Comparing the clinical efficacy of resting and antihypertensive medication in patients of hypertensive urgency: a randomized, control trial

Initiation of oral antihypertensives in hospitalized patients with hypertensive urgency: A descriptive study

PURPOSE

In hypertensive urgency, guidelines recommend oral antihypertensives, but with limited guidance on implementation. The objective of this study was to determine whether time to initiation of oral antihypertensives impacts blood pressure (BP) reduction in patients with hypertensive urgency.

METHODS

A descriptive study was conducted of adult hospitalized patients with hypertensive urgency from November 2018 through November 2021. Patients with a systolic BP (SBP) of 180 mm Hg or higher or a diastolic BP (DBP) of 120 mm Hg or higher and receipt of oral antihypertensives within 48 hours of presentation were included. The primary outcome was the percentage change in SBP from baseline at 12 to 24 hours and 24 to 48 hours. Secondary outcomes included the change in DBP and mean arterial pressure (MAP), time to 3 consecutive goal SBP readings, continuation of home oral antihypertensives, administration of intravenous (IV) antihypertensives, and length of stay (LOS). Patients were stratified by quartile (Q1 through Q4) based on time to first oral antihypertensive.

RESULTS

A total of 220 patients were included. A significant difference in SBP was observed among the quartiles, due to the greater sustained SBP reduction in Q1 at 12 to 24 hours and 24 to 48 hours (median [interquartile range, IQR], 22.9% [13.1%-30.5%] and 22.5% [IQR, 15.8%-32.9%] reduction, respectively). There were also reductions in DBP and MAP, with Q1 consistently having larger reductions than Q4. Patients in Q1 had 3 consecutive goal SBP readings earlier than those in the other quartiles (median [IQR], 13.1 [7.0-21.5] hours). Continuation of home medications, number of IV antihypertensives, and LOS did not differ among the quartiles.

CONCLUSION

In this analysis, earlier administration of oral antihypertensives was associated with a larger sustained reduction in SBP.

Safety And Efficacy of Clonidine for Acute Hypertensive Urgency in an Older and Hospitalized Population

Objective To describe the use of clonidine in hospitalized older people for acute management of hypertension. Methods This was an observational retrospective cross-sectional chart review study. Older people hospitalized between November 2017 and November 2018, with a one-time or as-needed clonidine order were eligible, and a random sample of these patients were included. Hospitalized patients could be admitted for hypertensive urgency or emergency, or for other reasons. Results During the 12-month study period, 546 charts were identified as having at least one clonidine prescription, 248 were screened and 205 were included. The mean age was 75 years of age ± 8 years of age and men made up 53% (n = 109) of the group. One hundred fifty-one patients (74%) received at least one dose of clonidine and the remaining patients has a clonidine prescription but did not reach the blood pressure threshold for clonidine administration. The mean number of doses per patient was 1.8 ± 2.0. Twenty-nine percent of clonidine doses were given when systolic and diastolic blood pressure was below 180 mmHg and 120 mmHg respectively. A total of 25 patients (17%) had a potential adverse reaction following clonidine administration. One patient had a stroke and two patients fell. Sixty-eight patients had evidence of target organ dysfunction related to hypertension prior to clonidine administration. Conclusions Clonidine remains widely prescribed in hospitalized older people. It is possibly due to its rapid onset and little need for dosing adjustment. Clinical interventions should be designed and implanted to reduce its prescription.

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.

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.

Poor guideline adherence in a real-world evaluation of hypertensive emergency management

BACKGROUND

The American College of Cardiology and American Heart Association define hypertensive emergency (HTN-E) as a systolic blood pressure greater than 180 mmHg or a diastolic blood pressure greater than 120 mmHg with evidence of end-organ damage (EOD). Based on expert opinion, current guidelines recommend antihypertensive therapy to reduce blood pressure (BP) at specific hourly rates to reduce progression of EOD, outlined by four criteria. Our goal was to describe compliance with guideline recommendations for early management of HTN-E and to analyze safety outcomes related to pharmacologic intervention.

METHODS

This was a retrospective chart review including patients presenting to the emergency department with HTN-E between September 2016 and August 2020. We excluded patients with a compelling indication for altered therapeutic goals (e.g. acute aortic dissection, hemorrhagic or ischemic stroke, and pheochromocytoma). The primary outcome was complete adherence with guideline recommendations in the first 24 h.

RESULTS

Of 758 screened records, 402 were included. Mean age was 54 years and majority Black race (72%). Overall, total adherence was poor (<1%): 30% received intravenous therapy within 1 h, 64% achieved 1-h BP goals, 44% achieved 6-h goals, and 9% had appropriate 24-h maintenance BP. Hypotensive events (N = 67) were common and antihypertensive-associated EOD (N = 21) did occur. Predictors of hypotension include treatment within 1 h and management with continuous infusion medication.

CONCLUSIONS

Current practice is poorly compliant with guideline criteria and there are risks associated with recommended treatments. Our results favor relaxing the expert opinion-based recommendations.

Arterial hypertension and antihypertensive therapy in older patients. The agreed opinion of experts from the Russian Association of Gerontologists and Geriatricians, the Antihypertensive League, the National Society for Preventive Cardiology

High blood pressure is a risk factor for cardiovascular morbidity and mortality, as well as cognitive decline and loss of autonomy in the elderly and old age. Randomized clinical trials (RCTs) in populations of older patients living at home with low comorbidity and preserved autonomy indicate the benefit of lowering elevated blood pressure in patients over 80 years of age. Older patients with senile asthenia, loss of autonomy and other geriatric problems were excluded from RCTs, and observational studies in these groups of patients indicate an increase in morbidity and mortality with lower blood pressure and antihypertensive therapy. Obviously, in very elderly patients, a universal strategy for the treatment of arterial hypertension cannot be applied due to the significant heterogeneity of their functional status. The geriatric approach to the management of arterial hypertension in older patients involves an assessment of the functional status, the presence of senile asthenia, and the degree of autonomy for the choice of antihypertensive therapy tactics.

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.

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.

The effect of pursed-lip breathing combined with number counting on blood pressure and heart rate in hypertensive urgency patients: A randomized controlled trial

Hypertensive urgency (HT urgency) is an alarming sign of uncontrolled hypertension. It is aggravated by nonadherence to medication, as well as psychosocial stress. Mindfulness is beneficial for reducing stress, while deep and slow breathing is effective for lowering blood pressure (BP). In our study, we aimed to assess BP and heart rate effects in HT urgency patients practicing pursed‐lip breathing and number counting (PLB with NC)—a practice that promotes mindfulness with deep/slow breathing patterns. In a randomized controlled trial, 110 patients were equally allocated to intervention and control groups. The intervention group was trained and encouraged to do PLB with NC during their emergency room admission, while the control group received conventional medical care. The mean systolic BP (SBP), diastolic BP (DBP), and HR of the intervention group in the 3rd hour were significantly lower than the baseline values at −28.2 mm Hg (95%CI;‐23.5 to −32.4), −17.1 mm Hg (95%CI;‐14.2 to −20.0), and −4.9 beats per minute (bpm) (95%CI;‐4.0 to −5.8), respectively. In the control group, both the mean SBP and DBP were also significantly lower in the 3rd hour. However, HR reduction was inconclusive. When the two groups were compared, a greater degree of reduction was found in the intervention group for SBP (9.80 mm Hg, 95%CI; 4.10 to 15.50), DBP (7.69 mm Hg, 95%CI; 3.61 to 11.77), and HR (3.85 bpm, 95%CI; 1.99 to 5.72). In conclusion, PLB with NC was effective for lowering BP and HR. It might be used as a complementary treatment for HT urgency patients.

<p>Immediate Prescription of Oral Antihypertensive Agents in Hypertensive Urgency Patients and the Risk of Revisits with Elevated Blood Pressure</p>

Background

The steps and goals of treatment of hypertensive urgencies in the emergency department are not clear. The aim of this study was to compare the risk of revisits with elevated blood pressure in hypertensive urgency patients in the emergency department managed with and without oral antihypertensive medications.

Methods

This retrospective cohort study was conducted at the Emergency Medicine Department of Ramathibodi Hospital, a university-affiliated super tertiary care hospital in Bangkok, Thailand, from January 2018 to April 2020. A total of 692 hypertensive urgency patients were enrolled and categorized into oral antihypertensive drugs group and no oral antihypertensive drugs group.

Results

There were 298 patients in the antihypertensive drugs group and 394 patients in the no antihypertensive drugs group. There were no statistically significant differences of revisit rate with elevated blood pressure between oral antihypertensive drugs group and no antihypertensive drugs group within 1 day (4.36% vs 6.35%, P=0.313) and 7 days (32.55% vs 31.22%, P=0.742). The risk of revisits with elevated blood pressure was similar in both groups at 1 day (OR=0.58, 95% CI=0.26–1.27) and 7 days (OR=1.11, 95% CI=0.77–1.61). We found no case of major adverse cardiovascular events (MACE) in 1 day and a similar risk of MACE in 7 days (OR=0.23, 95% CI=0.01–4.18). Blood pressure control within 2 weeks was also not different (OR=0.76, 95% CI=0.45–1.30).

Conclusion

We have found no obvious evidence of benefit from oral antihypertensive agents in managing hypertensive urgencies in the ED. Oral hypertensive agents had no benefit in the reduction of blood pressure, no effect on reduction of ED length of stay, and blood pressure control within 2 weeks.

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.

Outcomes of minority patients with very severe hypertension (>220/>120 mmHg)

OBJECTIVES

Acute severe hypertension is a common problem among inner-city ethnic minority populations. Nevertheless, the effects of currently employed treatment regimens on blood pressure have not been determined in a clinical practice setting. We determined the SBP responses to acute antihypertensive drug protocols and the 2-year natural history of patients presenting with severe hypertension.

METHODS

Retrospective cohort investigation in consecutive patients with SBP at least 220 mmHg and/or DBP at least 120 mmHg during 3-month enrollment in 2014 with 2-year follow-up. Primary outcomes were SBP versus time for the first 5 h of emergency treatment and 2-year follow-up including repeat visits, target organ events, and hospitalizations.

RESULTS

One hundred and fifty-six unique patients met criteria with 69% Black; 34% Hispanic; 56% had previous visits for severe hypertension; 31% had preexisting target injury. Acute management: Acute antihypertensive regimens resulted in grossly unpredictable and often exaggerated effects on SBP. Treatment acutely reduced SBP to less than 140 mmHg in 30 of 159 patients. Clonidine reduced SBP to less than 140 mmHg in 19/61. Two-year follow-up: We observed 389 repeat visits for severe hypertension, 99 new target events, and 76 hospitalizations accounting for 620 hospital days.

CONCLUSION

Acute treatment of severe hypertension produced unpredictable and potentially dangerous responses in SBP. Two-year follow-up demonstrated extraordinary rates of recurrent visits, target organ events, and hospitalizations. Our findings indicate a need to develop effective management strategies to lower blood pressure safely and to prevent long-term consequences. Our findings may apply to other hospitals caring for ethnic minority populations.

[Hypertensive urgencies: Description of clinical characteristics, management, variables associated with re-entry and short-term prognosis]

OBJECTIVES

To describe the characteristics of hypertensive urgencies at the emergency department, as well as the variables associated with early re-admission (<7 days) and re-admission at one month (<30 days).

METHODS

We conducted a descriptive, retrospective study of all patients who were admitted to the emergency department of a third level hospital during 2013. Subsequently, a case-control analysis was performed to analyze the group of patients with readmission.

RESULTS

A total of 398 hypertensive urgencies were collected (32.4% men, mean age 67.75 years), which led to an incidence of 3.28/1000 visits. Eighty point nine percent had a previous history of hypertension, and the mean Charlson Index was 2.23. Headache was the most frequent symptom (49.1%), followed by dizziness/instability (29.5%) and nausea/vomiting (17.1%). Eighty point seven percent of the patients were prescribed pharmacological treatment. The rates of cardiovascular events or mortality at one month were low (2.26% and 0.25% respectively). Despite this, 7.53% and 11.31% of patients were readmitted in under 7 days or 30 days, respectively. The variables associated with readmission in the multivariate analysis were elevated systolic blood pressure in the first determination, previous hypertension and the presence of palpitations.

CONCLUSIONS

Hypertensive emergencies are high-incidence conditions in the Emergency Department. In our study, patients with a prior diagnosis of hypertension and elevated systolic blood pressure at the first determination had a higher risk of re-entry and would be candidates for closer follow-up on discharge.