Epidemiology of hypertensive crisis in the Buea Regional Hospital, Cameroon

Hypertensive crisis and its predictors in Africa: Systematic review and meta-analysis, 2024

Introduction

Hypertensive crises are a leading cause of visits to emergency departments, carrying grave health implications. A significant number of patients presenting with these crises have a known history of hypertension.

Objective

The aim of this systematic review and meta-analysis is to examine the combined prevalence of hypertensive crises among individuals with either a history of hypertension or unknown status (newly diagnosed with a hypertensive crisis).

Methods

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered with the Prospective Register of Systematic Reviews (PROSPERO). Research databases, including PubMed, Embase, Scopus, Africa Index Medicus, Science Direct, HINARI, and Google Scholar, were systematically searched. Study quality was evaluated using the Newcastle-Ottawa Scale, while publication bias was explored through Egger's regression test, funnel plots, and sensitivity analyses. Data collection adhered to the Joanna Briggs Institute (JBI) format. Meta-analysis was performed using STATA version 17, employing the random-effects DerSimonian-Laird model.

Results

Amongst the 15 studies analyzed, the application of the random-effects DerSimonian-Laird statistical model indicated that the prevalence of hypertensive crisis was determined to be 9.09 %, with a 95 % confidence interval (CI) ranging from 7.41 % to 10.77 %. Factors such as poor medication adherence (POR 5.00; 95 % CI: 3.61, 6.93), patients with comorbidities (POR 4.73; 95 % CI: 3.29, 6.80), patients with a history of hypertension (POR 5.64; 95 % CI: 4.57, 6.94), patients aged >65 (POR 2.77; 95 % CI: 2.16, 6.59), and excessive alcohol intake (POR 5.01; 95 % CI: 3.82, 6.58) were associated with higher odds of hypertensive crisis.

Conclusion

The findings indicate a markedly higher incidence of hypertensive crisis among hospital-presenting patients in Africa. Factors such as medication non-adherence, co-existing comorbidities, historical hypertension, being over 65, and alcohol misuse significantly contribute to this condition. These insights call for a comprehensive healthcare strategy that targets both the management of hypertension and its complications, aiming to improve the overall health outcomes of affected patients.

In-hospital mortality and length of stay of patients with hypertensive crisis treated at public hospitals in Harari Regional State, Eastern Ethiopia

Hypertensive crisis poses substantial cardiovascular morbidity and mortality. This study aimed to assess in-hospital mortality, length of stay (LOS), and their predictors among patients with hypertensive crisis treated at public hospitals in Harari Regional State, Eastern Ethiopia. An institutional-based retrospective cohort study was conducted from October 1 to 31, 2022. The medical records of 328 patients with hypertensive crisis treated at two public hospitals between September 1, 2017 and August 31, 2022 were reviewed. Cox proportional hazards regression and negative binomial regression were used to identify predictors of in-hospital mortality and LOS, respectively. The in-hospital mortality rate of patients with hypertensive crisis was 18.94 (95% confidence interval (CI): 12.08-29.70) per 1000 person-day observation. The median (interquartile range) LOS of these patients was 10 (4-120) hours. Age ≥65 years (adjusted hazard ratio (AHR): 3.30; 95% CI: 1.17- 9.33); increment in initial systolic blood pressure (AHR: 1.040; 95% CI: 1.014-1.066); and having acute brain-related damage (AHR: 4.02; 95% CI: 1.48-10.88) were predictors of in-hospital mortality. Rural residence (adjusted incident-rate ratio (IRR): 1.34; 95% CI: 1.03-1.75); having a history of medication discontinuation (adjusted IRR: 1.59; 95% CI: 1.16-2.18); comorbidity (adjusted IRR: 1.90; 95% CI: 1.49-2.43); acute brain-related damage (adjusted IRR: 13.32; 95% CI: 9.22-19.24), acute cardiac-related damage (adjusted IRR: 7.40; 95% CI: 4.90-11.16); and acute kidney injury (adjusted IRR: 7.64; 95% CI: 5.46-10.69) were predictors of LOS. Thus, it is necessary to develop strategies that allow early screening and follow-up of patients at risk.

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

Objective

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

Methods

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

Findings

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

Conclusion

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

Clinical 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.

Hypertensive emergency occurred due to forgetting to take antihypertensive medication: A case study

A life-threatening condition known as a "hypertensive emergency" is marked by a severe increase in blood pressure together with acute or significant target-organ damage. On 1 June 2022, a 67-year-old black male farmer was admitted to the emergency department with a major chief complaint of breathing difficulty. The patient was traveling to the village for work and forgetting his medication at home, and he was losing consciousness and motor activity at his workplace. He presented with symptoms of shortness of breath, confusion, dizziness, nausea, vomiting, blurred vision, and faintness. An abnormal cardiac region was visible on chest X-rays, and there were no changes to the pulmonary parenchyma or fluid overload. Upon admission, hydralazine (5 mg) intravenously was administered immediately, and he was reassessed after 20 min and kept at the emergency department. The next day, sustained-release nifedipine (20 mg) was initiated orally twice a day for the patient, and he was transferred to the medical ward. In the medical ward, the patient was assessed for 4 days, and in those 4 days, he showed marked improvement. Hypertensive emergency treatment intends to reverse target-organ damage, readily lowering blood pressure, decreasing adverse clinical complications, and enhancing the quality of life.

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

Background

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

Methods

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

Results

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

Conclusion

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

Cardiac Complications of Hypertensive Emergency: Classification, Diagnosis and Management Challenges

While mortality in patients with hypertensive emergency has significantly improved over the past decades, the incidence and complications associated with acute hypertension-mediated organ damage have not followed a similar trend. Hypertensive emergency is characterized by an abrupt surge in blood pressure, mostly occurring in people with pre-existing hypertension to result in acute hypertension-mediated organ damage. Acute hypertension-mediated organ damage commonly affects the cardiovascular system, and present as acute heart failure, myocardial infarction, and less commonly, acute aortic syndrome. Elevated cardiac troponin with or without myocardial infarction is one of the major determinants of outcome in hypertensive emergency. Despite being an established entity distinct from myocardial infarction, myocardial injury has not been systematically studied in hypertensive emergency. The current guidelines on the evaluation and management of hypertensive emergencies limit the cardiac troponin assay to patients presenting with features of myocardial ischemia and acute coronary syndrome, resulting in underdiagnosis, especially of atypical myocardial infarction. In this narrative review, we aimed to give an overview of the epidemiology and pathophysiology of hypertensive emergencies, highlight challenges in the evaluation, classification, and treatment of hypertensive emergency, and propose an algorithm for the evaluation and classification of cardiac acute hypertension-mediated organ damage.

Gender Differences in Cardiovascular Risk Factors, Clinical Presentation, and Outcome of Patients Admitted with a Hypertensive Crisis at the Buea Regional Hospital, Cameroon

Background. Several recent studies have shown differences in the risk profile and outcome of cardiovascular diseases between men and women, with a dearth of data from African populations. This study aimed to examine gender differences in a group of patients from Cameroon hospitalized with a hypertensive crisis. Methods. We conducted a cross-sectional study from June 2018 until June 2019. The criteria to define a hypertensive crisis (HC) were systolic and/or diastolic blood pressure should be ≥180/110 mmHg. We compared the clinical presentation and outcome of males versus females. Results. Out of the 1536 patients admitted, 95 (6.2%) had an HC. There were 49 (51.6%) men. There was no significant age difference between men and women (52.7 years vs. 49.3 years, $p=0.28$ ). Alcohol consumption ( $p<0.0001$ ), previous stroke ( $p=0.04$ ), and smoking ( $p=0.03$ ) were significantly higher in men compared to women. Men had a higher proportion of psychomotor agitation ( $p=0.05$ ). There was an equal proportion of men and women with hypertensive emergencies. Although acute left ventricular failure was most frequent in women (46.4% vs 42.9%), cerebral infarction (14.3% vs 17.9%), and acute coronary syndrome (0% vs 7.1%) were higher in men, the differences were not statistically significant (all $p>0.05$ ). Case fatality was also higher in men compared to women but the difference was not statistically significant. Conclusions. Men admitted for an HC had a significantly higher cardiovascular risk burden and higher psychomotor agitation. However, there were no significant differences in the types of hypertensive emergencies and outcomes between men and women.

Global interventions in hypertension: new and emerging concepts

PURPOSE OF REVIEW

Hypertension (HTN) is the most prevalent risk factor for cardiovascular disease (CVD) worldwide, affecting 1.39 billion people. This review discusses recent literature regarding the global burden of HTN and emerging concepts in prevalence, treatment, and control in different regions around the globe.

RECENT FINDINGS

Community-based interventions and telemedicine may be useful in increasing access to care and identifying/assisting patients with HTN, especially in populations with geographical and economic barriers to healthcare. Home blood pressure monitoring is beneficial for HTN control in diverse regions. Polypills have proven benefits to decrease HTN and CVD risk. Continuation of treatment with angiotensin-converting-enzyme inhibitors and angiotensin-receptor blockers in high risk COVID-19 patients appears appropriate.

SUMMARY

Extensive research demonstrates that early screening/treatment, lifestyle modification, and pharmacotherapy are essential to control HTN worldwide. This review highlights recent research and novel concepts on effective interventions being used globally.