence of interventions performed. A sensitivity analysis was performed with the subgroup of patients diagnosed with sepsis or septic shock.

RESULTS

After propensity score matching, 2981 patients were included per group according to the presence of dedicated doctors in the RRS. The presence of the dedicated doctors was not associated with patients' overall likelihood of survival (hazard ratio for death 1.05, 95% confidence interval [CI] 0.93‒1.20). Interventions, such as arterial line insertion (odds ratio [OR] 25.33, 95% CI 15.12‒42.44) and kidney replacement therapy (OR 10.77, 95% CI 6.10‒19.01), were more commonly performed for patients detected using RRS with dedicated doctors. The presence of dedicated doctors in the RRS was associated with better survival of patients with sepsis or septic shock (hazard ratio for death 0.62, 95% CI 0.39‒0.98) and lower intensive care unit admission rates (OR 0.53, 95% CI 0.37‒0.75).

CONCLUSIONS

The presence of dedicated doctors within the RRS was not associated with better survival in the overall population but with better survival and lower intensive care unit admission rates for patients with sepsis or septic shock.

Pharmacological blood pressure control and outcomes in patients with hypertensive crisis discharged from the emergency department

Pharmacological blood pressure (BP) intervention for high blood pressure is controversial for a wide spectrum of hypertensive crisis in the emergency department (ED). We evaluated whether medical control of BP altered the short- and long-term outcomes among patients with hypertensive crisis who were discharged from the ED under universal health care. This retrospective cohort comprised 22 906 adults discharged from the ED of a tertiary hospital with initial systolic BP ≥ 180 mmHg or diastolic BP ≥ 120 mmHg between 2010 and 2016. The main exposure was the use of antihypertensive medication during the ED stay. Clinical endpoints were revisits to the ED or inpatient admission (at 7, 30, and 60 days), cardiovascular mortality (at 1, 3, and 5 years), and incident stroke (at 1, 3, and 5 years). The associations between pharmacological intervention for BP and outcomes were evaluated using multivariable Cox proportional-hazards models. Of the patient data analyzed, 72.2% were not treated pharmacologically and 68.4% underwent evaluation of end-organ damage. Pharmacological intervention for BP was significantly associated with a 11% and 11% reduced risk of hospital revisits within 30 or 60 days of discharge from ED, respectively, particularly among patients with polypharmacy. No association between pharmacological intervention for BP and incident stroke and cardiovascular mortality was observed. A revision of diagnostic criteria for hypertensive crisis is essential. Although pharmacological intervention for BP may not alter the long-term risk of cardiovascular mortality, it significantly reduces short-term health care utilization.

Sinigrin attenuates angiotensin II‑induced kidney injury by inactivating nuclear factor‑κB and extracellular signal‑regulated kinase signaling in vivo and in vitro

The present study investigated the function of sinigrin in angiotensin II (Ang II)‑induced renal damage. The results demonstrated that systolic blood pressure (SBP) and diastolic blood pressure (DBP) were increased in Ang II‑challenged rats, and sinigrin treatment inhibited their increase. The levels of blood urea nitrogen (BUN) and serum creatinine (SCR) were increased by Ang II in the rats, and these were reversed by sinigrin in a dose‑dependent manner. In addition, the Ang II‑induced elevation of urinary protein levels was inhibited by sinigrin treatment. Glomerular basement membrane thickness and ECM degradation markers, such as collagen I, collagen IV and fibronectin, were suppressed by sinigrin in the Ang II‑challenged rats. Moreover, the levels of inflammatory regulators, including tumor necrosis factor‑α (TNF‑α), interleukin‑6 (IL‑6) and monocyte chemoattractant protein‑1 (MCP‑1), were reduced following sinigrin treatment of the Ang II‑challenged rats and in Ang II‑exposed proximal tubule epithelial cells. Furthermore, the superoxide dismutase (SOD) and catalase (CAT) levels were downregulated, whereas the malondialdehyde (MDA) levels were upregulated by Ang II; these effects were reversed by sinigrin treatment in vivo and in vitro. Mechanistically, sinigrin inhibited the Ang II‑induced phosphorylation of ERK, p65 and IκBα. Thus, sinigrin attenuated Ang II‑induced renal injury by inactivating ERK and NF‑κB signaling. Sinigrin may thus prove to be a potential candidate for the treatment of hypertension‑induced kidney damage.

Hypertensive urgency or emergency? The use of intravenous medications in hospitalized hypertensive patients without organ dysfunction

BACKGROUND

Current guidelines poorly define hypertensive urgency and recommend Oral (PO) medications over intravenous (IV).

OBJECTIVE

To describe hospital management of hypertensive urgency and compare characteristics and outcomes of PO vs. IV medications.

METHODS

We used descriptive statistics and created generalized linear models to evaluate within-subject blood pressure (BP) changes over 24 hours.

RESULTS

179 patients had an average age of 62 and 58% female. Chronic hypertension was common (165, 88%), as was chronic renal disease (40.6%). IV medications were common (146, 81.6%) and associated with higher comorbidity burden, prior kidney disease, and longer length of stay (2.5, 1.6-3.8 vs. 1.4, 0.9-2.2, p=0.007). 66 (35.3%) developed and 43 (23.5%) new organ dysfunction, but outcomes were similar between groups. BP was similar between groups after 12 hours.

CONCLUSIONS

IV medication use was common and decreased BP more rapidly. Outcomes including BP were similar to PO administration, except for length of stay.

Hypertensive crisis: clinical characteristics of patients with hypertensive urgency, emergency and pseudocrisis at a public emergency department

Objective:

To assess patients with hypertensive crisis, classified as urgency, emergency or pseudocrisis, and identify the associated variables.

Methods:

We evaluated a total of 508 patients (57% women; 56.3±13.8 years old) with hypertensive crisis (diastolic blood pressure of 120mmHg), aged 18 years or over, seen at the emergency department of a public general hospital.

Results:

The prevalence of hypertensive crises was 6/1,000; in that, 71.7% presented hypertensive urgency, 19.1% hypertensive emergency, and 9.2% hypertensive pseudocrisis. In the multinominal logistic regression, pseudocrisis and urgency conditions were compared to hypertensive emergency. Therefore, the presence of pain (OR: 55.58; 95%CI: 10.55-292.74) except chest pain and headache, and emotional problems (OR: 17.13; 95%CI: 2.80-104.87) increased the likelihood of hypertensive pseudocrisis. Age >60 years (OR: 0,32; 95%CI: 0.10-0.96) and neurologic problems (OR: 1.5.10^-8; 95%CI: 1.5.10^-8-1.5.10^-8) protected against hypertensive pseudocrisis. The comparison of hypertensive urgency with hypertensive emergency showed that age >60 years (OR: 0.50; 95%CI: 0.27-0.92), neurologic (OR: 0.09; 95%CI: 0.04-0.18) and emotional problems (OR: 0.06; 95%CI: 4.7.10^-3-0.79) protected against hypertensive urgency. Moreover, only headache (OR: 14.28; 95%CI: 3.32-61.47) increased the likelihood of hypertensive urgency.

Conclusion:

Advanced age and neurological problems were associated to hypertensive emergency. Headache was associated with hypertensive urgency. Pain and emotional problems were associated with hypertensive pseudocrisis. Our results can contribute to identifying patients with hypertensive crisis who seek emergency services.

Biodegradable Therapeutic Microneedle Patch for Rapid Antihypertensive Treatment

A hypertensive emergency causes severe cardiovascular diseases accompanied by acute target organ damage, requiring rapid and smooth blood pressure (BP) reduction. Current medicines for treating hypertensive emergencies, such as sodium nitroprusside (SNP), require careful dose control to avoid side effects (e.g., cyanide poisoning). The clinical administration of SNP using intravenous injection or drip further restrict its usage for first aid or self-aid in emergencies. Here, we developed an antihypertensive microneedle (aH-MN) technique to transdermally deliver SNP in combination with sodium thiosulfate (ST) as a cyanide antidote in a painless way. Dissolvable microneedles loaded with SNP and ST were fabricated via the centrifugation casting method, where the SNPs were stably packaged in microneedles and would be immediately released into the systemic circulation via subcutaneous capillaries when aH-MNs penetrated the skin. The antihypertensive effects were demonstrated on spontaneously hypertensive rat models. Rapid and potent BP reduction was achieved via aH-MN treatment, fulfilling clinical BP-control requirements for hypertensive emergencies. The side effects including skin irritation and target organ damage of aH-MN therapies were evaluated; the combinative delivery of ST effectively suppressed these side effects induced by the consecutive intake of SNP. This study introduces an efficient and patient-friendly antihypertensive therapy with a favorable side-effect profile, particularly a controllable and self-administrable approach to treat hypertensive emergencies.

Supplemental Nutrition Assistance Program size and timing and hypertension-related emergency department claims among Medicaid enrollees

The Supplemental Nutrition Assistance Program (SNAP) is a public policy program that aims to reduce food insecurity-a social determinant of health that has been associated with suboptimal blood pressure control in the United States. The aim of the article was to explore the association between SNAP benefit timing and size and probability of hypertension-related emergency department (ED) claims. This study used the SNAP data from the Missouri's Department of Social Services for January 2010 to December 2013 linked to Medicaid ED claims data. The dependent variable was probability of hypertension-related and hypertensive emergency ED claims. The independent variables of interest were week of calendar and SNAP benefit months and SNAP benefit amount. Probit regression analyses were conducted. Average marginal effects are reported.In a sample of 6,013,951 Medicaid-insured SNAP beneficiaries, 11,709 hypertension-related claims were submitted for every 100,000 claims. The average marginal effect of SNAP benefit amount on hypertension-related ED claims was -0.0000638 (P < .001); thus, a $100 increase in SNAP benefits will reduce hypertension-related claims by 638 claims per 100,000 claim. The reduction in ED claims was higher for lower SNAP benefit amounts than at higher SNAP benefit amounts. There was no statistically significant association between week of calendar month in which SNAP benefit was received and probability of hypertension-related ED claims. Higher SNAP benefit amount was associated with a decreased probability of hypertension-related ED claims. The impact of an additional dollar of SNAP benefits was larger at lower SNAP benefit amounts.

Transient myopic shift due to ciliary body detachment as the sole ocular manifestation of hypertensive emergency - A case report

Purpose

Hypertensive emergency usually presents to ophthalmologists in the form of hypertensive retinopathy. We present a case of hypertensive emergency that presented as bilateral transient myopic shift due to ciliary body detachment in the absence of any retinal pathology. The purpose of this paper is to showcase another ocular manifestation of hypertensive emergency.

Observations

A 35 year-old female with a blood pressure of 192/114 mmHg presented to the emergency department with headache and acute onset blurry vision. Computed Tomography (CT) of the head, and lumbar puncture were within normal limits. Visual acuity was counting fingers in the right eye and 6/90 in the left eye, both of which improved to 6/9 with −5.00 diopters spherical correction in the right eye, and −4.75 diopters correction in the left eye. Intraocular pressures were normal. Anterior chambers were shallow, and there were no retinal changes on dilated fundus examination. Enhanced-depth optical coherence tomography (EDI-OCT) showed bilateral increased choroidal thickness and ultrasound biomicroscopy (UBM) showed 360° ciliary body detachment with angle closure. With improved blood pressure control, her ciliary body detachment resolved and her refractive error returned to baseline.

Conclusions

& Importance: Hypertensive emergency may present with choroidal thickening with anterior ciliary body rotation and detachment. A review of medications is important, as this presentation has also been reported as a rare side effect of sulphonamide drugs. In the absence of retinopathy, UBM and EDI-OCT imaging should be considered in the acutely hypertensive patient presenting with myopic shift.

New Developments in Hypertensive Encephalopathy

PURPOSE OF REVIEW

This review summarizes the latest science on hypertensive encephalopathy and posterior reversible encephalopathy syndrome (PRES). We review the epidemiology and pathophysiology of these overlapping syndromes and discuss best practices for diagnosis and management.

RECENT FINDINGS

Diagnosis of hypertensive encephalopathy largely relies on exclusion of other neurological emergencies. We review the extensive causes of PRES and its imaging characteristics. Management strategies have not changed substantially in the past decade, though newer calcium channel blockers simplify the approach to blood pressure reduction. While this alone may be sufficient for treatment of hypertensive encephalopathy in most cases, management of PRES also depends on modification of other precipitating factors. Hypertensive encephalopathy and PRES are overlapping disorders for which intensive blood pressure lowering is critical. Further research is indicated to both in diagnosis and additional management strategies for these critical conditions.