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Roth MA, Leyba K, Garg I, Madrid WH, Quazi MA, Sohail AH, Khan R, Sultan S, Sheikh AB. Mortality and in-patient outcomes in pheochromocytoma patients with hypertensive emergency in the United States: A propensity score matched analysis. Curr Probl Cardiol 2024; 49:102578. [PMID: 38657719 DOI: 10.1016/j.cpcardiol.2024.102578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/20/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Pheochromocytoma is a rare cause of hypertensive emergency. The objective of this analysis was to compare the clinical characteristics, comorbidities, and in-hospital outcomes of patients admitted with hypertensive emergencies with and without co-existing pheochromocytoma. METHODS A retrospective analysis of the National Inpatient Sample (NIS) Database from 2016 to 2020 was conducted, encompassing 640,395 patients hospitalized for hypertensive emergencies, including 2535 patients diagnosed with pheochromocytoma. We compared demographics, comorbidities, in-hospital outcomes and resource utilization metrics in patients with and without pheochromocytoma. Propensity-score matching was utilized to account for potential confounders and risk of complications was compared. RESULTS Among the pheochromocytoma cohort (51.9% female), a significant portion (35.7%) were under 50 years of age, with the majority being Caucasian (47.9%). Comorbid conditions such as obesity, diabetes, and smoking were prevalent, with notable differences in cancer (7.5% vs. 2.3%, p < 0.001) and peripheral vascular disease (17% vs. 8.2%, p < 0.001) rates compared to the non-pheochromocytoma cohort. Pheochromocytoma patients had a longer hospital stay (7.5 vs. 6 days, p = 0.002) and higher odds of acute kidney injury (AKI) (1.54, 1.18-2, p=0.001) but lower odds of requiring hemodialysis (0.52, 0.32-0.79, p < 0.001) or experiencing major cardiovascular events (0.5, 0.36-0.69, p < 0.001). No significant difference in inflation-adjusted hospitalization costs was found between the groups. CONCLUSIONS Patients with hypertensive emergencies and pheochromocytoma had a higher incidence of AK, certain comorbidities (cancer, peripheral vascular disease), and more complex hospital courses suggested by longer length of stay. However, the overall cost of hospitalization did not significantly differ between the two cohorts.
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Affiliation(s)
- Margaret A Roth
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM 87113, USA
| | - Katarina Leyba
- Department of Internal Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Ishan Garg
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM 87113, USA
| | | | - Mohammed A Quazi
- Department of Biostatistics and Mathematics, University of New Mexico, Albuquerque, NM 87113, USA
| | - Amir H Sohail
- Department of Surgical Oncology, University of New Mexico, Albuquerque, NM 87113, USA
| | - Rozi Khan
- Department of Internal Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Sulaiman Sultan
- Department of Nephrology, University of New Mexico, Albuquerque, NM 87113, USA
| | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM 87113, USA.
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Liberman AL, Razzak J, Lappin RI, Navi BB, Bruce SS, Liao V, Kaiser JH, Ng C, Segal AZ, Kamel H. Risk of Major Adverse Cardiovascular Events After Emergency Department Visits for Hypertensive Urgency. Hypertension 2024; 81:1592-1598. [PMID: 38660784 DOI: 10.1161/hypertensionaha.124.22885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/28/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Chronic hypertension is an established long-term risk factor for major adverse cardiovascular events (MACEs). However, little is known about short-term MACE risk after hypertensive urgency, defined as an episode of acute severe hypertension without evidence of target-organ damage. We sought to evaluate the short-term risk of MACE after an emergency department (ED) visit for hypertensive urgency resulting in discharge to home. METHODS We performed a case-crossover study using deidentified administrative claims data. Our case periods were 1-week intervals from 0 to 12 weeks before hospitalization for MACE. We compared ED visits for hypertensive urgency during these case periods versus equivalent control periods 1 year earlier. Hypertensive urgency and MACE components were all ascertained using previously validated International Classification of Diseases, Tenth Revision Clinical Modification codes. We used McNemar test for matched data to calculate risk ratios. RESULTS Among 2 225 722 patients with MACE, 1 893 401 (85.1%) had a prior diagnosis of hypertension. There were 4644 (0.2%) patients who had at least 1 ED visit for hypertensive urgency during the 12 weeks preceding their MACE hospitalization. An ED visit for hypertensive urgency was significantly more common in the first week before MACE compared with the same chronological week 1 year earlier (risk ratio, 3.5 [95% CI, 2.9-4.2]). The association between hypertensive urgency and MACE decreased in magnitude with increasing temporal distance from MACE and was no longer significant by 11 weeks before MACE (risk ratio, 1.2 [95% CI, 0.99-1.6]). CONCLUSIONS ED visits for hypertensive urgency were associated with a substantially increased short-term risk of subsequent MACE.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | | | | | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Samuel S Bruce
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Vanessa Liao
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Jed H Kaiser
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Catherine Ng
- Information Technologies and Services Department, Weill Cornell Medicine, New York (C.N.)
| | - Alan Z Segal
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
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Abebe AT, Kebede YT, Mohammed BD. An Assessment of the Prevalence and Risk Factors of Hypertensive Crisis in Patients Who Visited the Emergency Outpatient Department (EOPD) at Adama Hospital Medical College, Adama, Oromia, Ethiopia: A 6-Month Prospective Study. Int J Hypertens 2024; 2024:6893267. [PMID: 38711482 PMCID: PMC11073854 DOI: 10.1155/2024/6893267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 04/02/2024] [Accepted: 04/09/2024] [Indexed: 05/08/2024] Open
Abstract
Background Over 1 billion people worldwide suffer from the common chronic medical condition of hypertension. A hypertensive crisis occurs when blood pressure exceeds 180/110 mmHg. Depending on whether the target organ is harmed, the situation may be presented as a hypertensive emergency or urgency. Objective To assess the prevalence and risk factors of patients with hypertensive crises who visited the Emergency Outpatient Department (EOPD) at Adama Hospital Medical College in Adama, Oromia, Ethiopia, between January 01 and August 31, 2021, G.C. Methodology. A cross-sectional, prospective study on the hypertensive crisis was conducted at Adama Hospital Medical College from January 01 to August 31, 2021, G.C. The data were collected using a standardized questionnaire, validated for completeness, and analyzed using SPSS. The findings were tabulated, and conclusions and recommendations were conveyed. Result Out of 9,082 patients who visited the EOPD during the six-month period, 444 individuals with hypertensive crises were identified, representing a prevalence of 4.9%. Of these, 56.8% were men, resulting in a M : F ratio of 1.31 : 1. Those between the ages of 66 and 75 were the most affected. At presentation, 91.0% of the study participants were known hypertensive patients. Among the known hypertensive patients, the majority (34.9%) were known to have been hypertensive for 5-10 years. Of the known hypertensive patients, 48.6% were found to be adherent. Hypertensive urgency was discovered to be far more common than hypertensive emergencies (63.5% vs. 36.5%). Headache was the most common presenting symptom, and most patients (36.5%) presented to the health setup in less than 24 hours. The main risk variables identified were drug discontinuation, family history of hypertension, salt consumption, and alcohol usage. The main excuse for the lack of adherence was the cost of the medications. More than half of the patients do not have any additional comorbidities, and of those who do, diabetes mellitus is the most prevalent. A stroke was identified as a major complication. Conclusions and Recommendations. Hypertensive crises are one of the most prevalent reasons for EOPD admission and are linked to significant consequences. At presentation, most of the study subjects were known hypertension patients. Diabetes mellitus was discovered to be a comorbid condition in one-quarter of them. Although more than half of the patients had improved, the death rate still remained high. Infrastructure and capacity building to provide hospitals with the requisite baseline investigations are among the government's recommendations. Health practitioners are expected to make improvements, such as by educating the public about the need for lifestyle changes and evaluating and managing any hypertension problems.
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Affiliation(s)
- Abel Tezera Abebe
- School of Medicine, Faculty of Medical Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Yabets Tesfaye Kebede
- School of Medicine, Faculty of Medical Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Bekri Delil Mohammed
- School of Medicine, Faculty of Medical Sciences, Institute of Health, Jimma University, Jimma, Ethiopia
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Eurick-Bering K, Todd B, Cameron-Comasco L. Slow on the Draw-ED Management of Elevated BP in Older Adults. Curr Hypertens Rep 2024; 26:107-117. [PMID: 37987967 DOI: 10.1007/s11906-023-01284-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/22/2023]
Abstract
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.
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Affiliation(s)
- Kianna Eurick-Bering
- Department of Emergency Medicine, William Beaumont University Hospital, 3601 W. 13 Mile Rd, Royal Oak, MI, 48073, USA
| | - Brett Todd
- Department of Emergency Medicine, William Beaumont University Hospital, 3601 W. 13 Mile Rd, Royal Oak, MI, 48073, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Lauren Cameron-Comasco
- Department of Emergency Medicine, William Beaumont University Hospital, 3601 W. 13 Mile Rd, Royal Oak, MI, 48073, USA.
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.
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Matsuki H, Genma T, Mandai S, Fujiki T, Mori Y, Ando F, Mori T, Susa K, Iimori S, Naito S, Sohara E, Rai T, Fushimi K, Uchida S. National Trends in Mortality and Urgent Dialysis after Acute Hypertension in Japan From 2010 Through 2019. Hypertension 2023; 80:2591-2600. [PMID: 37818643 DOI: 10.1161/hypertensionaha.123.21880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/25/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND Despite increasing incidences of hypertension, recent trends in mortality and urgent dialysis following acute hypertension (AHT) remain undetermined. METHODS This retrospective observational cohort study evaluated 50 316 hospitalized AHT patients from 2010 to 2019, using an administrative claims database in Japan. We examined trends in incidence, urgent dialysis, mortality, and its risk factors using Poisson regression models. Using International Classification of Disease and Related Health Problems, 10th Revision codes, AHT was categorized into 5 spectrums: malignant hypertension (n=1792), hypertensive emergency (n=17 907), hypertensive urgency (n=1562), hypertensive encephalopathy (n=6593), and hypertensive heart failure (HHF; n=22 462). RESULTS The median age of the patients was 76 years, and 54.9% were women. The total AHT incidence was 70 cases per 100 000 admission year. The absolute death rate increased from 1.83% (95% CI, 1.40-2.40) to 2.88% ([95% CI, 2.42-3.41]; Cochran-Armitage trend test, P<0.0001). Upward trends were observed in patients aged ≥80, with lean body mass index ≤18.4, and with HHF. Urgent dialysis rates increased from 1.52% (95% CI, 1.12-2.06) to 2.60% (2.17-3.1; Cochran-Armitage trend test; P=0.0071) in 48 235 patients, excluding maintenance dialysis patients. Older age, men, lean body mass, malignant hypertension, HHF, and underlying chronic kidney disease correlated with higher mortality risk; greater hospital volume correlated with lower mortality risk; and malignant hypertension, HHF, diabetes, chronic kidney disease, and scleroderma correlated with a higher risk of urgent dialysis. CONCLUSIONS Mortality and urgent dialysis rates following AHT have increased. Aging, complex comorbidities, and HHF-type AHT contributed to the rising trend of mortality.
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Affiliation(s)
- Hisazumi Matsuki
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
| | - Taku Genma
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
| | - Shintaro Mandai
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
| | - Tamami Fujiki
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
| | - Yutaro Mori
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
| | - Fumiaki Ando
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
| | - Takayasu Mori
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
| | - Koichiro Susa
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
| | - Soichiro Iimori
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
| | - Shotaro Naito
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
| | - Eisei Sohara
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
| | - Tatemitsu Rai
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
- Department of Nephrology and Hypertension, Dokkyo Medical University, Shimotsuga, Tochigi, Japan (T.R.)
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (K.F.)
| | - Shinichi Uchida
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan (H.M., T.G., S.M., T.F., Y.M., F.A., T.M., K.S., S.I., S.N., E.S., T.R., S.U.)
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Ojinnaka CO, Arteaga I, Hodges L, Heflin C. SNAP Participation and Medication Adherence Among Older Black Medicaid-Insured Individuals Living With Hypertension. Am J Hypertens 2023; 36:485-490. [PMID: 37225664 DOI: 10.1093/ajh/hpad052] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 12/03/2022] [Accepted: 05/23/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Black people are more likely to be diagnosed with hypertension and to experience food insecurity and antihypertensive medication non-adherence compared to White people in the U.S. The Supplemental Nutrition Assistance Program (SNAP)-a means-tested program that targets food insecurity has been shown to affect health outcomes. This study analyzed the relationship between SNAP participation and antihypertensive medication adherence among older Black Medicaid-insured individuals. METHODS This is a retrospective cohort study using linked 2006-2014 state of Missouri Medicaid and SNAP administrative claims data. Analyses were restricted to older (≥60 years) Black individuals who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60 years with at least one pharmacy claim (n = 10,693). Our outcome measure is a dichotomous measure of antihypertensive medication adherence defined using the Proportion of Days Covered (≥80% PDC = 1). The exposure variables are four measures of SNAP participation. RESULTS A higher proportion of SNAP participants were adherent to their antihypertensive medications compared to non-SNAP participants (43.5% vs. 32.0%). On multivariable analyses, compared to non-SNAP participants there was an increased likelihood of antihypertensive medication adherence among SNAP participants (prevalence ratio [PR] = 1.25; 95% confidence interval [CI] = 1.16-1.35). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of antihypertensive medication adherence among those who were enrolled for 10-12 months (PR = 1.41; 95% CI = 1.08-1.85). CONCLUSIONS Medicaid-insured older Black adults who were SNAP participants had a higher likelihood of antihypertensive medication adherence compared to non-SNAP participants.
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Affiliation(s)
- Chinedum O Ojinnaka
- College of Health Solutions, Arizona State University, 550 North 3rd Street, Phoenix, Arizona 85004
| | - Irma Arteaga
- Harry S Truman School of Public Affairs, University of Missouri, 239 Middlebush Hall, Columbia, Missouri 65211
| | - Leslie Hodges
- Economic Research Service, United States Department of Agriculture, PO Box 419205, MS 9999, Kansas City, Missouri 64141-6205
| | - Colleen Heflin
- Maxwell School of Citizenship and Public Affairs, Syracuse University, 426 Eggers Hall, Syracuse, New York 13244-1020
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Siddiqi TJ, Usman MS, Rashid AM, Javaid SS, Ahmed A, Clark D, Flack JM, Shimbo D, Choi E, Jones DW, Hall ME. Clinical Outcomes in Hypertensive Emergency: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2023; 12:e029355. [PMID: 37421281 PMCID: PMC10382109 DOI: 10.1161/jaha.122.029355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 05/30/2023] [Indexed: 07/10/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Aymen Ahmed
- Department of MedicineDow University of Health SciencesKarachiPakistan
| | - Donald Clark
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
| | - John M. Flack
- Department of Internal MedicineSouthern Illinois School of MedicineSpringfieldILUSA
| | - Daichi Shimbo
- Department of MedicineColumbia University Irving Medical CenterNew YorkNYUSA
| | - Eunhee Choi
- Department of Pathology and Cell BiologyVagelos College of Physicians and Surgeons, Columbia UniversityNew YorkNYUSA
| | - Daniel W. Jones
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
| | - Michael E. Hall
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
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Abstract
PURPOSE OF REVIEW Hypertensive crisis (HTN-C) is a condition of increasing prevalence. It carries significant morbidity and mortality, and prompt recognition and treatment are crucial. There is a paucity of controlled trials, so a working knowledge of the most recent literature in the area of HTN-C is helpful. RECENT FINDINGS Novel serological markers, including serum corin, have been found to aid in the early identification of end-organ damage from severely elevated blood pressure (BP). In the area of BP following thrombolysis for ischemic stroke, lower target BP (130-140 mmHg) is associated with some improved outcomes. Two large trials of lower BP following mechanical thrombectomy in stroke have failed to show improved outcomes; however, observed data show benefits at lower than currently recommended levels. Clevidipine, a calcium channel blocker marketed for unique use in HTN-C, was found to be noninferior to the generic less expensive nicardipine. Oral nifedipine was found to be the most effective agent for sustained BP reduction in preeclampsia. SUMMARY HTN-C remains an area with few prospective randomized trials, but there is active research on identifying lower goals for specific clinical scenarios. Ideal therapeutic agents should be tailored for specific end-organ damage.
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Affiliation(s)
- Merrill H Stewart
- Department of Cardiology, Ochsner Heart & Vascular Institute
- Department of Cardiology, Ochsner Clinical School, Queensland University School of Medicine, New Orleans, Los Angeles, USA
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Benenson I, Waldron FA, Holly C. A Systematic Review and Meta-analysis of the Clinical and Epidemiological Characteristics of Patients with Hypertensive Emergencies: Implication for Risk Stratification. High Blood Press Cardiovasc Prev 2023:10.1007/s40292-023-00586-1. [PMID: 37284909 DOI: 10.1007/s40292-023-00586-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/29/2023] [Indexed: 06/08/2023] Open
Abstract
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.
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Francis-Morel G, Guevara NA, Malik M, Sotello D. Gender Disparities in Hypertensive Emergency Admissions: A National Retrospective Cohort Study. Cureus 2023; 15:e40287. [PMID: 37448423 PMCID: PMC10336740 DOI: 10.7759/cureus.40287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2023] [Indexed: 07/15/2023] Open
Abstract
Background Hypertension is one of the most common conditions affecting almost one in every five adults globally and hypertensive emergency is a life-threatening complication of uncontrolled hypertension leading to significant disability. Despite advances in treatment, gender disparities are yet to be addressed. Methods This retrospective cohort study used nationally representative data from the Healthcare Cost and Utilization Project (HCUP), specifically the National Inpatient Sample, to study two cohorts divided by sex (males and females). The primary outcome was all-cause inpatient mortality. Multivariate logistic regression analysis yielded adjusted odds ratios (aORs) for confounders. Secondary outcomes included length of stay (LOS) and total hospital charges. Multivariate linear regression identified independent predictors. We described crude rates of mechanical ventilation, acute kidney injury (AKI) requiring hemodialysis (HD), and vasopressor requirements. Patient demographics were also presented. We used the chi-squared (χ2) test for categorical variables and Student's t-test for continuous variables. Statistical significance was defined as a two-tailed p-value<0.05. Results A total of 229,025 patients met the inclusion criteria, where 52% were male and 48% were female. The mean patient age was 58 years (55 for men and 62 for women, p <0.001). White patients represented 40% of hospitalizations (males: 37%; females: 42%), black patients represented 42% (males: 43%; females: 41%), and Hispanics 11% (males: 12%; females: 10%). Medicare was the primary payer 47% of the time (males: 38%; females: 56%), Medicaid in 21% (males: 23%; females: 18%), private insurance in 20% (males: 23%; females: 17%), and no insurance in 10% (males: 14%; females: 7%). Female patients had higher rates of chronic obstructive pulmonary disease (COPD) (21% for females vs. 15% for males), connective tissue disease (4.6% for females vs. 0.98% for males; p<0.001), and dementia (6% for females vs. 3% for males). Conversely, males had a higher rate of chronic kidney disease (CKD) (51% vs. 42% for females). Male sex was a predictor of mortality (aOR 1.39, p=0.036), along with age (aOR 1.02, p<0.001) and Charlson Comorbidity Index (http://mchp-appserv.cpe.umanitoba.ca/viewConcept.php?printer=Y&conceptID=1098) (aOR 1.20, p<0.001). Sex was not a predictor of length of stay (LOS) (p=0.496) or total hospital charges (p=0.192). Conclusions In an attempt to achieve better outcomes in patients affected by hypertensive emergency, our retrospective cohort study found that male patients who experienced hypertensive emergency had 39% higher odds of mortality than female patients. Age and Charlson Comorbidity Index were additionally found to be independent predictors of mortality.
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Affiliation(s)
| | | | - Mushrin Malik
- Internal Medicine, St. Barnabas Hospital Health System, Bronx, USA
| | - David Sotello
- CoxHealth Pulmonology, CoxHealth Pulmonology and Sleep Medicine, Branson, USA
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Ojinnaka CO, Arteaga I, Hodges L, Heflin C. Supplemental Nutrition Assistance Program Participation and Medication Adherence Among Medicaid-Insured Older Adults Living with Hypertension. J Gen Intern Med 2023; 38:1349-1356. [PMID: 36707458 PMCID: PMC10160273 DOI: 10.1007/s11606-022-07994-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 12/23/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Food insecurity has been associated with medication non-adherence among individuals living with chronic diseases like hypertension. The relationship between Supplemental Nutrition Assistance Program (SNAP)-a public program that addresses food insecurity-and Medication adherence among older Medicaid-insured adults living with hypertension is not clear. OBJECTIVE To analyze the association between patterns of SNAP participation and adherence to antihypertensive medications among older Medicaid-insured individuals. DESIGN Retrospective study using linked 2006-2014 state of Missouri's Medicaid claims and Supplemental Nutrition Assistance Program data. PARTICIPANTS Older adults (≥ 60 years) who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60. MAIN MEASURES The outcome measure was medication adherence assessed using the proportion of days covered (PDC). The exposure measures were as follows: (1) receipt of SNAP benefits (no [0], yes [1]); (2) SNAP benefits receipt during the 12-month Medicaid continuous enrollment (no [0], yes [1]); (3) duration of SNAP participation during the 12-month continuous Medicaid enrollment; and (4) SNAP participation pattern. KEY RESULTS On multivariable analyses, there was a statistically significant association between ever participating in SNAP and medication adherence (β = 0.32; S.E. = 0.011). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of medication adherence among those who were enrolled for 10-12 months (β = 0.44, S.E. = 0.041). CONCLUSIONS Medicaid-insured older adults who are SNAP participants or enrolled in SNAP for 10-12 months of a 12-month Medicaid continuous enrollment period are more likely to be adherent to antihypertensive medication compared to non-SNAP participants or those enrolled for 1-3 months, respectively.
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Affiliation(s)
| | - Irma Arteaga
- Harry S Truman School of Government and Public Affairs, University of Missouri, Columbia, MO, USA
| | - Leslie Hodges
- Economic Research Service, United States Department of Agriculture, Kansas City, MO, USA
| | - Colleen Heflin
- Maxwell School of Citizenship and Public Affairs, Syracuse University, Syracuse, NY, USA
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Pothuru S, Chan WC, Mehta H, Vindhyal MR, Ranka S, Hu J, Yarlagadda SG, Wiley MA, Hockstad E, Tadros PN, Gupta K. Burden of Hypertensive Crisis in Patients With End-Stage Kidney Disease on Maintenance Dialysis: Insights From United States Renal Data System Database. Hypertension 2023; 80:e59-e67. [PMID: 36752114 DOI: 10.1161/hypertensionaha.122.20546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND There is paucity of information on the incidence, clinical characteristics, admission trends, and outcomes of hypertensive crisis (HTN-C) in patients with end-stage kidney disease (ESKD) who are on maintenance dialysis. METHODS We conducted a retrospective observational study of HTN-C admissions in patients with end-stage kidney disease using the United States Renal Data System. We identified patients with end-stage kidney disease aged ≥18 years on dialysis and were hospitalized for HTN-C from January 2006 to August 2015. RESULTS A total of 54 483 patients with end-stage kidney disease were hospitalized for HTN-C during the study period. After study exclusions, 37 214 patients were included in the analysis. A majority of patients were Black, there were more women than men and the South region of the country accounted for a great majority of patients. During the study period, hospitalization rates increased from 1060 per 100 000 beneficiary years to 1821 (Ptrend<0.0001). Overall, in-hospital mortality, 30-day, and 1-year mortality were 0.6%, 2.3%, and 21.8%, respectively, and 30-day readmission rate was 31.1%. During the study period, most study outcomes showed a significant decreasing trend (in-hospital mortality 0.6%-0.5%, 30-day mortality 2.4%-1.9%, 1-year mortality 23.9%-19.7%, Ptrend<0.0001 for all). CONCLUSIONS Hospitalizations for HTN-C have increased consistently during the decade studied. Although temporal trends showed improving mortality and readmission rates, the absolute rates were still high with 1 in 3 patients readmitted within 30 days and 1 in 5 patients dying within 1 year of index hospitalization.
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Affiliation(s)
- Suveenkrishna Pothuru
- Department of Cardiovascular Medicine (S.P., W.-C.C., H.M., M.R.V., S.R., M.A.W., E.H., P.N.T., K.G.), University of Kansas School of Medicine, Kansas City.,Department of Internal Medicine, Ascension Via Christi Hospital, Manhattan, KS (S.P.)
| | - Wan-Chi Chan
- Department of Cardiovascular Medicine (S.P., W.-C.C., H.M., M.R.V., S.R., M.A.W., E.H., P.N.T., K.G.), University of Kansas School of Medicine, Kansas City
| | - Harsh Mehta
- Department of Cardiovascular Medicine (S.P., W.-C.C., H.M., M.R.V., S.R., M.A.W., E.H., P.N.T., K.G.), University of Kansas School of Medicine, Kansas City
| | - Mohinder R Vindhyal
- Department of Cardiovascular Medicine (S.P., W.-C.C., H.M., M.R.V., S.R., M.A.W., E.H., P.N.T., K.G.), University of Kansas School of Medicine, Kansas City
| | - Sagar Ranka
- Department of Cardiovascular Medicine (S.P., W.-C.C., H.M., M.R.V., S.R., M.A.W., E.H., P.N.T., K.G.), University of Kansas School of Medicine, Kansas City
| | - Jinxiang Hu
- Department of Biostatistics and Data Science, University of Kansas School of Medicine (J.H.)
| | - Sri G Yarlagadda
- Division of Nephrology and Hypertension, Department of Internal Medicine (S.G.Y.), University of Kansas School of Medicine, Kansas City
| | - Mark A Wiley
- Department of Cardiovascular Medicine (S.P., W.-C.C., H.M., M.R.V., S.R., M.A.W., E.H., P.N.T., K.G.), University of Kansas School of Medicine, Kansas City
| | - Eric Hockstad
- Department of Cardiovascular Medicine (S.P., W.-C.C., H.M., M.R.V., S.R., M.A.W., E.H., P.N.T., K.G.), University of Kansas School of Medicine, Kansas City
| | - Peter N Tadros
- Department of Cardiovascular Medicine (S.P., W.-C.C., H.M., M.R.V., S.R., M.A.W., E.H., P.N.T., K.G.), University of Kansas School of Medicine, Kansas City
| | - Kamal Gupta
- Department of Cardiovascular Medicine (S.P., W.-C.C., H.M., M.R.V., S.R., M.A.W., E.H., P.N.T., K.G.), University of Kansas School of Medicine, Kansas City
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Rayamajhi S, Sharma S, Regmi S, Anwar FM, Gandhi H. Hypertensive Emergency As Initial Presentation of Systemic Sclerosis Sine Scleroderma. Cureus 2023; 15:e37817. [PMID: 37214048 PMCID: PMC10198668 DOI: 10.7759/cureus.37817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 05/23/2023] Open
Abstract
Hypertensive emergency is a common cause of emergency room (ER) visits. Scleroderma renal crisis (SRC) is one of the rare causes of hypertensive emergency. SRC is a life-threatening condition that presents with acute onset severe hypertension accompanied by retinopathy, encephalopathy, and rapidly worsening renal function. We present a case of hypertensive emergency and renal failure with positive anti-Scl 70 and RNA polymerase III which is characteristic of SRC. Despite appropriate supportive care and timely treatment with angiotensin-converting enzyme inhibitors, the patient progressed to end-stage kidney disease.
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Affiliation(s)
- Sumugdha Rayamajhi
- Internal Medicine, Michigan State University College of Human Medicine, East Lansing, USA
| | | | - Subash Regmi
- Nephrology, University of Southern Carolina, Columbia, USA
| | - Farah M Anwar
- Internal Medicine, Michigan State University, East Lansing, USA
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Hypertensive emergencies and urgencies: a preliminary report of the ongoing Italian multicentric study ERIDANO. Hypertens Res 2023:10.1038/s41440-023-01232-y. [PMID: 36805031 PMCID: PMC9940066 DOI: 10.1038/s41440-023-01232-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/10/2023] [Accepted: 02/03/2023] [Indexed: 02/22/2023]
Abstract
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.
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Kaiser J, Liao V, Kamel H, Ng C, Lappin RI, Liberman AL. The International Classification of Diseases, 10 th Edition, Clinical Modification (ICD-10-CM) Code I16.0 Accurately Identifies Patients with Hypertensive Urgency. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.05.23285422. [PMID: 36798280 PMCID: PMC9934714 DOI: 10.1101/2023.02.05.23285422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Objective Hypertensive urgency, defined as acutely elevated BP without target organ damage, is associated with an increased risk of adverse cardiovascular events and accounts for a substantial proportion of national emergency department (ED) visits. To advance research in this space, we sought to validate the new ICD-10-CM diagnostic code for hypertensive urgency within a single healthcare system. Methods We performed a retrospective chart-review study of ED encounters at Weill Cornell Medicine from 2016 â€" 2021. We randomly selected 25 encounters with the ICD-10-CM code I16.0 as the primary discharge diagnosis and 25 encounters with primary ICD-10-CM discharge diagnosis codes for benign headache disorders. A single board-certified vascular neurologist reviewed all 50 encounters while blinded to the assigned ICD-10-CM codes to identify cases of hypertensive urgency. We calculated the sensitivity, specificity, and positive predictive values of the ICD-10-CM code I16.0 with 95% confidence intervals (CI). Results Out of 50 randomly selected ED encounters, 24 were adjudicated as hypertensive urgency. All encounters adjudicated as hypertensive urgency had been assigned the ICD-10-CM discharge diagnosis code of I16.0. All 25 of the encounters adjudicated as headache were assigned an ICD-10-CM discharge diagnosis code for a benign headache disorder. The ICD-10-CM code for hypertensive urgency, I16.0, was thus found to have a sensitivity of 100% (95% CI: 86-100%), specificity of 96% (95% CI: 80-100%), and positive predictive value of 96% (95% CI: 78-99%). Conclusion We found that the new ICD-10-CM code for hypertensive urgency, I16.0, can reliably identify patients with this condition.
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Prevalence of Myocardial Injury and Myocardial Infarction in Patients with a Hypertensive Emergency: A Systematic Review. Diagnostics (Basel) 2022; 13:diagnostics13010060. [PMID: 36611351 PMCID: PMC9818542 DOI: 10.3390/diagnostics13010060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/12/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
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.
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Samuel N, Nigussie S, Jambo A, Dechasa M, Demeke F, Godana A, Birhanu A, Gashaw T, Agegnehu Teshome A, Siraj A. Treatment Outcome and Associated Factors Among Patients Admitted with Hypertensive Crisis in Public Hospitals at Harar Town, Eastern Ethiopia: A Cross-Sectional Study. Integr Blood Press Control 2022; 15:113-122. [PMID: 36536824 PMCID: PMC9758999 DOI: 10.2147/ibpc.s386461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/22/2022] [Indexed: 10/10/2023] Open
Abstract
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.
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Affiliation(s)
- Nahom Samuel
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Science, Haramaya University, Harar, Ethiopia
| | - Shambel Nigussie
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Science, Haramaya University, Harar, Ethiopia
| | - Abera Jambo
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Science, Haramaya University, Harar, Ethiopia
| | - Mesay Dechasa
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Science, Haramaya University, Harar, Ethiopia
| | - Fekade Demeke
- Department of Epidemiology, College of Medicine and Health Science, Jigjiga University, Jigjiga, Ethiopia
| | - Abduro Godana
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Science, Haramaya University, Harar, Ethiopia
| | - Abdi Birhanu
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Tigist Gashaw
- Department of Pharmacology, School of Pharmacy, College of Health and Medical Science, Haramaya University, Harar, Ethiopia
| | - Assefa Agegnehu Teshome
- Department of Biomedical Science, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Amas Siraj
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Science, Haramaya University, Harar, Ethiopia
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Beeston D, Jepson R, Cortellini S. Evaluation of presentation, treatment and outcome in hypertensive emergency in dogs and cats: 15 cases (2003-2019). J Small Anim Pract 2022; 63:784-791. [PMID: 35811381 PMCID: PMC9796549 DOI: 10.1111/jsap.13530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/25/2022] [Accepted: 06/14/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Hypertensive emergency is well recognised in human medicine, yet there is limited veterinary evidence. This study aimed to determine the presentation, treatment and outcome in dogs and cats with hypertensive emergency. MATERIALS AND METHODS A retrospective case series of dogs and cats with hypertensive emergency identified as follows: acute history with non-invasive Doppler systolic blood pressure greater than 180 mmHg and target organ damage including acute onset seizures, altered mentation with or without lateral recumbency or blindness. Data collected included signalment, history, physical examination and clinicopathological findings, systolic blood pressure, antihypertensive treatment and outcome. RESULTS Seven dogs and eight cats were included presenting with seizures (n=9), blindness (n=4), altered mentation with (n=2) or without (n=2) lateral recumbency. Median age was 9 years (range 1 to 15) and duration of clinical signs before presentation was 1.5 days (range 1 to 15). Median systolic blood pressure on presentation was 230 mmHg (range 190 to 300). Amlodipine was the most common first-line agent (n=10), followed by hydralazine (n=4) and hypertonic saline (n=1). Aetiology of hypertensive emergency was acute kidney injury (n=9), idiopathic hypertension (n=3), hyperthyroidism (n=1), lymphoma (n=1) and suspected cutaneous and renal glomerular vasculopathy (n=1). Five cats and three dogs survived to discharge with an overall survival of 53.3%. CLINICAL SIGNIFICANCE Hypertensive emergencies had various presenting signs in this series. AKI was considered to be the cause of hypertension in the majority of patients. Further evaluation of treatment for hypertensive emergencies is warranted, considering almost half of the cases did not survive to discharge.
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Affiliation(s)
- D. Beeston
- Queen Mother Hospital for AnimalsRoyal Veterinary CollegeBrookmans ParkAL9 7TAUK
| | - R. Jepson
- Queen Mother Hospital for AnimalsRoyal Veterinary CollegeBrookmans ParkAL9 7TAUK
| | - S. Cortellini
- Queen Mother Hospital for AnimalsRoyal Veterinary CollegeBrookmans ParkAL9 7TAUK
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Andrade DO, Aguiar FL, Mansor ALP, Valente FM, Souza DRS, Lopes VDS, Fernandes LB, Godoy MF, Yugar-Toledo JC, Cosenso-Martin LN, Vilela-Martin JF. Inflammatory cytokines are associated to lower glomerular filtration rate in patients with hypertensive crisis. Front Cardiovasc Med 2022; 9:969339. [PMID: 36247461 PMCID: PMC9559728 DOI: 10.3389/fcvm.2022.969339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/06/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionHypertension 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).ObjectivesTo evaluate the relationship between renal function and inflammatory cytokines in HC, subdivided into hypertensive urgency (HUrg) and emergency (HEmerg).Materials and methodsThis 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 < 0.05.ResultsThe 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 < 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 < 0.0001 among groups). BP and heart rate levels were significantly higher in the HC group compared to the NT and ContrHT groups (P < 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 < 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.ConclusionElevated 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.
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Affiliation(s)
- Days O. Andrade
- Hypertension Clinical and Medicine Department, State Medical School at São José do Rio Preto, São Paulo, Brazil
| | - Franciana L. Aguiar
- Hypertension Clinical and Medicine Department, State Medical School at São José do Rio Preto, São Paulo, Brazil
| | - Ana Luiza P. Mansor
- Hypertension Clinical and Medicine Department, State Medical School at São José do Rio Preto, São Paulo, Brazil
| | - Flavia M. Valente
- Hypertension Clinical and Medicine Department, State Medical School at São José do Rio Preto, São Paulo, Brazil
| | - Doroteia R. S. Souza
- Biochemistry and Molecular Biology Research Nucleus and Molecular Biology Department, State Medical School at São José do Rio Preto, São Paulo, Brazil
| | - Valquiria da Silva Lopes
- Hypertension Clinical and Medicine Department, State Medical School at São José do Rio Preto, São Paulo, Brazil
| | - Leticia B. Fernandes
- Hypertension Clinical and Medicine Department, State Medical School at São José do Rio Preto, São Paulo, Brazil
| | - Moacir F. Godoy
- Transdisciplinary Nucleus for the Study of Chaos and Complexity, de Cardiology and Cardiovascular Surgery Department, State Medical School at São José do Rio Preto, São Paulo, Brazil
| | - Juan C. Yugar-Toledo
- Hypertension Clinical and Medicine Department, State Medical School at São José do Rio Preto, São Paulo, Brazil
| | - Luciana N. Cosenso-Martin
- Hypertension Clinical and Medicine Department, State Medical School at São José do Rio Preto, São Paulo, Brazil
| | - Jose F. Vilela-Martin
- Hypertension Clinical and Medicine Department, State Medical School at São José do Rio Preto, São Paulo, Brazil
- *Correspondence: Jose F. Vilela-Martin,
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Kotruchin P, Tangpaisarn T, Mitsungnern T, Sukonthasarn A, Hoshide S, Turana Y, Siddique S, Buranakitjaroen P, Van Huynh M, Chia Y, Park S, Chen C, Nailes J, Tay JC, Wang J, Kario K. Hypertensive emergencies in Asia: A brief review. J Clin Hypertens (Greenwich) 2022; 24:1226-1235. [PMID: 36196470 PMCID: PMC9532896 DOI: 10.1111/jch.14547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/22/2022] [Accepted: 06/29/2022] [Indexed: 11/29/2022]
Abstract
Hypertensive emergency is one of the most challenging conditions to treat in the emergency department (ED). From previous studies, about 1%-3% of hypertensive individuals experienced hypertensive emergencies. Its prevalence varied by country and region throughout Asia. Asian populations have more different biological and cultural backgrounds than Caucasians and even within Asian countries. However, there is a scarcity of research on clinical features, treatment, and outcomes in multinational Asian populations. The authors aimed to review the current evidence about epidemiology, clinical characteristics and outcomes, and practice guidelines in Asia. Five observational studies and nine clinical practice guidelines across Asia were reviewed. The prevalence of hypertensive emergencies ranged from .1% to 1.5%. Stroke was the most common target organ involvement in Asians who presented with hypertensive emergencies. Although most hypertensive emergency patients required hospitalization, the mortality rate was low. Given the current lack of data among Asian countries, a multinational data repository and Asian guidelines on hypertensive emergency management are mandatory.
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Affiliation(s)
- Praew Kotruchin
- Faculty of MedicineDepartment of Emergency MedicineKhon Kaen UniversityKhon KaenThailand
| | - Thanat Tangpaisarn
- Faculty of MedicineDepartment of Emergency MedicineKhon Kaen UniversityKhon KaenThailand
| | | | - Apichard Sukonthasarn
- Faculty of Medicine, Cardiology DivisionDepartment of Internal MedicineChiang Mai UniversityChiang MaiThailand
| | - Satoshi Hoshide
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineTochigiJapan
| | - Yuda Turana
- Department of Neurology, School of Medicine and Health SciencesAtma Jaya Catholic University of IndonesiaJakartaIndonesia
| | | | - Peera Buranakitjaroen
- Division of HypertensionDepartment of MedicineFaculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Minh Van Huynh
- Department of Internal MedicineHue University of Medicine and PharmacyHue UniversityHue CityVietnam
| | - Yook‐Chin Chia
- Department of Medical SciencesSchool of Medical and Life SciencesSunway UniversityBandar SunwayMalaysia
- Faculty of Medicine, Department of Primary Care MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Sungha Park
- Division of CardiologySeverance Cardiovascular HospitalYonsei University Health SystemSeoulKorea
| | - Chen‐Huan Chen
- Department of Internal MedicineNational Yang Ming Chiao Tung University College of MedicineTaipeiTaiwan
| | - Jennifer Nailes
- Department of Preventive and Community Medicine and Research Institute for Health SciencesUniversity of the East Ramon Magsaysay Memorial Medical Center Inc.Quezon CityPhilippines
| | - Jam Chin Tay
- Department of General MedicineTan Tock Seng HospitalSingaporeSingapore
| | - Ji‐Guang Wang
- Department of HypertensionCentre for Epidemiological Studies and Clinical TrialsThe Shanghai Institute of HypertensionShanghai Key Laboratory of HypertensionRuijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
| | - Kazuomi Kario
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineTochigiJapan
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21
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Talle MA, Ngarande E, Doubell AF, Herbst PG. Cardiac Complications of Hypertensive Emergency: Classification, Diagnosis and Management Challenges. J Cardiovasc Dev Dis 2022; 9:jcdd9080276. [PMID: 36005440 PMCID: PMC9409837 DOI: 10.3390/jcdd9080276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Mohammed A. Talle
- Department of Medicine, Division of Cardiology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town 7505, South Africa
- Department of Medicine, Faculty of Clinical Sciences, College of Medical Sciences, University of Maiduguri and University of Maiduguri Teaching Hospital, Maiduguri 600004, Nigeria
- Correspondence: ; Tel.: +27-1631425117
| | - Ellen Ngarande
- Department of Medicine, Division of Cardiology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town 7505, South Africa
| | - Anton F. Doubell
- Department of Medicine, Division of Cardiology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town 7505, South Africa
| | - Philip G. Herbst
- Department of Medicine, Division of Cardiology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town 7505, South Africa
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22
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Park DY, An S, Rodriguez MA, Odeh R, Hammo H, Haque M, Arif AW. Impact of end-stage renal disease on in-hospital outcomes of hypertensive emergency from the National Inpatient Sample, 2016 to 2018. Proc (Bayl Univ Med Cent) 2022; 35:783-789. [DOI: 10.1080/08998280.2022.2098771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, Illinois
| | - Seokyung An
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
| | | | - Raghad Odeh
- Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Hasan Hammo
- Department of Medicine, Cook County Health, Chicago, Illinois
| | - Mahaim Haque
- Department of Medicine, Cook County Health, Chicago, Illinois
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23
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Epidemiology and outcomes of hypertensive crisis in patients with chronic kidney disease: a nationwide analysis. J Hypertens 2022; 40:1288-1293. [PMID: 35703297 DOI: 10.1097/hjh.0000000000003136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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24
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The Management of Hypertensive Emergencies-Is There a "Magical" Prescription for All? J Clin Med 2022; 11:jcm11113138. [PMID: 35683521 PMCID: PMC9181665 DOI: 10.3390/jcm11113138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 12/04/2022] Open
Abstract
Hypertensive emergencies (HE) represent high cardiovascular risk situations defined by a severe increase in blood pressure (BP) associated with acute, hypertension mediated organ damage (A-HMOD) to the heart, brain, retina, kidneys, and large arteries. Blood pressure values alone do not accurately predict the presence of HE; therefore, the search for A-HMOD should be the first step in the management of acute severe hypertension. A rapid therapeutic intervention is mandatory in order to limit and promote regression of end-organ damage, minimize the risk of complications, and improve patient outcomes. Drug therapy for HE, target BP, and the speed of BP decrease are all dictated by the type of A-HMOD, specific drug pharmacokinetics, adverse drug effects, and comorbidities. Therefore, a tailored approach is warranted. However, there is currently a lack of solid evidence for the appropriate treatment strategies for most HE. This article reviews current pharmacological strategies while providing a stepwise, evidence based approach for the management of HE.
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25
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Vadeboncoeur A, Marcil MJ, Cyr S, Gupta M, Cournoyer A, Minichiello A, Larose D, Sirois-Leclerc J, Tardif JC, Morin J, Masson V, Cossette M, Brouillette J. Trajectory of patients consulting the emergency department for high blood pressure values. CAN J EMERG MED 2022; 24:515-519. [PMID: 35503402 PMCID: PMC9345802 DOI: 10.1007/s43678-022-00307-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/24/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Emergency department (ED) visits for high blood pressure are increasing in frequency. We aimed to map those patients' trajectory, from referral sources to the type of care received at the ED to anticipated actions for future high blood pressure concerns, and to better understand their reasons for consulting the ED for high blood pressure values. METHODS Between 2018 and 2020, patients who presented to the Montreal Heart Institute's ED for elevated blood pressure were recruited in a prospective observational study including a post hoc structured telephone interview and medical chart review. Five possible referral sources were predetermined. We provided proportions and 95% confidence intervals. RESULTS A total of 100 patients were recruited (female: 59%, mean age: 69 ± 12). A majority (93%, 95% CI 88-98%) possessed a home blood pressure device, among which 46% (95% CI 36-56%) remembered receiving advice for its use. The main referral sources for high blood pressure to the ED were self-reference (53%, 95% CI 43-63%), advice of a lay person (19%, 95% CI 11-27%) or a nurse (13%, 95% CI 6-20%). Mainly, patients reported being concerned by concomitant symptoms or experiencing acute medical consequences (44%, 95% CI 34-54%), having followed the recommendation of a third party (33%, 95% CI 24-42%), or having concerns about their medication (6%, 95% CI 1-11%). Two weeks following their ED visits, consulting ED remained the main choice for future concerns about high blood pressure for 27% of participants. When specifically asked if they would return to the ED for elevated blood pressure, 73% (95% CI 64-83%) said yes. CONCLUSIONS Most patients who consulted the ED for elevated blood pressure values were self-referred. More can be done to promote blood pressure education, effective use of personal blood pressure devices, and recommendations for patients and health professionals when confronted with high blood pressure results.
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Affiliation(s)
- Alain Vadeboncoeur
- Research Centre, Montréal Heart Institute, Université de Montréal, 5000 Belanger Street, Montréal, QC, H1T 1C8, Canada
| | - Marie-Joelle Marcil
- Research Centre, Montréal Heart Institute, Université de Montréal, 5000 Belanger Street, Montréal, QC, H1T 1C8, Canada.,Department of Psychiatry and Addiction, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Samuel Cyr
- Research Centre, Montréal Heart Institute, Université de Montréal, 5000 Belanger Street, Montréal, QC, H1T 1C8, Canada.,Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada
| | - Mona Gupta
- Centre de recherche, Centre Hospitalier de L'Université de Montréal, Montréal, QC, Canada
| | - Alexis Cournoyer
- Centre de recherche, Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Anthony Minichiello
- Research Centre, Montréal Heart Institute, Université de Montréal, 5000 Belanger Street, Montréal, QC, H1T 1C8, Canada
| | - Dominic Larose
- Research Centre, Montréal Heart Institute, Université de Montréal, 5000 Belanger Street, Montréal, QC, H1T 1C8, Canada
| | - Julie Sirois-Leclerc
- Research Centre, Montréal Heart Institute, Université de Montréal, 5000 Belanger Street, Montréal, QC, H1T 1C8, Canada
| | - Jean-Claude Tardif
- Research Centre, Montréal Heart Institute, Université de Montréal, 5000 Belanger Street, Montréal, QC, H1T 1C8, Canada
| | - Josée Morin
- Research Centre, Montréal Heart Institute, Université de Montréal, 5000 Belanger Street, Montréal, QC, H1T 1C8, Canada
| | - Violaine Masson
- Centre de recherche, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada
| | - Mariève Cossette
- Montreal Health Innovations Coordinating Center, Montréal, QC, Canada
| | - Judith Brouillette
- Research Centre, Montréal Heart Institute, Université de Montréal, 5000 Belanger Street, Montréal, QC, H1T 1C8, Canada. .,Department of Psychiatry and Addiction, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada.
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26
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Ghazi L, Li F, Chen X, Simonov M, Yamamoto Y, Biswas A, Hanna J, Shah T, Peixoto AJ, Wilson FP. Blood pressure response to commonly administered antihypertensives for severe inpatient hypertension. PLoS One 2022; 17:e0265497. [PMID: 35385506 PMCID: PMC8985959 DOI: 10.1371/journal.pone.0265497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/02/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Blood pressure (BP) elevations are commonly treated in hospitalized patients; however, treatment is not guideline directed. Our objective was to assess BP response to commonly prescribed antihypertensives after the development of severe inpatient hypertension (HTN). METHODS This is a cohort study of adults, excluding intensive care unit patients, within a single healthcare system admitted for reasons other than HTN who developed severe HTN (systolic BP>180 or diastolic BP >110 mmHg at least 1 hour after admission). We identified the most commonly administered antihypertensives given within 6 hours of severe HTN (given to >10% of treated patients). We studied the association of treatment with each antihypertensive vs. no treatment on BP change in the 6 hours following severe HTN development using mixed-effects model after adjusting for demographics and clinical characteristics. RESULTS Among 23,147 patients who developed severe HTN, 9,166 received antihypertensive treatment. The most common antihypertensives given were oral metoprolol (n = 1991), oral amlodipine (n = 1812), oral carvedilol (n = 1116), IV hydralazine (n = 1069) and oral hydralazine (n = 953). In the fully adjusted model, treatment with IV hydralazine led to 13 [-15.9, -10.1], 18 [-22.2, -14] and 11 [-14.1, -8.3] mmHg lower MAP, SBP, and DBP in the 6 hours following severe HTN development compared to no treatment. Treatment with oral hydralazine and oral carvedilol also resulted in significantly lower BPs in the 6 hours following severe HTN development (6 [-9.1, -2.1 and -7 [-9.1, -4.2] lower MAP, respectively) compared to no treatment. Receiving metoprolol and amlodipine did not result in a drop in BP compared to no treatment. CONCLUSION Among commonly used antihypertensives, IV hydralazine resulted in the most significant drop in BP following severe HTN, while metoprolol and amlodipine did not lower BP. Further research to assess the effect of treatment on clinical outcomes and if needed which antihypertensives to administer are necessary.
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Affiliation(s)
- Lama Ghazi
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, CT, United States of America
- * E-mail:
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, United States of America
| | - Xinyuan Chen
- Department of Mathematics and Statistics, Mississippi State University, Mississippi State, MS, United States of America
| | - Michael Simonov
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, CT, United States of America
| | - Yu Yamamoto
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, CT, United States of America
| | - Aditya Biswas
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, CT, United States of America
| | - Jonathan Hanna
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, United States of America
| | - Tayyab Shah
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, United States of America
| | - Aldo J. Peixoto
- Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, and the Hypertension Program, Yale New Haven Hospital Heart and Vascular Center, New Haven, CT, United States of America
| | - F. Perry Wilson
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, CT, United States of America
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27
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Heflin C, Hodges L, Ojinnaka CO, Arteaga I. Hypertension, Diabetes and Medication Adherence among the Older Supplemental Nutritional Assistance Program Population. J Appl Gerontol 2022; 41:780-787. [PMID: 34137290 PMCID: PMC8678375 DOI: 10.1177/07334648211022493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The burdens of chronic diseases such as hypertension and diabetes for older Americans are profound. Yet, data on the population-level prevalence of hypertension and diabetes among the older adult Supplemental Nutritional Assistance Program (SNAP) population and the associated level of medication adherence is lacking despite evidence of the "treat or eat" trade-off in the general population. We used linked administrative data from SNAP and Medicaid between 2006 and 2014 in the state of Missouri to document rates of hypertension or diabetes diagnoses and medication adherence. About 69% of the study sample were found to be diagnosed with a hypertension and 40% with diabetes. Approximately 1 in 4 of those living with hypertension and 1 and 3 of those living with diabetes were nonadherent to antihypertensive or antidiabetic medications each year, on average. Furthermore, medication non-adherence increases with age and is more common among non-White and urban residents.
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Affiliation(s)
- Colleen Heflin
- Maxwell School of Citizenship and Public Affairs, Syracuse University, 426 Eggers Hall, Syracuse, NY 13244-1020.,Corresponding author Phone: (315) 443-9042.
| | - Leslie Hodges
- Economic Research Service, United States Department of Agriculture, PO Box 419205, MS 9999, Kansas City, MO 64141-6205
| | - Chinedum O. Ojinnaka
- College of Health Solutions, Arizona State University, 326 Mercado Building C, Phoenix, AZ 85004
| | - Irma Arteaga
- Harry S Truman School of Public Affairs, University of Missouri, 239 Middlebush Hall, Columbia, MO 65211
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28
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Ghazi L, Li F, Chen X, Simonov M, Yamamoto Y, Biswas A, Hanna J, Shah T, Townsend R, Peixoto A, Wilson FP. Severe inpatient hypertension prevalence and blood pressure response to antihypertensive treatment. J Clin Hypertens (Greenwich) 2022; 24:339-349. [PMID: 35174627 PMCID: PMC8925013 DOI: 10.1111/jch.14431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/20/2021] [Accepted: 12/27/2021] [Indexed: 12/15/2022]
Abstract
Severe hypertension (HTN) that develops during hospitalization is more common than admission for HTN; however, it is poorly studied, and treatment guidelines are lacking. Our goal is to characterize hospitalized patients who develop severe HTN and assess blood pressure (BP) response to treatment. This is a multi-hospital retrospective cohort study of adults admitted for reasons other than HTN who developed severe HTN. The authors defined severe inpatient HTN as the first documented BP elevation (systolic BP > 180 or diastolic BP > 110) at least 1 hour after admission. Treatment was defined as receiving antihypertensives (intravenous [IV] or oral) within 6h of BP elevation. As a measure of possible overtreatment, the authors studied the association between treatment and time to mean arterial pressure (MAP) drop ≥ 30% using the Cox proportional hazards model. Among 224 265 hospitalized adults, 10% developed severe HTN of which 40% were treated. Compared to patients who did not develop severe HTN, those who did were older, more commonly women and black, and had more comorbidities. Incident MAP drop ≥ 30% among treated and untreated patients with severe HTN was 2.2 versus 5.7/1000 person-hours. After adjustment, treated versus. untreated patients had lower rates of MAP drop ≥ 30% (hazard rate [HR]: 0.9 [0.8, 0.99]). However, those receiving only IV treatment versus untreated had greater rates of MAP drop ≥ 30% (1.4 [1.2, 1.7]). Overall, the authors found that clinically significant MAP drop is observed among inpatients with severe HTN irrespective of treatment, with greater rates observed among patients treated only with IV antihypertensives. Further research is needed to phenotype inpatients with severe HTN.
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Affiliation(s)
- Lama Ghazi
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Xinyuan Chen
- Department of Mathematics and Statistics, Mississippi State University, Mississippi State, Mississippi, USA
| | - Michael Simonov
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
| | - Yu Yamamoto
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
| | - Aditya Biswas
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
| | - Jonathan Hanna
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Tayyab Shah
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Raymond Townsend
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aldo Peixoto
- Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, and the Hypertension Program, Yale New Haven Hospital Heart and Vascular Center, New Haven, Connecticut, USA
| | - F Perry Wilson
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
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29
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Zhang X, Qiu P, Prushinskaya A, Jiang Y, Fan H, Yang S. Characteristics of emergency department admissions with congestive heart failure in the United States: a Nationwide cross-sectional study. BMC Emerg Med 2022; 22:16. [PMID: 35090395 PMCID: PMC8795967 DOI: 10.1186/s12873-021-00564-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/24/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To understand the characteristics and clinical presentation of patients with Congestive Heart Failure (CHF) visiting the emergency department (ED), and to examine the factors associated with clinical outcomes and medical resource utilization amongst the studied population.
Methods
We analyzed the 2014–2016 ED visit data collected by the National Hospital Ambulatory Medical Care Survey Emergency Department Subfile. We described patients’ characteristics and clinical outcomes after ED visits with CHF vs. without CHF. Logistic regression models were used to estimate the association between these characteristics and CHF.
Results
ED visits with CHF visits represented 3.9% of annual ED visits (3,647,113 out of 92,899,685). ED patients with CHF were mostly non-Hispanic White (69.9%). Compared with other ED patients, those with CHF were older, including 71.2% that were were older than 60. ED patients with CHF were more likely to be admitted to the hospital (aOR: 2.56; 95% CI: 2.28–2.87) and intensive care unit (ICU) (aOR: 2.19; 95% CI: 1.77–2.71).
Conclusions
This study describes the demographic, socioeconic, and clinical characteristics of patients who present to the ED with CHF through analysis of a comprehensive national survey. These patients require a higher level of emergency care due to their higher chance of admittance to the hospital and ICU.
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30
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Koracevic G, Stojanovic M, Lovic D, Radovanovic RV, Koracevic M. Rationale for the Concept of Impending Hypertension-Mediated Organ Damage. Curr Vasc Pharmacol 2022; 20:127-133. [DOI: 10.2174/1570161120666220124105846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/13/2021] [Accepted: 12/30/2021] [Indexed: 11/22/2022]
Abstract
Background:
The number of patients with hypertension urgencies (HTN-Us) and emergencies (HTN-Es) in the emergency department is relatively constant despite improved detection, awareness and control of arterial hypertension.
Objective:
This study analyses the precision of the often-used definition of HTN-E, particularly the phrase ‘with the evidence of impending or progressive hypertension-mediated organ damage (HMOD)’. We then provide a rationale for the concept of impending HMOD.
MethodS:
We searched PubMed, Science Direct, Springer, Oxford Press, Wiley, SAGE and Google Scholar and analysed the relevant definition.
Results:
The definition of HTN-E is suboptimal and requires a consensus on whether to include the phrase ‘impending hypertensive HMOD’ in the definition.
Conclusion:
A consensus on the principles of treating the ‘impending hypertensive HMOD’ does not exist, making its use inconsistent in emergency departments worldwide. In this paper, we present a rationale for the concept of ‘impending HMOD’.
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Affiliation(s)
- Goran Koracevic
- Department for Cardiovascular Diseases, University Clinical Centre Nis, Serbia
| | | | - Dragan Lovic
- Clinic for Internal Diseases Inter Medica, Nis, Serbia
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31
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Satheeshkumar A, Pena C, Nugent K. Current U.S. Guideline-Based Management Strategies for Special Clinical Situations Involving Hypertensive Crises: A Narrative Review of the Literature. Cardiol Rev 2022; 30:44-49. [PMID: 33093305 DOI: 10.1097/crd.0000000000000364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Anudeeksha Satheeshkumar
- From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX
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Paini A, Tarozzi L, Bertacchini F, Aggiusti C, Rosei CA, De Ciuceis C, Malerba P, Broggi A, Perani C, Salvetti M, Muiesan ML. Cardiovascular prognosis in patients admitted to an emergency department with hypertensive emergencies and urgencies. J Hypertens 2021; 39:2514-2520. [PMID: 34420015 PMCID: PMC9698186 DOI: 10.1097/hjh.0000000000002961] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 06/26/2021] [Accepted: 06/27/2021] [Indexed: 11/26/2022]
Abstract
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.
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Clinical characteristics, practice patterns, and outcomes of patients with acute severe hypertension visiting the emergency department. J Hypertens 2021; 39:2506-2513. [PMID: 34738992 DOI: 10.1097/hjh.0000000000002960] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Lu Y, Wang Y, Spatz ES, Onuma O, Nasir K, Rodriguez F, Watson KE, Krumholz HM. National Trends and Disparities in Hospitalization for Acute Hypertension Among Medicare Beneficiaries (1999-2019). Circulation 2021; 144:1683-1693. [PMID: 34743531 DOI: 10.1161/circulationaha.121.057056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the past 2 decades, hypertension control in the US population has not improved and there are widening disparities. Little is known about progress in reducing hospitalizations for acute hypertension. METHODS We conducted serial cross-sectional analysis of Medicare fee-for-service beneficiaries age 65 years or older between 1999 and 2019 using Medicare denominator and inpatient files. We evaluated trends in national hospitalization rates for acute hypertension overall and by demographic and geographical subgroups. We identified all beneficiaries admitted with a primary discharge diagnosis of acute hypertension on the basis of International Classification of Diseases codes. We then used a mixed effects model with a Poisson link function and state-specific random intercepts, adjusting for age, sex, race and ethnicity, and dual-eligible status, to evaluate trends in hospitalizations. RESULTS The sample consisted of 397 238 individual Medicare fee-for-service beneficiaries. From 1999 through 2019, the annual hospitalization rates for acute hypertension increased significantly, from 51.5 to 125.9 per 100 000 beneficiary-years; the absolute increase was most pronounced among the following subgroups: adults ≥85 years (66.8-274.1), females (64.9-160.1), Black people (144.4-369.5), and Medicare/Medicaid insured (dual-eligible, 93.1-270.0). Across all subgroups, Black adults had the highest hospitalization rate in 2019, and there was a significant increase in the differences in hospitalizations between Black and White people from 1999 to 2019. Marked geographic variation was also present, with the highest hospitalization rates in the South. Among patients hospitalized for acute hypertension, the observed 30-day and 90-day all-cause mortality rates (95% CI) decreased from 2.6% (2.27-2.83) and 5.6% (5.18-5.99) to 1.7% (1.53-1.80) and 3.7% (3.45-3.84) and 30-day and 90-day all-cause readmission rates decreased from 15.7% (15.1-16.4) and 29.4% (28.6-30.2) to 11.8% (11.5-12.1) and 24.0% (23.5-24.6). CONCLUSIONS Among Medicare fee-for-service beneficiaries age 65 years or older, hospitalization rates for acute hypertension increased substantially and significantly from 1999 to 2019. Black adults had the highest hospitalization rate in 2019 across age, sex, race and ethnicity, and dual-eligible strata. There was significant national variation, with the highest rates generally in the South.
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Affiliation(s)
- Yuan Lu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (Y.L., Y.W., E.S.S., O.O. H.M.K.).,Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT (Y.L., E.S.S., O.O. H.M.K.)
| | - Yun Wang
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (Y.L., Y.W., E.S.S., O.O. H.M.K.).,Richard and Susan Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Y.W.)
| | - Erica S Spatz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (Y.L., Y.W., E.S.S., O.O. H.M.K.).,Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT (Y.L., E.S.S., O.O. H.M.K.)
| | - Oyere Onuma
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (Y.L., Y.W., E.S.S., O.O. H.M.K.).,Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT (Y.L., E.S.S., O.O. H.M.K.)
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, TX (K.N.).,Center for Outcomes Research, Houston Methodist Research Institute, TX (K.N.)
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University School of Medicine, CA (F.R.)
| | - Karol E Watson
- David Geffen School of Medicine, University of California, Los Angeles (K.E.W.)
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (Y.L., Y.W., E.S.S., O.O. H.M.K.).,Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT (Y.L., E.S.S., O.O. H.M.K.).,Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
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Fragoulis C, Dimitriadis K, Siafi E, Iliakis P, Kasiakogias A, Kalos T, Leontsinis I, Andrikou I, Konstantinidis D, Nihoyannopoulos P, Tsivgoulis G, Thomopoulos C, Tousoulis D, Muiesan ML, Tsioufis KP. Profile and management of hypertensive urgencies and emergencies in the emergency cardiology department of a tertiary hospital: a 12-month registry. Eur J Prev Cardiol 2021; 29:194-201. [PMID: 34718521 DOI: 10.1093/eurjpc/zwab159] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/12/2021] [Accepted: 09/08/2021] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Christos Fragoulis
- First Cardiologic Department (Clinic), Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, 11527 Athens, Greece
| | - Kyriakos Dimitriadis
- First Cardiologic Department (Clinic), Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, 11527 Athens, Greece
| | - Eirini Siafi
- First Cardiologic Department (Clinic), Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, 11527 Athens, Greece
| | - Panagiotis Iliakis
- First Cardiologic Department (Clinic), Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, 11527 Athens, Greece
| | - Alexandros Kasiakogias
- First Cardiologic Department (Clinic), Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, 11527 Athens, Greece
| | - Theodoros Kalos
- First Cardiologic Department (Clinic), Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, 11527 Athens, Greece
| | - Ioannis Leontsinis
- First Cardiologic Department (Clinic), Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, 11527 Athens, Greece
| | - Ioannis Andrikou
- First Cardiologic Department (Clinic), Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, 11527 Athens, Greece
| | - Dimitrios Konstantinidis
- First Cardiologic Department (Clinic), Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, 11527 Athens, Greece
| | - Petros Nihoyannopoulos
- First Cardiologic Department (Clinic), Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, 11527 Athens, Greece
| | - Georgios Tsivgoulis
- Second Neurologic Department (Clinic), Medical School, University of Athens, Attikon Hospital, Athens, Greece
| | | | - Dimitrios Tousoulis
- First Cardiologic Department (Clinic), Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, 11527 Athens, Greece
| | - Maria L Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Konstantinos P Tsioufis
- First Cardiologic Department (Clinic), Medical School, University of Athens, Hippokration Hospital, 114 Vasilissis Sofias Avenue, 11527 Athens, Greece
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Posen A, Benken S, Kaluzna SD, Sabouni M, Miglo J, Cai J, Gimbar RP. Poor guideline adherence in a real-world evaluation of hypertensive emergency management. Am J Emerg Med 2021; 51:46-52. [PMID: 34673475 DOI: 10.1016/j.ajem.2021.09.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/13/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew Posen
- University of Illinois at Chicago, College of Pharmacy, Department of Pharmacy Practice, S Wood St. 164 Pharm, MC 886, Chicago, IL 60612, United States; University of Illinois Hospital and Health Sciences System, 1740 W Taylor, St. Chicago, IL 60612, United States.
| | - Scott Benken
- University of Illinois at Chicago, College of Pharmacy, Department of Pharmacy Practice, S Wood St. 164 Pharm, MC 886, Chicago, IL 60612, United States; University of Illinois Hospital and Health Sciences System, 1740 W Taylor, St. Chicago, IL 60612, United States.
| | - Stephanie Dwyer Kaluzna
- University of Illinois at Chicago, College of Pharmacy, Department of Pharmacy Practice, S Wood St. 164 Pharm, MC 886, Chicago, IL 60612, United States; University of Illinois Hospital and Health Sciences System, 1740 W Taylor, St. Chicago, IL 60612, United States.
| | - Murrah Sabouni
- University of Illinois at Chicago, College of Pharmacy, Department of Pharmacy Practice, S Wood St. 164 Pharm, MC 886, Chicago, IL 60612, United States.
| | - Jane Miglo
- University of Illinois at Chicago, College of Pharmacy, Department of Pharmacy Practice, S Wood St. 164 Pharm, MC 886, Chicago, IL 60612, United States.
| | - Jiaqi Cai
- University of Illinois at Chicago, College of Pharmacy, Department of Pharmacy Practice, S Wood St. 164 Pharm, MC 886, Chicago, IL 60612, United States.
| | - Renee Petzel Gimbar
- University of Illinois at Chicago, College of Pharmacy, Department of Pharmacy Practice, S Wood St. 164 Pharm, MC 886, Chicago, IL 60612, United States; University of Illinois Hospital and Health Sciences System, 1740 W Taylor, St. Chicago, IL 60612, United States.
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Abstract
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.
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Affiliation(s)
- Essie P Mathews
- Kartavya Sharma is an assistant professor in the Departments of Neurology and Neurological Surgery at the University of Texas Southwestern Medical Center, Dallas, where Essie P. Mathews is an advanced practice RN in the Department of Neurology and Faith Newton is an adult-gerontology acute care NP in the Department of Neurology. Contact author: Kartavya Sharma, . The authors and planners have disclosed no potential conflicts of interest, financial or otherwise. A podcast with the authors is available at www.ajnonline.com
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Shin JH, Kim BS, Lyu M, Kim HJ, Lee JH, Park JK, Lim YH, Shin J. Clinical Characteristics and Predictors of All-Cause Mortality in Patients with Hypertensive Urgency at an Emergency Department. J Clin Med 2021; 10:4314. [PMID: 34640330 PMCID: PMC8509826 DOI: 10.3390/jcm10194314] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 12/19/2022] Open
Abstract
Hypertensive urgency is characterized by an acute increase in blood pressure without acute target organ damage, which is considered to be managed with close outpatient follow-up. However, limited data are available on the prognosis of these cases in emergency departments. We investigated the characteristics and predictors of all-cause mortality in Korean emergency patients with hypertensive urgency. This cross-sectional study included patients aged ≥18 years who visited an emergency tertiary referral center between January 2016 and December 2019 for hypertensive urgency, which was defined as a systolic blood pressure of ≥180 mmHg and a diastolic blood pressure of ≥110 mmHg, or both, without acute target organ damage. The 1 and 3 year all-cause mortality rates were 6.8% and 12.1%, respectively. The incidence of emergency department revisits and readmission after 3 months and 1 year was significantly higher in non-survivors than in survivors. In a multivariate analysis, age ≥ 60 years (hazard ratio (HR), 16.66; 95% CI, 6.20-44.80; p < 0.001), male sex (HR, 1.54; 95% CI, 1.22-1.94; p < 0.001), history of chronic kidney disease (HR, 2.18; 95% CI, 1.53-3.09; p < 0.001), and proteinuria (HR, 1.94; 95% CI, 1.53-2.48; p < 0.001) were independent predictors of 3 year all-cause mortality. The all-cause mortality rate of hypertensive urgency remains high despite the increased utilization of antihypertensive medications. Old age, male sex, history of chronic kidney disease, and proteinuria were poor prognostic factors for all-cause mortality in patients with hypertensive urgency.
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Affiliation(s)
- Jeong-Hun Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si 11923, Korea; (B.S.K.); (M.L.); (H.-J.K.)
| | - Byung Sik Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si 11923, Korea; (B.S.K.); (M.L.); (H.-J.K.)
| | - Minhyung Lyu
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si 11923, Korea; (B.S.K.); (M.L.); (H.-J.K.)
| | - Hyun-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si 11923, Korea; (B.S.K.); (M.L.); (H.-J.K.)
| | - Jun Hyeok Lee
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju 26426, Korea;
| | - Jin-kyu Park
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul 04763, Korea; (J.-k.P.); (Y.-H.L.); (J.S.)
| | - Young-Hyo Lim
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul 04763, Korea; (J.-k.P.); (Y.-H.L.); (J.S.)
| | - Jinho Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul 04763, Korea; (J.-k.P.); (Y.-H.L.); (J.S.)
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Lin YT, Liu YH, Hsiao YL, Chiang HY, Chen PS, Chang SN, Tsai HC, Chen CH, Kuo CC. Pharmacological blood pressure control and outcomes in patients with hypertensive crisis discharged from the emergency department. PLoS One 2021; 16:e0251311. [PMID: 34403407 PMCID: PMC8370605 DOI: 10.1371/journal.pone.0251311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/24/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Yu-Ting Lin
- Big Data Center, China Medical University Hospital, Taichung, Taiwan
| | - Yen-Hung Liu
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Ya-Luan Hsiao
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Hsiu-Yin Chiang
- Big Data Center, China Medical University Hospital, Taichung, Taiwan
| | - Pei-Shan Chen
- Big Data Center, China Medical University Hospital, Taichung, Taiwan
| | - Shih-Ni Chang
- Big Data Center, China Medical University Hospital, Taichung, Taiwan
| | - Hsiu-Chen Tsai
- Big Data Center, China Medical University Hospital, Taichung, Taiwan
| | - Chun-Hung Chen
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chin-Chi Kuo
- Big Data Center, China Medical University Hospital, Taichung, Taiwan
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- * E-mail:
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Hypertensive emergencies and urgencies in emergency departments: a systematic review and meta-analysis. J Hypertens 2021; 38:1203-1210. [PMID: 32510905 DOI: 10.1097/hjh.0000000000002372] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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.
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Richard AE, Chomienne MH. Review of Referrals Sent to the Emergency Department for Management of Hypertension. Cardiol Res 2021; 12:156-160. [PMID: 34046109 PMCID: PMC8139747 DOI: 10.14740/cr1233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/09/2021] [Indexed: 11/15/2022] Open
Abstract
Background Hypertensive urgencies, unlike hypertensive emergencies, are severe episodes of hypertension without evidence of end-organ damage. Most recent guidelines advise against referring patients with hypertensive urgencies to the emergency department (ED) for treatment. There is a lack of Canadian data surrounding whether referrals to the ED regarding hypertension are appropriate. We analyzed referrals to the Montfort Hospital ED due to hypertension and assessed if they met the criteria for hypertensive emergencies. Methods This was a retrospective chart study of all ED visits at Montfort Hospital from the 2016 fiscal year with a final diagnosis/chief complaint of hypertension. Charts were assessed to determine if these patients met the criteria for having true hypertensive emergencies. Results Out of the 54,000 visits to the Montfort ED, 254 reported hypertension as a final diagnosis/chief complaint. Of those, 67 patients had been referred by a healthcare practitioner, while 187 were self-referred. None of the referred patients met the criteria for hypertensive emergency; however, eight of these patients did have symptoms indicating a possibility of hypertensive emergency. Six of the self-referred patients met criteria for hypertensive emergency. The majority (71.6%) of patients referred did not require on-site antihypertensive treatment, and 37.3% of patients were sent home with new outpatient prescriptions. Conclusion All the cases referred to the Montfort ED for hypertension were considered hypertensive urgencies and none of them required ED hypertensive treatment. Further investigation is required to help optimize appropriate patient referral to the ED for true hypertensive emergencies and improve management of hypertensive urgencies in the community.
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Affiliation(s)
- Andre Emmanuel Richard
- Department of Family Medicine, University of Ottawa, 713 Montreal Road, Ottawa, ON H2Z OA2, Canada
| | - Marie-Helene Chomienne
- Department of Family Medicine, University of Ottawa, 713 Montreal Road, Ottawa, ON K1K 0T2, Canda
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Rossi GP, Rossitto G, Maifredini C, Barchitta A, Bettella A, Latella R, Ruzza L, Sabini B, Seccia TM. Management of hypertensive emergencies: a practical approach. Blood Press 2021; 30:208-219. [PMID: 33966560 DOI: 10.1080/08037051.2021.1917983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Acute increases of high blood pressure values, usually described as 'hypertensive crises', 'hypertensive urgencies' or 'hypertensive emergencies', are common causes of patients' presentation to emergency departments. Owing to the lack of ad hoc randomized clinical trials, current recommendations/suggestions for treatment of these patients are not evidenced-based and, therefore, the management of acute increases of blood pressure values represent a clinical challenge. However, an improved understanding of the underlying pathophysiology has changed radically the approach to management of the patients presenting with these conditions in recent years. Accordingly, it has been proposed to abandon the terms 'hypertensive crises' and 'hypertensive urgencies', and restrict the focus to 'hypertensive emergencies'. Aims and Methods: Starting from these premises, we aimed at systematically review all available studies (years 2010-2020) to garner information on the current management of hypertensive emergencies, in order to develop a novel symptoms- and evidence-based streamlined algorithm for the assessment and treatment of these patients.Results and Conclusions: In this educational review we proposed the BARKH-based algorithm for a quick identification of hypertensive emergencies and associated acute organ damage, to allow the patients with hypertensive emergencies to receive immediate treatment in a proper setting.
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Affiliation(s)
- Gian Paolo Rossi
- Department of Medicine - Emergencies and Hypertension Unit, University of Padua, Padova, Italy
| | - Giacomo Rossitto
- Department of Medicine - Emergencies and Hypertension Unit, University of Padua, Padova, Italy
| | - Chiarastella Maifredini
- Department of Medicine - Emergencies and Hypertension Unit, University of Padua, Padova, Italy
| | - Agata Barchitta
- Department of Medicine - Emergencies and Hypertension Unit, University of Padua, Padova, Italy
| | - Andrea Bettella
- Department of Medicine - Emergencies and Hypertension Unit, University of Padua, Padova, Italy
| | - Raffaele Latella
- Department of Medicine - Emergencies and Hypertension Unit, University of Padua, Padova, Italy
| | - Luisa Ruzza
- Department of Medicine - Emergencies and Hypertension Unit, University of Padua, Padova, Italy
| | - Beatrice Sabini
- Department of Medicine - Emergencies and Hypertension Unit, University of Padua, Padova, Italy
| | - Teresa M Seccia
- Department of Medicine - Emergencies and Hypertension Unit, University of Padua, Padova, Italy
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Alhasan D, Yaseen A. Hypertensive Emergencies in the Ambulance: Characteristics, Clinical Presentations and Complications - A Prospective Cohort Study. Open Access Emerg Med 2021; 13:75-81. [PMID: 33664601 PMCID: PMC7924252 DOI: 10.2147/oaem.s293413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 02/03/2021] [Indexed: 12/02/2022] Open
Abstract
Background The objective of this study is to describe the characteristics of hypertensive emergencies in Kuwait aiming to provide a preliminary background to update the current guidelines and improve patients’ management. Methods This is a prospective analysis of hypertensive emergency cases retrieved from emergency medical services (EMS) archived data between 1 January – 30 June 2020. Collected variables included patient characteristics, clinical presentations, vital signs, interventions, and complications. Outcome variable collected was: en route complications. Results Hypertensive emergency prevalence in Kuwait is 4.75 per 100,000. Most were non-Kuwaiti (62%) males (59%) with a mean age of 57 ±14 years. Most hypertensive emergency cases occurred at home (62%). The hypertensive emergency BP threshold was; SBP 182 (SD=31) and diastolic BP (DBP) 108 (SD=18). 36% of hypertensive emergency cases had silent hypertension. 67% of hypertensive emergencies were verified using ambulance verification tools. Nitroglycerin was administered to only hypertensive emergencies suspected to have acute coronary syndrome or acute heart failure (50%). Complications were seen in 9.5% of hypertensive emergency cases. Conclusion Hypertensive emergency is rare in the ambulance but can progress into a serious situation. One in every 10 hypertensive emergency cases will require en route resuscitation. Hypertensive emergencies should be recognized and managed within their clinical context. The most common clinical presentation of hypertensive emergency is cardiac chest pain. Some pre-hospital verification tools confirm acute HMOD. Further research is required to establish hypertension emergency recognition and management guidelines in the prehospital setting.
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Affiliation(s)
- Dalal Alhasan
- Department of Applied Medical Sciences, College of Health Sciences, Public Authority of Applied Education and Training, Kuwait, Kuwait
| | - Ameen Yaseen
- Audit Department, Emergency Medical Services, Ministry of Health, Kuwait, Kuwait
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Rastogi R, Sheehan MM, Hu B, Shaker V, Kojima L, Rothberg MB. Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions. JAMA Intern Med 2021; 181:345-352. [PMID: 33369614 PMCID: PMC7770615 DOI: 10.1001/jamainternmed.2020.7501] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Despite high prevalence of elevated blood pressure (BP) among medical inpatients, BP management guidelines are lacking for this population. The outcomes associated with intensifying BP treatment in the hospital are poorly studied. OBJECTIVES To characterize clinician response to BP in the hospital and at discharge and to compare short- and long-term outcomes associated with antihypertensive treatment intensification. DESIGN, SETTING, AND PARTICIPANTS This cohort study took place from January 1 to December 31, 2017, with 1 year of follow-up at 10 hospitals within the Cleveland Clinic Hospitals health care system. All adults admitted to a medicine service in 2017 were evaluated for inclusion. Patients with cardiovascular diagnoses were excluded. Demographic and BP characteristics were used for propensity matching. EXPOSURES Acute hypertension treatment, defined as administration of an intravenous antihypertensive medication or a new class of an oral antihypertensive treatment. MAIN OUTCOMES AND MEASURES The association between acute hypertension treatment and subsequent inpatient acute kidney injury, myocardial injury, and stroke was measured. Postdischarge outcomes included stroke and myocardial infarction within 30 days and BP control up to 1 year. RESULTS Among 22 834 adults hospitalized for noncardiovascular diagnoses (mean [SD] age, 65.6 [17.9] years; 12 993 women [56.9%]; 15 963 White patients [69.9%]), 17 821 (78%) had at least 1 hypertensive BP recorded during their admission. Of these patients, 5904 (33.1%) were treated. A total of 8692 of 106 097 cases (8.2%) of hypertensive systolic BPs were treated; of these, 5747 (66%) were treated with oral medications. In a propensity-matched sample controlling for patient and BP characteristics, treated patients had higher rates of subsequent acute kidney injury (466 of 4520 [10.3%] vs 357 of 4520 [7.9%]; P < .001) and myocardial injury (53 of 4520 [1.2%] vs 26 of 4520 [0.6%]; P = .003). There was no BP interval in which treated patients had better outcomes than untreated patients. A total of 1645 of 17 821 patients (9%) with hypertension were discharged with an intensified antihypertensive regimen. Medication intensification at discharge was not associated with better BP control in the following year. CONCLUSIONS AND RELEVANCE In this cohort study, hypertension was common among medical inpatients, but antihypertensive treatment intensification was not. Intensification of therapy without signs of end-organ damage was associated with worse outcomes.
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Affiliation(s)
- Radhika Rastogi
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Megan M Sheehan
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Bo Hu
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Victoria Shaker
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
| | - Lisa Kojima
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
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45
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Kotruchin P, Pratoomrat W, Mitsungnern T, Khamsai S, Imoun S. Clinical treatment outcomes of hypertensive emergency patients: Results from the hypertension registry program in Northeastern Thailand. J Clin Hypertens (Greenwich) 2021; 23:621-627. [PMID: 33615688 PMCID: PMC8029559 DOI: 10.1111/jch.14119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/13/2020] [Accepted: 11/19/2020] [Indexed: 11/29/2022]
Abstract
Hypertensive emergency care is a challenge in clinical practices due to vital organ complications that may lead to unfavorable outcomes if left untreated. The objectives of this study were to determine the prevalence, clinical characters, treatment, and outcomes of hypertensive emergency patients. A retrospective cohort study was conducted at a university hospital in Northeast Thailand from January 2016 to December 2019. Hypertensive crises patients were consecutively registered to the Hypertension Registry Program. There were 263 674 patients who were admitted to the ER, 60,755 of whom had BP ≥ 140/90 mm Hg and 1,342 of whom were diagnosed with a hypertensive emergency (127 per 100 000 patient-year). The mean age was 66 years old, and 52.1% of the registered patients were men. The most common target organ damage was caused by stroke (49.8%), followed by acute heart failure (19.3%), and then by acute coronary syndrome (6.5%). Intravenous antihypertensive medication was given in 42.1% of the patients, and 80% were admitted to the hospital. The in-hospital mortality rate was 1.6%. In conclusion, hypertensive emergencies were not uncommon among the emergency patients. Strokes caused the most common target organ damage. Although there was a high hospital admission rate, the mortality rate was low.
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Affiliation(s)
- Praew Kotruchin
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Wachira Pratoomrat
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Thapanawong Mitsungnern
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sittichai Khamsai
- Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Supap Imoun
- Accident and Emergency Nursing Division, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
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Muiesan ML, Rosei EA, Borghi C, De Luca N, Ghiadoni L, Grassi G, Perlini S, Pucci G, Salvetti M, Volpe M, Ferri C. The UrgeRe (Urgenze Ipertensive: Un Progetto Educazionale Fondato Sulla Vita Reale, Hypertensive Urgencies: A Project in the Real World) Project. High Blood Press Cardiovasc Prev 2021; 28:151-157. [PMID: 33544372 PMCID: PMC7952352 DOI: 10.1007/s40292-021-00433-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 01/04/2021] [Indexed: 12/04/2022] Open
Abstract
The approach to hypertensive emergiencies (HE) and urgencies (HU) may be different according to local clinical practice, despite recent guidelines and position papers recommendations. The Italian Society of Hypertension (Società Italiana della Ipertensione Arteriosa, SIIA) developed an online survey, in order to explore the awareness, management and treatment of HU in Italy, sending by e mail a 12 items questionnaire to the members of the SIIA. The results show that the definition of HU was correctly identified by 62% of the responders. Most physicians identified the role of pharmacological therapy or legal/illegal substances abuse as possible cause of BP elevation; the use of a benzodiazepine drugs was considered worthwhile by 65% of responders. The prescription of diagnostic test and drug administration significantly differed from guidelines recommendations and only 57% of the physicians reported to treat HU with oral drug administration. Sub-lingual nifedipine was prescribed by 13% or responders. This survey shows the need to further spread the updated scientific information on the management and treatment of HE and HU, along with the improvement of the interrelationship with the general practitioner health system in Italy.
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Affiliation(s)
- Maria Lorenza Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy.
| | - Enrico Agabiti Rosei
- Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Claudio Borghi
- Department of Medical and Surgical Science, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Nicola De Luca
- Department of Advanced Biomedical Science, Hypertension Research Center, Federico II University Hospital, Naples, Italy
| | - Lorenzo Ghiadoni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Guido Grassi
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Stefano Perlini
- Department of Emergency, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.,Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Giacomo Pucci
- Internal Medicine, Department of Medicine, University of Perugia, Terni University Hospital, Perugia, Italy
| | - Massimo Salvetti
- Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Massimo Volpe
- Cardiology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli, IS, Italy
| | - Claudio Ferri
- Department of Internal Medicine and Public Health, University of Aquila, L'Aquila, Italy
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Nijskens CM, Veldkamp SR, Van Der Werf DJ, Boonstra AH, Ten Wolde M. Funduscopy: Yes or no? Hypertensive emergencies and retinopathy in the emergency care setting; a retrospective cohort study. J Clin Hypertens (Greenwich) 2020; 23:166-171. [PMID: 33017517 PMCID: PMC8029924 DOI: 10.1111/jch.14064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/08/2020] [Accepted: 07/28/2020] [Indexed: 12/04/2022]
Abstract
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.
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Affiliation(s)
| | - Saskia R Veldkamp
- Department of Internal Medicine, Flevohospital, Almere, The Netherlands
| | | | - Arnold H Boonstra
- Department of Internal Medicine, Flevohospital, Almere, The Netherlands
| | - Marije Ten Wolde
- Department of Internal Medicine, Flevohospital, Almere, The Netherlands
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Gebresillassie BM, Debay YB. Characteristics, treatment, and outcome of patients with hypertensive crisis admitted to University of Gondar Specialized Hospital, northwest Ethiopia: A cross-sectional study. J Clin Hypertens (Greenwich) 2020; 22:2343-2353. [PMID: 32966697 DOI: 10.1111/jch.14056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/21/2020] [Accepted: 08/31/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Begashaw Melaku Gebresillassie
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yabsira Belayneh Debay
- Department of Pharmacy, Nordic Medical Centre As Ethiopian Branch, Addis Ababa, Ethiopia
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Desta DM, Wondafrash DZ, Tsadik AG, Kasahun GG, Tassew S, Gebrehiwot T, Asgedom SW. Prevalence of Hypertensive Emergency and Associated Factors Among Hospitalized Patients with Hypertensive Crisis: A Retrospective Cross-Sectional Study. Integr Blood Press Control 2020; 13:95-102. [PMID: 32904390 PMCID: PMC7455594 DOI: 10.2147/ibpc.s265183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/03/2020] [Indexed: 11/23/2022] Open
Abstract
Background Hypertensive emergency (HE) is an acute stage of uncontrolled blood pressure which poses a substantial cardiovascular morbidity and mortality in developing countries. In our setting, the prevalence of HE and the characteristics of patients with a hypertensive crisis are not certainly known yet. Objective The study assessed the prevalence of hypertensive emergency and associated factors among hospitalized patients with hypertensive crisis. Methods A retrospective cross-sectional study was conducted by reviewing records of patients having a diagnosis of hypertensive crisis with systolic/diastolic blood pressure raised to more than 180/120 mmHg admitted to Ayder Comprehensive Specialized Hospital (ACSH) from September 2018 to August 2019. Patients' medical records with complete information were enrolled consecutively. Socio-demographic, clinical characteristics, and other related variables were collected using a structured data collection tool from patient medical records. Data were entered and analyzed using SPSS version 20. Logistic regression was employed to determine factors associated with HE. Results A total of 141 patients' records with a diagnosis of a hypertensive crisis were enrolled in the study; the majority were females 77 (54.6%) and residing in the urban setting 104 (73.8%). The mean age of the participants was 58.8 years. HE was found in 42 (29.8%) of patients. Intravenous Hydralazine 39 (27.7%) and oral calcium channel blocker 102 (72.3%) were the prescribed drugs for acute blood pressure reduction in the emergency setting. Surprisingly, patients who had no history of hypertension (adjusted odds ratio (AOR)=2.469; 95% confidence interval (CI): 0.176‒0.933) and female sex (AOR=2.494; 95% CI: 1.111‒5.596) were found to be independently associated factors with HE. Conclusion The prevalence of HE was found to account a significant proportion of patients. Hence, hypertensive patients should be strictly managed accordingly, and promoting screening programs could reduce the risk of target organ damage.
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Affiliation(s)
- Desilu Mahari Desta
- Clinical Pharmacy Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Dawit Zewdu Wondafrash
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Afewerki Gebremeskel Tsadik
- Clinical Pharmacy Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | | | - Segen Tassew
- Clinical Pharmacy Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Teklu Gebrehiwot
- Clinical Pharmacy Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Solomon Weldegebreal Asgedom
- Clinical Pharmacy Unit, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Tigray, Ethiopia
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Bogdanov EI, Khasanov IA. [Posterior reversible encephalopathy syndrome and arterial hypertension]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:17-23. [PMID: 32678543 DOI: 10.17116/jnevro202012006117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To identify a correlation between systolicdiastolic blood pressure (BP) and severity of clinical/radiological presentations in patients with posterior reversible encephalopathy syndrome (PRES). MATERIAL AND METHODS Clinical and paraclinic data of patients with PRES hospitalized in the Republican Clinical Hospital, Kazan in 2010-2018 were analyzed. Nineteen patients were found, all of them were women, aged 18-67 years, mean age 33.50±15.03 years. Clinical and paraclinic data included anamnesis, neurological examination, neuroimaging, first measurements of systolic and diastolic BP after symptoms'onset. RESULTS AND CONCLUSION Diastolic BP values can be associated with the incidence of depression of consciousness, systolic BP values - with the number of damaged structures. In total, BP is the significant factor implemented in the presence of endothelial dysfunction that defines the severity of encephalopathy.
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Affiliation(s)
- E I Bogdanov
- Kazan State Medical University, Kazan, Russia.,Republican Clinical Hospital, Kazan, Russia
| | - I A Khasanov
- Kazan State Medical University, Kazan, Russia.,Republican Clinical Hospital, Kazan, Russia
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