Clinical review: the management of hypertensive crises

Management Strategies for Hypertensive Crisis: A Systematic Review

A hypertensive crisis is defined as a sudden and significant rise in blood pressure. The blood pressure reading is 180/120 mmHg or higher. A hypertensive crisis is a medical emergency. It can lead to a heart attack, stroke, or other life-threatening medical problems. Investigating the management of the hypertensive crisis was the goal of this study. English-language articles were collected from 2010 to 2024 demonstrating the management of the hypertensive crisis. Overall, there were 15 articles. Surveys and analyses of national databases were the most widely used methods (n=15). The scientific studies documented (1) all investigative studies or reports that included a hypertensive crisis diagnosis, (2) data integrity and reproducibility, and (3) management studies. Other studies show that acute severe hypertension in the hospital is associated with high rates of mortality and morbidity, particularly with new or worsening end-organ damage. The problem is linked to poor medical adherence, but alarmingly low follow-up rates are likely to contribute to a high recurrence rate. The treatment of acute severe hypertension varies according to the hospital unit (medical ward or intensive care unit), medication, and blood pressure targets or thresholds. Because of a lack of evidence-based guidance, arbitrary blood pressure control targets are used, or blood pressure targets are crudely extrapolated from guidelines intended primarily for outpatient management. Patients with acute aortic dissection need to be administered intravenous esmolol within 5 to 10 minutes in order to lower their blood pressure right away. The goal is to maintain a systolic reading of less than 120 mm Hg. Vasodilators such as nitroglycerin or nitroprusside may be administered if the blood pressure persists following beta blocking. Intravenous administration of clevidipine, nicardipine, or phentolamine is required; the initial dose is 5 mg, with subsequent doses given every 10 minutes as necessary to achieve the desired reduction in blood pressure.

Acute kidney injury after intracerebral hemorrhage: a mini review

Intracerebral hemorrhage (ICH) stands as a prevalent and pivotal clinical condition. The potential cooccurrence of acute kidney injury (AKI) among afflicted individuals can profoundly influence their prognosis. In recent times, there has been a growing focus among clinical practitioners on researching the relationship between ICH and AKI. AKI occurring concurrently with ICH predominantly arises from both hemodynamic and non-hemodynamic mechanisms. The latter encompasses neurohumoral regulation, inflammatory response, oxidative stress, and iatrogenic factors such as contrast agents, dehydrating agents, antibiotics, and diuretics. Moreover, advanced age, hypertension, elevated baseline creatinine levels, chronic kidney disease, and larger hematomas predispose patients to AKI. Additionally, the current utilization of biomarkers and the development of predictive models appear promising in identifying patients at risk of AKI after ICH. This article aims to underscore the potential of the aforementioned insights to inspire novel approaches to early clinical intervention.

Evaluation of the correlation between cerebral hemodynamics and blood pressure by comparative analysis of variation in cerebral blood flow in hypertensive versus normotensive individuals: A systematic review and meta-analysis

Current understanding of the cerebral vascular response to variations in blood pressure (BP) among individuals with hypertension is limited. The aim of this meta-analysis was to determine the correlation between hypertension, risk of stroke, and cerebral blood flow (CBF). We reviewed studies published between 2000 and 2023 from PubMed, Google Scholar, and Science Direct that compared mean CBF in normotensive (NTN) and hypertensive (HTN) patients. A random effects model was used to construct the risk ratio (RR), 95% confidence interval (CI), forest plot, and inverse variance weighting. Additionally, a mixed-effects meta-regression was employed to examine the impact of study-specific patient variables. This meta-analysis included eight prospective cross-sectional studies published from 2002 to 2023. It revealed a significant average difference in the standard mean CBF of -0.45 (95% CI -0.60 to -0.30, I2 = 69%, P < 0.00001), distinguishing NTN from HTN subjects. A RR of 0.90 (95% CI 0.63 to 1.30, I2 = 89%, P = 0.04) indicated a significant decrease in CBF among individuals with hypertension. We found a statistically significant relationship between changes in diastolic and systolic BPs and the mean CBF (R -0.81, P = 0.001 and R = -0.90, P = 0.005, respectively). Our research demonstrates a strong relationship between elevated BP and reduced CBF, with hypertension reducing CBF compared to NTN individuals, by increasing cerebrovascular resistance.

Hypertensive Emergency During Dialysis: A Paradoxical Physiologic Response

Most end-stage renal disease patients experience a reduction in blood pressure during their hemodialysis session compared to predialysis. Surprisingly, a small subset of patients will experience an unusual physiological response to dialysis that results in a paradoxical increase in blood pressure. We discuss a case that involved an exaggerated elevation in blood pressure, ultimately requiring immediate cessation of dialysis and admission to the intensive care unit for intravenous treatment of a hypertensive emergency. This case serves as a framework to introduce the infrequently discussed concept of intradialytic hypertension. The underlying pathogenesis is poorly understood with multiple theoretical etiologies including activation of the renin-angiotensin-aldosterone system, imbalances in circulating levels of endothelium-derived mediators, clearance of antihypertensive medications, increased cardiac output, and changes in arterial thickness. It is important to be cognizant of this phenomenon as emerging evidence suggests that patients with any elevation in blood pressure during hemodialysis have increased rates of both short-term and long-term mortality.

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

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.

Hypertensive Emergency with Thrombotic Microangiopathy or TTP? A Case Series and Literature Review

Thrombotic microangiopathy (TMA) is associated with both hypertensive emergency and primary thrombocytopenia purpura (TTP). However, their clinical management is vastly different, with the latter necessitating urgent plasma exchange (PEX). We report two cases of hypertension-associated TMA (HTN-TMA) and a literature review of the clinical management of malignant hypertension. We suggest that in patients presenting with hypertensive emergency associated with TMA, a clinical diagnosis of HTN-TMA should be made, with emergent treatment to lower blood pressure started immediately. Although TTP is a differential diagnosis for TMA, PEX should not be started concurrently in the absence of other supporting evidence for TTP.

Biochemically Silent Pheochromocytoma in an Asymptomatic Patient With a Unilateral Lipid-Poor Adrenal Adenoma

In this case, a Caucasian woman was incidentally found to have a left adrenal gland incidentaloma a decade ago. Initial tests indicated a non-functional lipid-poor adenoma, but ongoing surveillance revealed irregularities in biochemical testing for pheochromocytoma. The patient was concurrently taking an SNRI, known to elevate biochemical markers artificially. Given the adenoma's growth and mild biochemical abnormalities, laparoscopic surgery was performed, and the tumor was found to be a 2.4 cm × 1.8 cm pheochromocytoma. Following the procedure, hormone levels normalized, and the patient experienced relief from symptoms. This case underscores the rarity of pheochromocytomas, emphasizing the importance of accurate diagnosis and effective management. Imaging techniques, notably computed tomography (CT) and magnetic resonance imaging (MRI), played a crucial role in localization, particularly through contrast-enhanced methods. Key characteristics like Hounsfield density, enhancement patterns, and washout behavior aided in distinguishing diverse adrenal masses. For cases where imaging had limitations, complementary techniques such as 23I-metaiodobenzylguanidine (MIBG) scintigraphy, specialized MR sequences, and GA-DOTATATE scans provided supplementary diagnostic insights, collectively contributing to a comprehensive clinical understanding. Despite advancements, challenges persist in differentiating specific adrenal tumors, highlighting the need for continued research and refined imaging methodologies.

Neurogenic Hypertension, the Blood-Brain Barrier, and the Potential Role of Targeted Nanotherapeutics

Hypertension is a major health concern globally. Elevated blood pressure, initiated and maintained by the brain, is defined as neurogenic hypertension (NH), which accounts for nearly half of all hypertension cases. A significant increase in angiotensin II-mediated sympathetic nervous system activity within the brain is known to be the key driving force behind NH. Blood pressure control in NH has been demonstrated through intracerebrovascular injection of agents that reduce the sympathetic influence on cardiac functions. However, traditional antihypertensive agents lack effective brain permeation, making NH management extremely challenging. Therefore, developing strategies that allow brain-targeted delivery of antihypertensives at the therapeutic level is crucial. Targeting nanotherapeutics have become popular in delivering therapeutics to hard-to-reach regions of the body, including the brain. Despite the frequent use of nanotherapeutics in other pathological conditions such as cancer, their use in hypertension has received very little attention. This review discusses the underlying pathophysiology and current management strategies for NH, as well as the potential role of targeted therapeutics in improving current treatment strategies.

Treatment Outcome and Associated Factors Among Patients Admitted with Hypertensive Crisis in Public Hospitals at Harar Town, Eastern Ethiopia: A Cross-Sectional Study

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.

Clinical implications of cardiac troponin-I in patients with hypertensive crisis visiting the emergency department

OBJECTIVES

Cardiac troponin-I (cTnI) is a representative marker of myocardial injury. Elevation of cTnI is frequently observed in patients with hypertensive crisis, but few studies have examined its prognostic significance in hypertensive crisis. We aimed to determine whether cTnI could predict all-cause mortality in patients with hypertensive crisis visiting the emergency department (ED).

METHODS

This observational study included patients aged ≥18 years who visited an ED between 2016 and 2019 for hypertensive crisis, defined as systolic blood pressure (BP) ≥180 mmHg and/or diastolic BP ≥110 mmHg. Among 6467 patients, 3938 who underwent a cTnI assay were analysed.

RESULTS

Among the 3938 patients, 596 (15.1%) had cTnI levels above the 99th percentile upper reference limit (elevated cTnI >40 ng/L) and 600 (15.2%) had cTnI levels between the detection limit (≥10 ng/L) and the 99th percentile upper reference limit (detectable cTnI). The 3-year all-cause mortality in the elevated, detectable and undetectable cTnI groups were 41.6%, 36.5% and 12.8%, respectively. After adjusting for confounding variables, elevated cTnI patients (adjusted hazard ratio [HR], 2.01; 95% confidence interval [CI], 1.61-2.52) and detectable cTnI patients (adjusted HR, 1.64; 95% CI, 1.32-2.04) showed a significantly higher risk of 3-year all-cause mortality than did patients with undetectable cTnI.

CONCLUSIONS

In patients with hypertensive crisis, elevated cTnI levels provide useful prognostic information and permit the early identification of patients with an increased risk of death. Moreover, putatively normal but detectable cTnI levels also significantly correlated with a higher risk of all-cause mortality. Intensive treatment and follow-up strategies are needed for patients with hypertensive crisis with elevated and detectable cTnI levels.Key messagesCardiac troponin-I level was an independent prognostic factor for all-cause mortality in patients with hypertensive crisis.Detectable but normal range cardiac troponin-I, which was considered clinically insignificant, also had a prognostic impact on all-cause mortality comparable to elevated cardiac troponin-I levels.

Evaluation of presentation, treatment and outcome in hypertensive emergency in dogs and cats: 15 cases (2003-2019)

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.

Relevance of Troponin I Elevation among Individuals with Hypertensive Emergency

How to cite this article: Maheshwarappa HM, Rai AV. Relevance of Troponin I Elevation among Individuals with Hypertensive Emergency. Indian J Crit Care Med 2022;26(7):767-769.

Design and characterisation of an amorphous formulation of nifedipine for the treatment of autonomic dysreflexia

OBJECTIVES

Current treatment for autonomic dysreflexia (AD) involves rupturing a liquid-filled soft capsule of nifedipine to aid rapid drug release and absorption, however, this application is not covered under the manufacturer's license. The objective of the current work was to design a rapidly dissolving solid dosage formulation for the treatment of AD as an alternative to the off-license "bite and swallow" use of currently available commercial products.

METHODS

Amorphous solid dispersions (ASDs) of nifedipine were prepared by spray-drying using three different polymers: hydroxypropyl methyl cellulose (HPMC), polyvinyl pyrrolidone (PVP) and polyvinyl caprolactam-polyvinyl acetate-polyethylene glycol (Soluplus), at a 15% w/w drug loading and were formulated and compressed into tablets. Dissolution testing was performed in the paddle dissolution apparatus using either a monophasic or biphasic medium.

KEY FINDINGS

The PVP-nifedipine ASD tablets exhibited rapid dissolution, with 35% of the total nifedipine dose dissolving within 15 min in the monophasic dissolution medium. The HPMC-nifedipine ASD exhibited a very slow dissolution, while the Solupus-nifedipine system exhibited no nifedipine release over 120 min. When tested in the biphasic dissolution medium, the PVP-nifedipine ASD tablets exhibited a release profile comparable to that of the pre-split/ruptured nifedipine soft capsule product.

CONCLUSIONS

This study demonstrates that a nifedipine-PVP ASD is a promising formulation strategy in the treatment of AD.

Hypertensive Crisis in Pregnancy with COVID19: Confirmed with rt-PCR for Nasopharyngeal Swab

The novel coronavirus has already spread across the geographical borders to 213 countries and self-governing territories. However, the effect of SARS-CoV-2 infection on pregnant mothers is still poorly understood and sparsely documented. Here, we present a case of a primi mother, who presented with diarrheal episode and proceeded to a hypertensive crisis and placental abruption with rt-PCR (nasopharyngeal swab) confirmed for COVID19. SARS-CoV-2 enters and downregulates host cell-bounded enzyme ACE2 (angiotensin-converting enzyme). This activates the renin angiotensin aldosterone mechanism (RAAM). The activation of RAAM plays a pivotal role in the pathophysiology of hypertensive emergencies. Hence, there is a theoretical possibility of hypertensive crisis associated with ACE2/RAAM dysfunction in pregnant mothers who have COVID19. Therefore, close monitoring of blood pressure and early intervention are of paramount importance in anticipating and preventing serious complications related to hypertension in pregnancy in mothers who have tested positive for SARS-CoV-2, especially in this pandemic situation. Emergency hospital admission and urgent care must be afforded to mothers presenting with high blood pressure with the features suggestive of COVID19 as they are at a risk of rapid deterioration.

Malignant Hypertension Without End-Organ Damage Secondary to Stressful Condition in a Female

Malignant hypertension (hypertensive emergency), is an extreme elevation of blood pressure under certain conditions that can lead to organ damage and other serious consequences. It is a common condition that affects about one in three Americans, according to the Centers for Disease Control and Prevention. An elevation of systolic blood pressure above 180 mmHg and diastolic blood pressure above 120 mmHg is considered a hypertensive emergency. This article addresses the case of a 61-year-old female patient who presented to the ER with a semicomatose and gasping condition and response to painful stimuli with an unclear voice. She also had unstable vital signs, with a blood pressure of 370/200 mmHg, a pulse rate of 115, a respiratory rate of 22, and a pulse oximetry of 96%, but no fever. Her son provided a brief history and reported that a stressful condition had occurred at home one hour before; she had begun to scream and been brought to the ER by ambulance in the condition described above. Cardiac monitoring and an electrocardiograph were performed and indicated a normal condition besides the unstable vital signs. Oxygen was administered via a nasal cannula with 20 mg of intravenous hydralazine, and the patient’s blood pressure improved progressively. Moreover, she regained consciousness with no end-organ damage. A hypertensive emergency is usually associated with end-organ damage, such as heart, kidney, eye, or brain damage. However, in this case, despite the extreme elevation of her blood pressure, the patient suffered no organ damage. It is essential to manage the extreme elevation of blood pressure as soon as possible and monitor the patient for consequences.

[Hypertensive Crisis in the Elderly Patients]

A hypertensive crisis is a sudden increase in blood pressure (BP) to an individually high level associated with clinical symptoms and target organ damage, in which BP must be reduced immediately. Since 2018 in Europe and since 2020 in Russia, an uncomplicated hypertensive crisis is recommended to be considered as a part of malignant (uncontrolled) arterial hypertension. The clinical picture of increased BP in elderly patients is characterized by nonspecific symptoms even in target organ damage. Management of this group of patients requires a physician to know the patient's comorbidities and the drugs taken on a regular basis to minimize development of side effects of the administered drugs and their undesirable interaction with the chronic therapy.

Hypertensive crisis in children and adolescents

Hypertensive crisis is a relatively rare condition in children. However, if not treated, it might be life-threatening and lead to irreversible damage of vital organs. Clinical presentation of patients with hypertensive crisis can vary from very mild (hypertensive urgency) to severe symptoms (hypertensive emergency) despite similarly high blood pressure (BP). Individualized assessment of patients presenting with high BP with emphasis on the evaluation of end-organ damage rather than on the specific BP number is a key in guiding physician's initial management of a hypertensive crisis. The main aim of the treatment of hypertensive crisis is the prevention or treatment of life-threatening complications of hypertension-induced organ dysfunction, including neurologic, ophthalmologic, renal, and cardiac complications. While the treatment strategy must be directed toward the immediate reduction of BP to reduce the hypertensive damage to these organs, it should not be at a too fast rate to cause hypoperfusion of vital organs by an excessively rapid reduction of BP. Thus, intravenous continuous infusions rather than intravenous boluses of antihypertensive medications should be the preferable mode of initial treatment of children with hypertensive emergency.

Postoperative Management in Patients with Pheochromocytoma and Paraganglioma

Pheochromocytomas and paragangliomas (PPGLs) are rare catecholamine-secreting neuroendocrine tumors of the adrenal medulla and sympathetic/parasympathetic ganglion cells, respectively. Excessive release of catecholamines leads to episodic symptoms and signs of PPGL, which include hypertension, headache, palpitations, and diaphoresis. Intraoperatively, large amounts of catecholamines are released into the bloodstream through handling and manipulation of the tumor(s). In contrast, there could also be an abrupt decline in catecholamine levels after tumor resection. Because of such binary manifestations of PPGL, patients may develop perplexing and substantially devastating cardiovascular complications during the perioperative period. These complications include hypertension, hypotension, arrhythmias, myocardial infarction, heart failure, and cerebrovascular accident. Other complications seen in the postoperative period include fever, hypoglycemia, cortisol deficiency, urinary retention, etc. In the interest of safe patient care, such emergencies require precise diagnosis and treatment. Surgeons, anesthesiologists, and intensivists must be aware of the clinical manifestations and complications associated with a sudden increase or decrease in catecholamine levels and should work closely together to be able to provide appropriate management to minimize morbidity and mortality associated with PPGLs.

Hypertensive Emergencies: A Review of Common Presentations and Treatment Options

Approximately 33% of adults in the United States have high blood pressure; approximately 1% will present with a hypertensive emergency. Hypertension emergency is typically defined as a blood pressure great than 180/120 mmHg leading to end organ damage. However, it is important to note that an acute rise in blood pressure may also lead to end organ damage before achieving the blood pressure threshold. Therapeutic intervention should be a short-acting, easily titratable, intravenous antihypertensive medication based on the type of end-organ damage, pharmacokinetics, and comorbidities. This review focuses on presentations and treatment of hypertensive emergency.

Management of Blood Pressure During and After Recanalization Therapy for Acute Ischemic Stroke

Ischemic stroke is a common neurologic condition and can lead to significant long term disability and death. Observational studies have demonstrated worse outcomes in patients presenting with the extremes of blood pressure as well as with hemodynamic variability. Despite these associations, optimal hemodynamic management in the immediate period of ischemic stroke remains an unresolved issue, particularly in the modern era of revascularization therapies. While guidelines exist for BP thresholds during and after thrombolytic therapy, there is substantially less data to guide management during mechanical thrombectomy. Ideal blood pressure targets after attempted recanalization depend both on the degree of reperfusion achieved as well as the extent of infarction present. Following complete reperfusion, lower blood pressure targets may be warranted to prevent reperfusion injury and promote penumbra recovery however prospective clinical trials addressing this issue are warranted.

Sex-dependent difference in the association between frequency of spicy food consumption and risk of hypertension in Chinese adults

PURPOSE

The aim of our study was to explore the association between frequency of spicy food consumption and risk of hypertension in Chinese adults.

METHODS

Data were extracted from the 2009 wave of the China Health and Nutrition Survey, consisting of 9273 apparently healthy adults. Height, weight, and blood pressure (BP) were measured and diet was assessed with three consecutive 24-h recalls in combination with a weighed food inventory. Frequency of spicy food consumption and degree of pungency in spicy food consumption were self-reported. Hypertension was defined as systolic BP (SBP) ≥ 140 mmHg and/or diastolic BP (DBP) ≥ 90 mmHg, or having known hypertension. Multilevel mixed-effects models were constructed to estimate changes in SBP and DBP levels as well as risk of hypertension.

RESULTS

Higher frequency of spicy food consumption was significantly associated with lower SBP and DBP levels and lower risk of hypertension in female participants after adjustment for potential confounders (all P trend < 0.05) and cluster effects at different levels (individual, community, and province). Compared with female participants who did not eat spicy food, the adjusted odds ratios of hypertension were 0.740 (95% CI 0.569, 0.963; P = 0.025) in female participants who consumed usually, and 0.760 (95% CI 0.624, 0.925; P = 0.006) in female participants who ate spicy food with moderate pungency. There was no significant association of spicy food consumption with hypertension in male participants.

CONCLUSIONS

Frequency of spicy food consumption was inversely associated with risk of hypertension in female, but not male adults.

An Updated Review of Hypertensive Emergencies and Urgencies

A hypertensive crisis is an abrupt and severe rise in the arterial blood pressure (BP) occurring either in patients with known essential or secondary hypertension, or it may develop spontaneously. The most frequent cause for the severe and sudden increase in BP is inadequate dosing or stopping antihypertensive treatment in hypertensive patients. Severe hypertension can be defined as either a hypertensive emergency or an urgency, depending on the existence of organ damage. In hypertensive urgencies, there are no signs of acute end-organ damage, and orally administered drugs might be sufficient. In hypertensive emergencies, signs of acute end-organ damage are present, and in these cases, quickly-acting parenteral drugs must be used. The prompt recognition, assessment, and treatment of hypertensive urgencies and emergencies can decrease target organ damage and mortality. In this review, the definitions and therapeutic recommendations in a hypertensive crisis are presented in the light of the 2017 ACC/AHA Hypertension Guidelines.

Management of hypertensive crises in the elderly

Hypertensive crises are elevations of blood pressure higher than 180/120 mmHg. These can be urgent or emergent, depending on the presence of end organ damage. The clinical presentation of hypertensive crises is quite variable in elderly patients, and clinicians must be suspicious of non-specific symptoms. Managing hypertensive crises in elderly patients needs meticulous knowledge of the pathophysiological changes in them, pharmacological options, pharmacokinetics of the medications used, their side effects, and their interactions with other medications. Clevidipine, nicardipine, labetalol, esmolol, and fenoldopam are among the preferred choices in the elderly due to their efficacy and tolerability. Nitroprusside, hydralazine, and nifedipine should be avoided, unless there are no other options available, due to the high risk of complications and unpredictable responses.

Sublingual nitroglycerin for early blood pressure control in hypertensive emergencies: observations from an emergency department clinical audit in Sri Lanka

Objective

Hypertensive emergencies are potentially life threatening and require prompt blood pressure control with intravenous agents. Preparation of intravenous infusions is time consuming. Usefulness of sublingual nitroglycerin in this setting is not known. We aimed to assess the benefit of sublingual nitroglycerin as a bridge to IV therapy. In a clinical audit in an emergency department, patients presenting with hypertensive emergencies requiring intravenous nitroglycerin were administered single spray of sublingual nitroglycerin awaiting commencement of intravenous infusion. Blood pressure was monitored every 5 min to observe the degree and speed of reduction.

Results

Thirty-seven patients met the selection criteria. Mean age was 65.8 years (SD 7.04), and 29 were males (88.4%). Mean values of systolic, diastolic and mean blood pressures on admission were 217, 137, 163 mmHg. At 5 and 10 min after sublingual nitroglycerin, mean reduction of mean arterial blood pressure by 12.3 and 16.3% was achieved. Only 2 patients (5.4%) showed an overcorrection of blood pressure. Minimum of 15 min were required to set up a nitroglycerin intravenous infusion. Sublingual nitroglycerin spray allows rapid blood pressure control in hypertensive emergencies and is a useful bridge during the time to prepare intravenous infusion.

Evaluation of Acute Kidney Injury and Mortality After Intensive Blood Pressure Control in Patients With Intracerebral Hemorrhage

Background

We sought to assess the risk of acute kidney injury (AKI) and mortality associated with intensive systolic blood pressure reduction in acute intracerebral hemorrhage.

Methods and Results

Patients with acute intracerebral hemorrhage had spontaneous cause and symptom onset within 24 hours. We excluded patients with structural causes, coagulopathy, thrombocytopenia, and preexisting end‐stage renal disease. We defined AKI using the Acute Kidney Injury Network criteria. Chronic kidney disease status was included in risk stratification and was defined by Kidney Disease Outcomes Quality Initiative staging. Maximum systolic blood pressure reduction was defined over a 12‐hour period and dichotomized using receiver operating characteristic curve analysis. Descriptive statistics were done using independent sample t tests, χ² tests, and Mann‐Whitney U tests, whereas multivariable logistic regression analysis was used to evaluate for predictors for AKI and mortality. A total of 448 patients with intracerebral hemorrhage met inclusion criteria. Maximum systolic blood pressure reduction was dichotomized to 90 mm Hg and found to increase the risk of AKI in patients with normal renal function (odds ratio, 2.1; 95% confidence interval, 1.19–3.62; P=0.010) and chronic kidney disease (odds ratio, 3.91; 95% confidence interval, 1.26–12.15; P=0.019). The risk of AKI was not significantly different in normal renal function versus chronic kidney disease groups when adjusted for demographics, presentation characteristics, and medications associated with AKI. AKI positively predicted mortality for patients with normal renal function (odds ratio, 2.41; 95% confidence interval, 1.11–5.22; P=0.026) but not for patients with chronic kidney disease (odds ratio, 3.13; 95% confidence interval, 0.65–15.01; P=0.154).

Conclusions

These results indicate that intensive systolic blood pressure reduction with a threshold >90 mm Hg in patients with acute intracerebral hemorrhage may be an independent predictor for AKI.

Trends in Hospitalization for Hypertensive Emergency, and Relationship of End-Organ Damage With In-Hospital Mortality

BACKGROUND

There are no comprehensive guidelines on management of hypertensive emergency (HTNE) and complications. Despite advances in antihypertensive medications HTNE is accompanied with significant morbidity and mortality.

METHODS

We queried the 2002-2012 nationwide inpatient sample database to identify patients with HTNE. Trends in incidence of HTNE and in-hospital mortality were analyzed. Logistic regression analysis was used to assess the relationship between end-organ complications and in-hospital mortality.

RESULTS

Between 2002 and 2012, 129,914 admissions were included. Six hundred and thirty (0.48%) patients died during their hospital stay. There was an increase in the number of HTNE admissions (9,511-15,479; Ptrend < 0.001) with concurrent reduction of in-hospital mortality (0.8-0.3%; Ptrend < 0.001) by the year 2012 compared to 2002. Patients who died during hospitalization were older, had longer length of stay, higher cost of stay, more comorbidities, and higher risk scores. Presence of acute cardiorespiratory failure [adjusted odds ratio (OR), 15.8; 95% confidence interval (CI), 13.2-18.9], stroke or transient ischemia attack (TIA) (adjusted OR, 7.9; 95% CI, 6.3-9.9), chest pain (adjusted OR, 5.9; 95% CI, 4.4-7.7), stroke/TIA (adjusted OR, 5.9; 95% CI, 4.5-7.7), and aortic dissection (adjusted OR, 5.9; 95% CI, 2.8-12.4) were most predictive of higher in-hospital mortality in addition to factors such as age, aortic dissection, acute myocardial infarction, acute renal failure, and presence of neurological symptoms.

CONCLUSION

A rising trend in hospitalization for HTNE, with an overall decrease in in-hospital mortality was observed from 2002 to 2012, possibly related to changes in coding practices and improved management. Presence of acute cardiorespiratory failure, stroke/TIA, chest pain, and aortic dissection were most predictive of higher hospital mortality.

Management of acute postoperative hypertension for reducing cardiovascular complications in cancer patients: when and how aggressively?

BACKGROUND/AIM

We sought to determine what factors cardiovascular complications (CVCs) correlate with in cancer patients with acute postoperative hypertension (APH) and to define when and how aggressively to treat this disorder in the present study.

MATERIALS AND METHODS

A retrospective observational study of cancer patients with postoperative hypertension at a single intensive care unit between July 2007 and June 2013 was conducted. The outcome of interest was the incidence of a CVC.

RESULTS

There were 1162 patients enrolled, of which 92 (7.9%) experienced one or more CVCs. Preexisting hypertension (OR 38.3, 95% CI 3.2-457.4, P = 0.004) and choice of vasodilator (OR 6.5, 95% CI 2.3-18.6, P = 0.000) were predictors of a CVC. Cardiovascular complications were less likely to occur if pain was relieved efficiently during the postoperative period (OR 15.9, 95% CI 1.9-130.1, P = 0.01). Furthermore, there were increased CVCs among patients with postoperative hypertensive crises compared to those with stage 1 or stage 2 hypertension with the treatment threshold for systolic blood pressure (OR 5.7, 95% CI 2.0-16.5, P = 0.001) or diastolic blood pressure (OR 6.0, 95% CI 1.8-20.3, P = 0.004).

CONCLUSION

To reduce CVCs, APH may be defined and managed as a hypertensive crisis in cancer patients.

Impact of Hypertension on Cognitive Function: A Scientific Statement From the American Heart Association

BACKGROUND

Age-related dementia, most commonly caused by Alzheimer disease or cerebrovascular factors (vascular dementia), is a major public health threat. Chronic arterial hypertension is a well-established risk factor for both types of dementia, but the link between hypertension and its treatment and cognition remains poorly understood. In this scientific statement, a multidisciplinary team of experts examines the impact of hypertension on cognition to assess the state of the knowledge, to identify gaps, and to provide future directions.

METHODS

Authors with relevant expertise were selected to contribute to this statement in accordance with the American Heart Association conflict-of-interest management policy. Panel members were assigned topics relevant to their areas of expertise, reviewed the literature, and summarized the available data.

RESULTS

Hypertension disrupts the structure and function of cerebral blood vessels, leads to ischemic damage of white matter regions critical for cognitive function, and may promote Alzheimer pathology. There is strong evidence of a deleterious influence of midlife hypertension on late-life cognitive function, but the cognitive impact of late-life hypertension is less clear. Observational studies demonstrated a cumulative effect of hypertension on cerebrovascular damage, but evidence from clinical trials that antihypertensive treatment improves cognition is not conclusive.

CONCLUSIONS

After carefully reviewing the literature, the group concluded that there were insufficient data to make evidence-based recommendations. However, judicious treatment of hypertension, taking into account goals of care and individual characteristics (eg, age and comorbidities), seems justified to safeguard vascular health and, as a consequence, brain health.

A reversible posterior leucoencephalopathy syndrome including blindness caused by preeclampsia

Complications of (pre)eclampsia may involve multiple systems and organs. Neurological symptoms may occur. Visual symptoms concern up to 25% the of patients with severe preeclampsia and 50% of the patients with eclampsia. An uncommon effect of severe preeclampsia is sudden blindness. Blindness may be part of a clinical and radiological presentation named Posterior Reversible Encephalopathy Syndrome (PRES). PRES may lead to permanent neurological deficit, recurrences or death. We report the case of a 24-year-old Caucasian patient, gravida 5 para 2 who developed preeclampsia and PRES complicated with blindness at 32 weeks of gestation. Optimal care allowed visual symptoms to resolve within 24 hours and a favourable maternal outcome and no long- term sequelae. We describe different causes and manifestations of PRES and highlight the need for immediate care in order to optimize the chance of symptoms reversibility.

Implementing a Policy and Protocol on Managing Patients With Hypertensive Urgencies

Background: The use of short-acting agents, such as clonidine, for hypertensive urgency has been shown to worsen outcomes and, therefore, should be avoided in the office. Objectives: The primary objective was to achieve decreased rates of clonidine orders for immediate treatment of asymptomatic hypertension in the office. The secondary objective was to determine if reduced use leads to a decline in poor outcomes. Methods: This was an observational cohort study evaluating a protocol and algorithm developed by clinical pharmacists on the appropriate management of hypertensive urgencies. The protocol included the provision of avoiding short-acting antihypertensives (ie, clonidine). Preintervention and postintervention reports were generated to determine the number of times clonidine was ordered in the office. Electronic health charts were also reviewed for documentation of poor outcomes related to clonidine administration within 1 week of the hypertensive urgency visit date. Results: In the preintervention cohort, 106 (17.4%) orders of clonidine were captured compared with 73 (10.6%) in the postintervention group ( P = 0.001). Of the patients who were administered clonidine, 7 patients in the preintervention group were advised to go to the emergency department (ED) for additional hypertensive management, 2 of whom were subsequently hospitalized; 9 patients were advised to go to the ED in the postintervention group, and no patient was subsequently hospitalized. No adverse effects were documented from in-office clonidine administration in either cohort of patients. Conclusion: The hypertensive urgency protocol and education reduced the number of clonidine orders and hospital admissions. The increase in ED referrals needs further assessment.

An Emergency Department Approach to Drug Treatment of Hypertensive Urgency and Emergency

Patients who present with hypertensive urgency or emergency require immediate attention to assess the severity of illness. Guidelines from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure are available but do little to address the management of acute elevations in blood pressure. Various treatment options, both old and new, exist to manage these patients in the emergency department. Decisions on therapy are patient specific and depend on the underlying cause of elevated blood pressure. This article sets out to describe specific patient presentations and reviews current available options in the management of hypertensive urgencies and emergencies.

Hypertensive crisis in children: an experience in a single tertiary care center in Korea

BACKGROUND

Hypertensive crisis is a medical emergency that can cause acute damage to multiple end-organs. However, relatively little is known on the etiology, treatment, and outcomes of hypertensive crisis in Korean children. The aim of this study was to determine the etiologies and efficacy of drugs for hypertensive crisis in children during the past 5 years at a single center in Korea.

METHODS

We analyzed data from 51 children with hypertensive crisis during the period between January 1, 2010 and April 1, 2014. The patients were divided into two groups: those diagnosed with a hypertensive emergency (hypertension with organ injury, n = 31) and those diagnosed with a hypertensive urgency (hypertension without organ injury, n = 20). Baseline etiologies and risk factors were compared between the two groups. In addition, systolic and diastolic blood pressures were evaluated at 1, 2, 4, and 5 hours after the administration of intravenous antihypertensive drugs.

RESULTS

Kidney injury and cancer were the common causes in patients with hypertensive crisis. Cardiovascular complications (cardiac hypertrophy) (p = 0.002), central nervous system complications (p = 0.004), and retinopathy (p = 0.034) were more frequently observed in children with hypertensive emergency than those with hypertensive urgency. However, the proportion of renal complications was similar in both groups. Hydralazine was most commonly used in both groups to control acute increasing blood pressure at first. However, it was often ineffective for controlling abrupt elevated blood pressure. Therefore, intravenous antihypertensive drugs were changed from hydralazine to nicardipine, labetalol, or nitroprusside to control the high blood pressure in 45.1 % of the patients. Particularly, in patients with hypertensive crisis, there was no significant difference in reduction of systolic and diastolic blood pressure and in improvement of clinical outcomes between nicardipine and labetalol administration.

CONCLUSION

Close blood pressure monitoring and careful examinations should be mandatory in children with underlying disease, especially renal diseases and cancer. Furthermore, both nicardipine and labetalol may be effective antihypertensive drug in lowering high blood pressure in children with hypertensive crisis.

Hypertension in Women: Evaluation and Management

Hypertension is the most commonly encountered chronic medical condition in primary care and one of the most significant modifiable cardiovascular risk factors for women and men. Timely diagnosis and evidence-based management offer an important opportunity to reduce the risk of hypertension-related morbidity and mortality, including cardiovascular events, end-stage renal disease, and heart failure. Clinical trials have shown significant improvements in patient-oriented outcomes when hypertension is well-controlled, yet many hypertensive patients remain undiagnosed, uncontrolled, or managed with inappropriate pharmacotherapy. This article discusses the initial diagnosis, evaluation, and management of hypertension in nonpregnant women, with topics for obstetrician-gynecologists and women's health providers.

Blood pressure treatment and outcomes in hypertensive patients without acute target organ damage: a retrospective cohort

OBJECTIVES

The objective is of the study to evaluate the effect of antihypertensive therapy in emergency department (ED) patients with markedly elevated blood pressure (BP) but no signs/symptoms of acute target organ damage (TOD).

METHODS

This is a retrospective cohort study of ED patients age 18 years and older with an initial BP greater than or equal to 180/100 mm Hg and no acute TOD, who were discharged with a primary diagnosis of hypertension. Patients were divided based on receipt of antihypertensive therapy and outcomes (ED revisits and mortality) and were compared.

RESULTS

Of 1016 patients, 435 (42.8%) received antihypertensive therapy, primarily (88.5%) oral clonidine. Average age was 49.2 years, and 94.5% were African American. Treated patients more often had a history of hypertension (93.1% vs 84.3%; difference = -8.8; 95% confidence interval [CI], -12.5 to -4.9) and had higher mean initial systolic (202 vs 185 mm Hg; difference = 16.9; 95% CI, -19.7 to -14.1) and diastolic (115 vs 106 mm Hg; difference = -8.6; 95% CI, -10.3 to -6.9) BP. Emergency department revisits at 24 hours (4.4% vs 2.4%; difference = -2.0; 95% CI, -4.5 to 0.3) and 30 days (18.9% vs 15.2%; difference = -3.7; 95% CI, -8.5 to 0.9) and mortality at 30 days (0.2% vs 0.2%; difference = 0; 95% CI, -1.1 to 0.8) and 1 year (2.1% vs 1.6%; difference = -0.5; 95% CI, -2.5 to 1.2) were similar.

CONCLUSIONS

Revisits and mortality were similar for ED patients with markedly elevated BP but no acute TOD, whether they were treated with antihypertensive therapy, suggesting relative safety with either approach.

A case of hypertensive urgency

A 41-year-old male Nepalese soldier presented to the primary care medical centre with a 1-week history of fatigue and muscle aches following a trip to Nepal. His BP was 164/98 but was otherwise normal. Four days later he presented with new symptoms of sweating and palpitations and a BP of 200/127 whereupon he was admitted to hospital with the diagnosis of hypertensive crisis. Appropriate investigation and initial management were undertaken, and he was discharged after 12 h on antihypertensive treatment. This case highlights the risk of hypertensive crisis in both diagnosed and silent hypertensive disease, and the review highlights the presentations, initial investigation and different management of hypertensive crisis.

Emergency department patients with acute severe hypertension: a comparison of those admitted versus discharged in studying the treatment of acute hypertension registry

OBJECTIVES

To compare the characteristics, treatments, and outcomes for emergency department (ED) patients with severe hypertension by disposition (admitted versus discharged home).

METHODS

Studying the Treatment of Acute hyperTension (STAT) is a multicenter registry of 1566 patients with blood pressure ≥180/110 mm Hg who were treated with intravenous antihypertensive medications in an ED or intensive care unit. Presenting and in-hospital variables, and postdischarge outcomes for the 1053 patients in the ED subset were compared by disposition.

RESULTS

In the multivariable analysis, ED patients were less likely to be discharged if >75 years of age (odds ratio [OR] = 0.3, 95% confidence interval [CI] = 0.1-0.9) or if they had shortness of breath (OR = 0.4, 95% CI = 0.2-0.8) or alteration of mental status (OR = 0.1, 95% CI = 0.02-0.9) on arrival. Nondialysis patients with an admission creatinine concentration >1.5 mg/dL were 80% less likely to be discharged than those ≤1.5 mg/dL (OR = 0.2, 95% CI = 0.08-0.5). In the bivariate analysis, patients with a decrease in systolic blood pressure of <10% 2 hours after medication administration were more likely to be admitted than those discharged (57% vs. 44%; P = 0.041). Disposition did not correlate with 90-day or 6-month mortality or 30-day readmission. However, admitted patients had a higher 90-day readmission rate (38% vs. 24%; P = 0.038).

CONCLUSIONS

ED patients with severe hypertension were more likely to be admitted to the hospital if they were >75 years of age, presented with shortness of breath or altered mental status, or had a creatinine >1.5 mg/dL and were not on hemodialysis.