A study of the association between epistaxis and the severity of hypertension

Association of Hypertension With the Risk and Severity of Epistaxis

IMPORTANCE

The association between hypertension and epistaxis has long been a subject of debate.

OBJECTIVES

To evaluate the risk of epistaxis in patients with hypertension using a nationwide population cohort and to assess the association of hypertension with the methods of managing cases of epistaxis.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, a hypertension cohort and comparison cohort were built using the Korean National Health Insurance Service-National Sample Cohort that represents the entire population of the Republic of Korea from January 1, 2002, to December 31, 2015. The hypertension cohort comprised 35 749 patients with a record of 3 or more prescriptions of antihypertensive medication and a diagnosis of hypertension (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code I10). Patients with other diseases associated with epistaxis, such as sinonasal tumors, facial trauma, bleeding tendency, and coagulation disorder, as well as those taking anticoagulant medications, were excluded. A comparison cohort comprised 35 749 individuals without hypertension matched sociodemographically in a 1:1 ratio. Statistical analysis was performed from January 1, 2019, to March 31, 2020.

MAIN OUTCOMES AND MEASURES

The incidence and recurrence of epistaxis were evaluated in both cohorts. The risk factors for epistaxis and management strategies were also assessed.

RESULTS

Among the 35 749 patients in the hypertension cohort (20 579 men [57.6%]; median age, 52 years [interquartile range, 45-62 years]) the incidence rate (IR) of epistaxis was 32.97 per 10 000 persons (95% CI, 30.57-35.51 per 10 000 persons); among the 35 749 individuals in the comparison cohort (20 910 men [58.5%]; median age, 52 years [interquartile range, 45-62 years]), the IR of epistaxis was 22.76 per 10 000 persons (95% CI, 20.78-24.89 per 10 000 persons) (IR ratio, 1.45; 95% CI, 1.29-1.63; adjusted hazard ratio, 1.47; 95% CI, 1.30-1.66). The IR of recurrent epistaxis was 1.96 per 10 000 persons in the hypertension cohort and 1.59 per 10 000 persons in the nonhypertension cohort (IR ratio, 1.23; 95% CI, 0.77-2.00). Patients with hypertension who experienced epistaxis were more likely to use the emergency department (odds ratio, 2.69; 95% CI, 1.70-4.25; Cohen h effect size, 0.27; 95% CI, 0.16-0.39) and receive posterior nasal packing (odds ratio, 4.58; 95% CI, 1.03-20.38; Cohen h effect size, 0.15; 95% CI, 0.03-0.26) compared with the comparison cohort.

CONCLUSIONS AND RELEVANCE

This study suggests that patients with hypertension had an increased risk of epistaxis requiring hospital visits. In addition, epistaxis in patients with hypertension appeared to need more emergency department visits and require more posterior nasal packing procedures compared with patients without hypertension. Medical counseling about epistaxis is advisable for individuals with hypertension, and the presence of hypertension should be considered in managing nasal bleedings.

Evaluation of the Relationship Between Blood Pressure Control and Epistaxis Recurrence After Achieving Effective Hemostasis in the Emergency Department

BACKGROUND

Epistaxis is the most common cause of otorhinolaryngologic emergencies. There is a longstanding controversy regarding the relationship between epistaxis and hypertension (HTN), in terms of blood pressure (BP) control in the emergency department (ED) setting. The objective of this study is to evaluate the association between HTN, BP control, and recurrent epistaxis among patients initially admitted to the ED for epistaxis.

METHODS

This retrospective cohort study was conducted in the EDs of three different hospitals in Taiwan and included a total of 739 patients admitted for epistaxis.

RESULTS

Among ED patients with epistaxis, older age was significantly associated with a history of HTN, and a statistically significant difference in age was noted between groups classified according to the systolic BP/diastolic BP (SBP/DBP) at triage. Patients with a history of HTN had higher BP values at triage than did patients without a history of HTN (SBP: 175.68 ± 32.30 mmHg vs. 148.00 ± 26.26 mmHg, DBP: 95.04 ± 20.98 mmHg vs. 83.30 ± 16.65 mmHg; p < 0.0001). Antihypertensive medications were more commonly administered to patients with a history of HTN (p < 0.0001) and in those patients with SBP/DBP: ≥ 140/≥ 90 mmHg at triage (p < 0.0001). Among patients receiving antihypertensive medications, reductions in SBP by the time of discharge were significantly greater in patients with a history of HTN and in patients with SBP/DBP: ≥ 160/≥ 100 mmHg at triage. ED revisits due to recurrent epistaxis within 72 hours were significantly associated with male sex, a positive history of HTN, level of GOT, observation for recurrent epistaxis at ED, and duration of recurrent bleeding.

CONCLUSIONS

A positive history of HTN is related to recurrent epistaxis among ED patients. The effectiveness of administering antihypertensive agents before achieving hemostasis in patients admitted to the ED for epistaxis warrants further study.

Role of age and anticoagulants in recurrent idiopathic epistaxis

OBJECTIVE

Epistaxis is one of the commonest causes of attendance of Otolaryngology emergency rooms. Given its incidence, potential severity and high recurrence rate, a systematic and careful management is mandatory. This work aims to define prognostic factors of epistaxis recurrence.

MATERIAL AND METHODS

Retrospective review of medical records of patients with epistaxis admitted to our emergency department from January 2012 to December 2016. Data of 1005 patients with idiopathic epistaxis were analysed and independent risk factors for recurrence were determined by multiple logistic regression analysis.

RESULTS

Recurrence of epistaxis was found in 303 (30.1%) patients. Patients with recurrent epistaxis were older (p<.001) and more commonly had a history of hypertension (p=.001) and antiplatelet (p=.048) and anticoagulant (p=.001) use than those with episodic epistaxis. Age (adjusted OR 1.21, 95%CI 1.08-1.32, p=.003) and anticoagulant use (adjusted OR 2.68, 95%CI 1.94-3.70, p=.009) were predictors of increased risk of recurrent epistaxis. Gender, alcohol abuse, medical history, active bleeding at admission, unidentified bleeding point or treatment modalities were not associated with recurrence.

CONCLUSION

Age and use of anticoagulation drugs were risk factors for recurrence of epistaxis. None of the previously described risk factors for episodic epistaxis were found to increase the risk of recurrence. Knowledge of factors involved in recurrence might provide important information for assessment and management of increased risk patients.

[Pathogenesis of nasal bleeding in the patients presenting with arterial hypertension]

The objective of the present work was to study the pathogenetic mechanisms underlying nasal bleeding (NB) in the patients presenting with arterial hypertension (AH). A total of 47 patients with AH suffering from NB were available for the examination of whom 28 experienced a single bleeding episode and 19 had recurrent bleeding. 11 of them were treated by endonasal surgical intervention for the achievement of hemostasis. Simultaneously, mucoperichondreal biopsies were taken from the anterior septal portions and used for histological and ultrastructural investigations. The laboratory examination of all the patients has demonstrated hyperfibrinogenemia and the enhanced level of soluble monomeric fibrin complexes in the blood (especially in the patients with recurrent nasal bleeding) despite the normal platelet levels, prothrombin and thrombin times. These findings gave reason to characterize the hemostasiological status of the patients as chronic compensated disseminated intravascular coagulation (DIC) syndrome. The histological study revealed hyaline, erythrocyte-rich and fibrin thrombi in the vessels of the microcirculatory system whereas ultrastructural studies showed desquamation of endothelial cells, massive desendothelization, and disintegration of the basal membrane with the exposure of subendothelium. It is supposed that these changes provoked the development of thrombosis and focal necrosis in nasal mucosa. The authors conclude that the cause of nasal bleeding associated with arterial hypertension is directly related to the lesions of vascular endothelial, microcirculatory disorders, and modification of the blood coagulation processes rather than to the mechanical rupture of blood vessels. These changes are believed to be responsible for the development of local intravascular coagulation.

Epistaxis in Kaduna, Nigeria: a review of 101 cases

BACKGROUND

Epistaxis is defined as a hemorrhage from the nostril, nasal cavity, or nasopharynx. Sufferers and clinicians may develop significant anxiety despite the fact that majority of patients are treated successfully by the first attending physician.

OBJECTIVE

To review aetiology and management outcomes of epistaxis in a resource constrained setting.

METHODOLOGY

A retrospective review of 101 patients seen with epistaxis at the National Ear Care Centre, Kaduna over 7 years (January 2002- December 2008).

RESULTS

The age of patients ranged between 2 and 75 years. The incidence of epistaxis of 0.5% was recorded out of total patient visit and slight male preponderance with a male:female ratio of 1.4:1. Dry-hot and cold harmattan weather had the highest prevalence. Trauma and infections were the main aetiological factors identified but over 40% of cases are idiopathic in origin. About 25% presented with active bleeding and 11% required admission. All were managed conservatively. Less than 2% received blood transfusion.

CONCLUSION

Epistaxis is a common emergency that requires prompt intervention to reduce further morbidity and prevent mortality. Non operative intervention was a satisfactory approach in this study.

Epistaxis: some aspects of laterality in 326 patients

Lateralization of primary epistaxis was prospectively studied in 326 patients at Radebeul Elblandklinikum. The male-female-ratio was 1.3:1. A slight dominance of the right side (45% right vs. 39% left) was found in all patients. Further analyzed were the relationship to the localization of bleeding (anterior or posterior), the age and possible causes or risk factors. Nose bleeding from the posterior nasal portion appears to be statistically significantly higher than on both sides of anterior epistaxis. No statistically significant age dependence of laterality of epistaxis was observed in the age groups which we selected. However, nosebleed appears more frequently in women under the age of 50 years in both nostrils. With identified risk factors, idiopathic epistaxis occurs more frequently on the right side than does nosebleed. Mechanical trauma (intranasal sprays or nose picking) is a possible factor explaining the dominance of epistaxis on the right side, especially in idiopathic cases.

Serious spontaneous epistaxis and hypertension in hospitalized patients

The aim of the study was to evaluate the role of hypertension in patients hospitalized for serious spontaneous epistaxis. This 6-year retrospective study was based on 219 patients hospitalized in a University Hospital ENT and Head and Neck surgery department for serious spontaneous epistaxis. The following parameters were recorded: length of hospital stay, history of hypertension, blood pressure (BP) recordings (on admission, during hospitalization and on discharge), epistaxis severity criteria, including medical and/or surgical management of epistaxis (blood transfusion depending on blood count, embolization, surgery), medications affecting clotting. Epistaxis was classified into two groups: serious and severe. No significant differences were observed between the two groups in terms of age, sex ratio, history of epistaxis and BP characteristics including history of hypertension, mean BP on admission, mean arterial pressure on discharge and number of patients in whom BP was difficult to control. Patients with more severe epistaxis had a similar exposure to anticoagulant and platelet antiaggregant medications as patients with less severe epistaxis. Overall, on univariate logistic regression analysis, no factors were independently associated with severity of epistaxis. The pathophysiology of serious spontaneous epistaxis remains to be unclear. It concerns elderly patients (>60-70 years old) with a history of hypertension in about 50% of cases. Serious spontaneous epistaxis may also be the presenting sign of underlying true hypertension in about 43% of patients with no history of hypertension. However, hypertension per se does not appear to be a statistically significant causal factor and/or a factor of severity of serious spontaneous epistaxis.

Is severe epistaxis associated with acetylsalicylic acid intake?

OBJECTIVES/HYPOTHESIS

Epistaxis represents a very common emergency in any ear, nose, and throat (ENT) department around the world. Despite other risk factors, acetylsalicylic acid (ASA) contributes to nosebleeds by its intrinsic ability to impair thrombocyte aggregation. The aim of this study was to investigate the influence of ASA on the severity of epistaxis and to compare it with other potential risk factors.

STUDY DESIGN

A prospective cohort study was performed at the ENT department of University Hospital Zurich.

METHODS

A total of 591 events were evaluated concerning surgical interventions and the length of in-hospital stay. Further analyses regarding recurrences and number of treatments and a specially designed severity score, as well as other outcome parameters, were performed.

RESULTS

Ninety-nine patients needed to stay in-hospital for at least 1 day. Nearly 30% of all patients had ASA intake, and only 18% were on vitamin K antagonist therapy. Patients on ASA showed significantly more surgical interventions, a higher recurrence rate, and a larger number of required treatments as well as an increased severity score. Duration of in-hospital stay and the complication rate, however, were not associated with drug intake.

CONCLUSIONS

We not only identified ASA to be one of the major risk factors in epistaxis, but also quantified its impact on the severity of nose bleeding. We emphasize the importance of a well-indicated antiaggregational therapy, and strongly discourage using ASA as a life-style drug for the elderly. ASA therapy needs to be discontinued whenever possible and reasonable.

Epistaxis in adults: a clinical review

Epistaxis can be encountered in a wide range of specialties, and it is vital that doctors and nurses can identify the causes and manage it effectively. When managed correctly the potential morbidity and mortality can be significantly reduced.

Association between epistaxis and hypertension: a one year follow-up after an index episode of nose bleeding in hypertensive patients

Association between epistaxis and hypertension is controversial. In this study, we evaluated in hypertensive patients the incidence of epistaxis according to stages of hypertension and compared blood pressure (BP) readings in these episodes to routine readings. Thirty-six patients admitted to the Emergency Department (ED) with epistaxis were enrolled and divided into 3 groups according to hypertension severity (JNC-VI criteria). BP readings were obtained weekly (routine BP) and in the setting of a new episode of epistaxis (epistaxis BP). No difference in the incidence of epistaxis was found: patients with hypertension stage 1 had 7.6+/-4.1 episodes/year, those in stage 2 had 8.0+/-4.0 and in stage 3 the incidence was 8.2+/-3.9 (p=ns). The average SBP for all 36 patients was 154+/-19 mmHg on routine readings and 157+/-22 mmHg on epistaxes episodes (p=ns). No difference was also observed regarding DBP: 104+/-18 mmHg vs. 105+/-18 mmHg (p=ns). In conclusion, epistaxis incidence in hypertensive patients is not associated to hypertension severity. Moreover, BP readings in the setting of epistaxis are similar to readings obtained in routine situations.

Absence of association between hypertension and epistaxis: a population-based study

The association between epistaxis and hypertension is still disputed. In a cross-sectional study, we evaluated this association in a sample of 1174 individuals older than 18 years, representative of inhabitants of Porto Alegre, RS, Brazil. Epistaxis was defined as any episode of non-traumatic nosebleeding after 18 years of age. Hypertension was defined as the mean of two blood pressure readings > or = 160/95 mmHg or the use of antihypertensive drugs. The prevalence of epistaxis and hypertension were 14.7% (95% confidence interval, CI 12.7-16.7) and 24.1% (95% CI 21.7-26.6), respectively. History of epistaxis in the adulthood (risk ratio = 1.24, 95% CI 0.83-1.85), and in the previous 6 months (risk ratio 0.79, 95% CI 0.40-1.56; p = 0.510) were not associated with hypertension after controlling for gender, age, race, history of allergic rhinitis or nasal abnormalities, alcohol abuse, smoking and years of study. History of epistaxis was positively associated with history of allergic rhinitis and inversely associated with years at school. In conclusion, we demonstrated that hypertension is not associated with history of epistaxis in the adulthood in free-living individuals.

Antiplatelet agents and anticoagulants for hypertension

BACKGROUND

Although elevated systemic blood pressure results in high intravascular pressure, the main complications, coronary heart disease (CHD), ischaemic strokes and peripheral vascular disease (PVD), are related to thrombosis rather than haemorrhage. Some complications related to elevated blood pressure, heart failure or atrial fibrillation, are themselves associated with stroke and thromboembolism. It therefore seemed plausible that use of antithrombotic therapy may be particularly useful in preventing thrombosis-related complications of elevated blood pressure.

OBJECTIVES

To conduct a systematic review of the role of antiplatelet therapy and anticoagulation in patients with blood pressure, including those with elevations in both systolic and diastolic blood pressure, isolated elevations of either systolic or diastolic blood pressure, to address the following hypotheses: (i) antiplatelet agents reduce total deaths and/or major thrombotic events when compared to placebo or other active treatment; and (ii) oral anticoagulants reduce total deaths and/or major thromboembolic events when compared to placebo or other active treatment.

SEARCH STRATEGY

Reference lists of papers resulting from this search, electronic database searching (MEDLINE, EMBASE, DARE), and abstracts from national and international cardiovascular meetings were studied to identify unpublished studies. Relevant authors of these studies were contacted to obtain further data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with elevated blood pressure were included if they were of at least 3 months in duration and compared antithrombotic therapy with control or other active treatment.

DATA COLLECTION AND ANALYSIS

Data were independently collected and verified by two reviewers. Data from different trials were pooled where appropriate.

MAIN RESULTS

The ATC meta-analysis of antiplatelet therapy for secondary prevention in patients with elevated blood pressure reported an absolute reduction in vascular events of 4.1% as compared to placebo. Data on the patients with elevated blood pressure from the 29 individual trials included in this meta-analysis was requested but could not be obtained. Three additional trials met the inclusion criteria and are reported on here. Acetylsalicylic acid (ASA) did not reduce stroke or 'all cardiovascular events' compared to placebo in primary prevention patients with elevated blood pressure and no prior cardiovascular disease. Based on one large trial (HOT trial), ASA taken for 5 years reduced myocardial infarction (ARR, 0.5%, NNT 200 for 5 years), increased major haemorrhage (ARI, 0.7%, NNT 154), and did not reduce all cause mortality or cardiovascular mortality. There was no significant difference between ASA and clopidogrel for the composite endpoint of stroke, myocardial infarction or vascular death in one trial (CAPRIE 1996). In two small trials warfarin alone or in combination with ASA did not reduce stroke or coronary events.

REVIEWERS' CONCLUSIONS

For primary prevention in patients with elevated blood pressure, anti-platelet therapy with ASA cannot be recommended since the magnitude of benefit, a reduction in myocardial infarction, is negated by a harm of similar magnitude, an increase in major haemorrhage. For secondary prevention in patients with elevated blood pressure (ATC meta-analysis: APTC 1994) antiplatelet therapy is recommended because the magnitude of the absolute benefit is many times greater. Warfarin therapy alone or in combination with aspirin in patients with elevated blood pressure cannot be recommended because of lack of demonstrated benefit. Glycoprotein IIb/IIIa inhibitors as well as ticlopidine and clopidogrel have not been sufficiently evaluated in patients with elevated blood pressure. Further trials of antithrombotic therapy with complete documentation of all benefits and harms are required in patients with elevated blood pressure.

Headache is not more frequent among patients with moderate to severe hypertension

The association between hypertension and headache has been a contentious issue. Most studies have showed that mild hypertension and headache are not associated, but this may not be the case in patients with hypertension classified at more severe stages. We investigated the association between hypertension classified at moderate to severe stages and headache in a cross-sectional study conducted in the hypertension clinic of a tertiary care University hospital. In total, 1763 referred patients with a medical diagnosis of hypertension in most cases (95.7%) were evaluated by an extensive protocol questionnaire, detailed physical examination, laboratory examination, and had their blood pressure classified according to the VI Joint National Committee (JNC-VI) recommendation. Logistic regression models were used to explore the association between severity of hypertension and pulse pressure with the presence of headache, controlling for several potential confounders. The complaint of headache was referred by 903 (51.3% of whole sample), and a total of 378 patients (21.4%) were classified at the moderate to severe stage (stage III of the JNC-VI report). The diagnosis of moderate to severe hypertension was not associated with the complaint of headache (OR 1.02, 95% CI from 0.79 to 1.30). Pulse pressure and headache were inversely associated (OR 0.91, 95% CI from 0.86 to 0.97, for 10 mmHg). We concluded that headache and hypertension classified at moderate to severe stages were not associated in patients attending to a hypertension clinic. The novel finding of an inverse association between pulse pressure and headache should be addressed in further investigations.

Effectiveness of second-generation fibrin glue in endonasal operations

We evaluated the efficacy and safety of the Quixil fibrin sealant after its application to endonasal operative sites. A total of 153 patients underwent nasal surgery. The rate of hemorrhagic complications was compared in the group with nasal packing and in the group in whom fibrin glue was used to stop postoperative bleeding. Our results indicate that the application of Quixil fibrin glue to the operative sites in various endonasal operations provides effective hemostasis and sealing. This fibrin glue is a more effective hemostatic agent than foam nasal packing and provides no complications, as can occur with packing. Patients with hypertension have no greater risk for postoperative bleeding if Quixil is used.

Active epistaxis at ED presentation is associated with arterial hypertension

Epistaxis and hypertension are frequent in the general population, but an association is still controversial. Aim of this retrospective cohort study was to test if active epistaxis at emergency department (ED) presentation is associated with hypertension. Patients with active epistaxis at ED presentation (n = 271; 73%) were compared with controls without active bleeding (n = 101; 27%). By multivariate logistic regression modeling we found that active epistaxis was independently associated with history of hypertension (odds ratio 2.8 [95% CI 1.4 to 5.6; P =.004] adjusted for age, gender, rhinitis, diffuse bleeding, and malignant diseases). Patients with active epistaxis had higher blood pressure at presentation compared with controls (systolic blood pressure 165 v 153 mmHg, P <.001, diastolic blood pressure 85 v 77 mmHg, P <.001). Active epistaxis at ED presentation is associated with arterial hypertension.

Evaluation of Time of Nasal Packing After Nasal Surgery: A Randomized Trial

A randomized, prospective trial was carried out to compare the rate of hemorrhagic complications after removal of nasal packing left for 24 and 48 hours. A total of 104 patients underwent nasal surgery and were randomly assigned to 1 of 2 groups: group 1, 24 hours of nasal packing; group 2, 48 hours of nasal packing. No statistical difference was observed between the groups in terms of occurrence of hemorrhagic complications. Hypertension was the only prognostic factor for postoperative bleeding. The routine use of 48-hour postoperative nasal packing after nasal surgery is not justified because of the low incidence of bleeding and the potential associated morbidity. At the end of the procedure, surgeons should evaluate the risk of postoperative bleeding (ie, presence of hypertension) and decide whether 24-hour nasal packing is enough.

Is epistaxis evidence of end-organ damage in patients with hypertension?

OBJECTIVES/HYPOTHESIS

To study the association between history of mild to severe epistaxis with different stages of hypertension and with other evidence of target organ damage in a sample of patients attending an outpatient hypertension clinic, controlling for potential confounding factors.

STUDY DESIGN

A survey of adult patients with hypertension.

METHODS

A consecutive sample of 323 adults with hypertension was studied. The main outcome measures were history of adult epistaxis, high blood pressure, duration of hypertension, nasal abnormalities, and fundoscopic and electrocardiogram abnormalities.

RESULTS

Ninety-four patients (29.1% of the whole sample) reported at least one episode of nosebleed after 18 years of age. Of these, 59 (62.8%) needed medical assistance to control at least one of the episodes. The history of epistaxis was not associated with blood pressure classified according to the World Health Organization/International Society of Hypertension paradigm or classified as severe or not severe. There was a trend of an association between history of epistaxis and duration of hypertension. The history of severe epistaxis (epistaxis that needed medical assistance) was not associated with blood pressure classified as severe or not severe and with duration of hypertension. More patients with left ventricular hypertrophy had a positive history of adult epistaxis. There was no association between history of epistaxis or history of severe epistaxis and fundoscopic abnormalities. Among the abnormalities detected at rhinoscopy, only the presence of enlarged septal vessels was associated with history of epistaxis. The presence of enlarged septal vessels was strongly and independently associated with history of epistaxis in the logistic regression model. Duration of hypertension and left ventricular hypertrophy showed a trend for an association with the history of epistaxis in the adult life.

CONCLUSIONS

A definite association between blood pressure and history of adult epistaxis in hypertensive patients was not found. The evidence for an association of duration of hypertension and left ventricular hypertrophy with epistaxis suggests that epistaxis might be a consequence of long-lasting hypertension. The association between the presence of enlarged vessels at rhinoscopy with history of epistaxis in hypertensive patients is a novel observation that needs to be addressed in future observations.