Uncontrolled hypertension and hypertensive urgency: One-year single-center emergency department experience

BACKGROUND

The prevalence of uncontrolled hypertension remains a significant concern in public healthcare systems, including daily practices of emergency departments (ED).

AIM

We aimed to characterize patients admitted to an ED for elevated blood pressure (BP) and to identify factors leading to hospitalization.

METHODS

This retrospective analysis included all patients admitted to an ED in a tertiary hospital in 2022 due to an acute BP rise without hypertensive emergencies.

RESULTS

The studied group (n = 570) constituted 1.5% of all ED admissions in 2022. The median age was 67 years (Q1-Q3) (52-75), 68.9% were females. Systolic BP (200 mm Hg [180-212]) and diastolic BP (105 mm Hg [100-115]) at home were higher than during triage (173 mm Hg [160-190] and 95 mm Hg [84-103], respectively [P <0.0001]). Thirty-nine percent of the studied population had taken BP-lowering agents before ED admission (captopril in 91.8% of cases). In the ED, nitrendipine (54.2%), captopril (38.1%), furosemide (16.3%), urapidil (10.0%), and nitroglycerine (1.9%) were administered. Eventually, a median of 140/82 mm Hg BP was reached in the median time of 288 minutes (202-400). Hospitalization was necessary in 5.4% of patients. The need for furosemide or urapidil administration in the ED doubled the risk of hospitalization (OR, 2.0; P <0.01). Before ED admission, only 17.0% of patients received guidelines-recommended single-pill combination therapy, and 17.6% had already visited ED for uncontrolled hypertension (median of 388 days earlier).

CONCLUSIONS

Elevated BP is a common reason for admission to the ED. Crucially, improvements in long-term hypertension treatment and education are needed to reduce the number of patients seeking ED care for elevated BP.

A rare case of hypertensive urgency caused by linezolid was reported: A case report

RATIONALE

Linezolid itself is rarely reported to cause blood pressure elevation, and it is rare to report that linezolid causes hypertensive urgency.

PATIENTS CONCERNS

This case report describes a 38-year-old man who developed acute hypertension after a postoperative foot infection that was treated with linezolid antitherapy. Hypertensive urgency occurred without obvious potential interaction between linezolid and drugs. After receiving appropriate treatment and stopping medication, the patient's blood pressure returned to normal and did not recur.

DIAGNOSES

Hypertensive crises occurred during the treatment of linezolid.

INTERVENTIONS

After stopping linezolid, the patient's blood pressure gradually returned to normal.

OUTCOMES

The patient's blood pressure returned to normal on the 26th day after stopping linezolid, and no abnormal blood pressure was found in the follow-up 2 months after discharge.

LESSONS

Linezolid is rarely reported to cause elevated blood pressure, even though it may occur in the absence of obvious drug interactions. Case reported fewer reasons may be for clinicians statistically insignificant or notice, and hypertensive urgency often lead to clinical risk, should be given enough attention to clinical. Pay attention to blood pressure monitoring during use, when there is abnormal increase in blood pressure, should consider adverse drug reactions, give timely discontinuation and give symptomatic treatment.

Prospective review of 188 cases of epistaxis presenting to the emergency department: Etiology and outcome

Background

Due to a myriad of risk factors, epistaxis is a very frequent presentation to the emergency room (ER). This study aims to ascertain the prevalence of epistaxis in our population, risk factors, effectiveness of ER treatment, complications, and ER outcome.

Materials and Methods

This was a prospective observational study performed in the ER of a referral tertiary care center in south India. Data were categorized, coded, and analyzed to determine the objective of the study.

Results

During the study's six-month duration, 188 (0.6%) patients presented with epistaxis. The mean age was 42.9 (SD: 16.49) years, with a male preponderance of 143 (76.1%). A majority of these patients (n: 156; 82.9%) were triaged as priority II, with hypertension (n: 53, 28.2%) as the commonest comorbidities. Trauma-related epistaxis (n: 107, 56.9%) was the most frequent cause. Anterior nasal packing was carried out for 85 (45.2%) patients, posterior nasal packing was carried out for one (0.5%) patient, and bleeding had spontaneously resolved in the majority (n: 102; 54.3%) patients. Seven (3.7%; p-value: 0.001) patients had recurrent epistaxis, and of those, three (1.6%) required urgent resuscitation with crystalloid fluid and blood products. Two of these patients had bleeding dyscrasias, four had history of trauma, and one patient presented with uncontrolled hypertension. Two (1.1%) patients came back to us with recurrent bleeding within 12 h of discharge. Majority (69.2%; 130) were discharged stable, (23.9%; 45) were admitted for observation and (6.9%; 13) were discharged against medical advice. There was no mortality among these study populations.

Conclusion

Middle-young, aged males most commonly presented with epistaxis. Most of them were secondary to trauma. Anterior nasal bleeding was the most common source and hemostasis could be obtained by anterior nasal packing. Majority could be discharged stable from the ER. However, this cohort had seen patients in life-threatening conditions, so the severity cannot be overlooked.

Characteristics and factors associated with hypertensive crisis: a cross-sectional study in patients with hypertension receiving care in a tertiary hospital

Background

The hypertensive crisis is characterized by poorly controlled hypertension, which can lead to unfavorable outcomes and high utilization. The purpose of this study was to examine the prevalence, clinical characteristics, and factors associated with hypertensive emergency.

Material and Methods

This cross-sectional study collected data from the hospital information system that included patients greater than or equal to 18 years who were diagnosed with hypertensive crisis (blood pressure ≥180 and/or 120 mmHg) and receiving care from the primary care unit and emergency department from 2020 to 2022. The prevalence and clinical characteristics of these patients were examined. Multiple logistic regression analysis was used to analyze factors associated with hypertensive emergency.

Results

Among 3329 patients with hypertension, 17.33% had a hypertensive crisis (16.64 vs. 0.69%, urgency and emergency types). Most patients were female (63.6%), with a median age of 66 years. Almost half the patients (42.2%) with hypertensive crisis presented without specific symptoms, and the most common presenting symptom was vertigo/dizziness (27.7%). The initial and after treatment blood pressures were 203/98 and 174/91 mmHg. In the hypertensive emergency, the most common end-organ damage was ischemic stroke (33.3%), hemorrhagic stroke (25%), and acute heart failure (20.8%). An oral angiotensin-converting enzyme (57.5%) was the most commonly administered medication. Multiple logistic regression was performed but did not reveal any statistically significant.

Conclusion

Our result revealed a high prevalence of hypertensive crises; most were of hypertensive urgency. The most common presenting symptom was vertigo/dizziness. There was no factor significantly associated with the hypertensive emergency in this study. Further studies should explore the cause of the hypertensive crisis to improve care delivery to patients with hypertension.

Cardiac Morphology, Function, and Left Ventricular Geometric Pattern in Patients with Hypertensive Crisis: A Cardiovascular Magnetic Resonance-Based Study

(1) Background: Altered cardiac morphology and function are associated with increased risks of adverse cardiac events in hypertension. Our study aimed to assess left ventricular (LV) morphology, geometry, and function using cardiovascular magnetic resonance (CMR) imaging in patients with hypertensive crisis. (2) Methods: Patients with hypertensive crisis underwent CMR imaging at 1.5 Tesla to assess cardiac volume, mass, function, and contrasted study. Left ventricular (LV) function and geometry were defined according to the guideline recommendations. Late gadolinium enhancement (LGE) was qualitatively assessed and classified into ischemic and nonischemic patterns. Predictors of LGE was determined using regression analysis. (3) Results: Eighty-two patients with hypertensive crisis (aged 48.5 ± 13.4 years, and 57% males) underwent CMR imaging. Of these patients, seventy-eight percent were hypertensive emergency and twenty-two percent were urgency. Diastolic blood pressure was higher under hypertensive emergency (p = 0.032). Seventy-nine percent (92% of emergency vs. 59% of urgency, respectively; p = 0.003) had left ventricular hypertrophy (LVH). The most prevalent LV geometry was concentric hypertrophy (52%). Asymmetric LVH occurred in 13 (22%) of the participants after excluding ischemic LGE. Impaired systolic function occurred in 46% of patients, and predominantly involved hypertensive emergency. Nonischemic LGE occurred in 75% of contrasted studies (67.2% in emergency versus 44.4% in urgency, respectively; p < 0.001). Creatinine and LV mass were independently associated with nonischemic LGE. (5) Conclusion: LVH, altered geometry, asymmetric LVH, impaired LV systolic function, and LGE are common under hypertensive crisis. LVH and LGE more commonly occurred under hypertensive emergency. Longitudinal studies are required to determine the prognostic implications of asymmetric LVH and LGE in hypertensive crisis.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Peer Counselor Intervention for Reducing Mortality and/or Hospitalization in Adults With Hypertensive Urgency in Tanzania: A Pilot Study

BACKGROUND

Worldwide, people with hypertensive urgency experience high rates of hospitalization and death due to medication non-adherence. Interventions to improve medication adherence and health outcomes after hypertensive urgency are urgently needed.

METHODS

This prospective cohort assessed the effect of a peer counselor intervention-named Rafiki mwenye msaada-on the 1-year incidence of hospitalization and/or death among adults with hypertensive urgency in Mwanza, Tanzania. We enrolled 50 patients who presented with hypertensive urgency to 2 hospitals in Mwanza, Tanzania. All 50 patients received a Rafiki mwenye msaada an individual-level, time-limited case management intervention. Rafiki mwenye msaada aims to empower adult patients with hypertensive urgency to manage their high blood pressure. It consists of 5 sessions delivered over 3 months by a peer counselor. Outcomes were compared to historical controls.

RESULTS

Of the 50 patients (median age, 61 years), 34 (68%) were female, and 19 (38%) were overweight. In comparison to the historical controls, the intervention cohort had a significantly lower proportion of patients with a secondary level of education (22% vs. 35%) and health insurance (40% vs. 87%). Nonetheless, the 1-year cumulative incidence of hospitalization and/or death was 18% in the intervention cohort vs. 35% in the control cohort (adjusted Hazard Ratio, 0.48, 95% CI 0.24-0.97; P = 0.041). Compared to historical controls, intervention participants maintained higher rates of medication use and clinic attendance at both 3- and 6-months but not at 12 months. Of intervention participants who survived and remained in follow-up, >90% reported good medication adherence at all follow-up time points.

CONCLUSION

Our findings support the hypothesis that a peer counselor intervention may improve health outcomes among adults living with hypertensive urgency. A randomized clinical trial is needed to evaluate the intervention's effectiveness.

Management of acute severe hypertension in youth: from the philosophical to the practical

PURPOSE OF REVIEW

Acute severe hypertension remains an uncommon but important source of morbidity and mortality in youth. However, there has been very little progress made in our understanding of how to best manage youth with acute severe hypertension to improve patient outcomes.

RECENT FINDINGS

Our understanding of what is acute severe hypertension is undergoing a philosophical change. Management of patients with acute severe hypertension is evolving towards more of a risk and outcomes-based approach.

SUMMARY

We should be intentional when we consider whether a patient has acute severe hypertension and if they are truly at an increased risk for life-threatening target organ injury. We should consider their specific risk factors to best interpret the risks and benefits of how best to treat a patient with acute severe hypertension, rather than relying on traditional approaches and conventional wisdom. We should always ask 'why' when we are pursuing a given management course. Future studies should clearly define the research questions they are investigating to best advance the field to ultimately improve patient outcomes.

Hypertensive Urgency and Anterior Epistaxis Caused by Antihypertensive Medication Noncompliance: A Case Report

Background and Aims

A sudden increase in blood pressure without serious, life-threatening symptoms or indications of immediate target organ damage is referred to as "hypertensive urgency." This case study revealed the rare direct cause of epistaxis and the direct cause of hypertensive urgency in an elderly man due to antihypertensive medication noncompliance.

Case Presentation

A black male farmer, age 63, was brought to the emergency room on June 1st, 2022, with chief complaints of breathing difficulties, epistaxis, and disorientation. The patient was hospitalized after exhibiting symptoms of breathlessness, malaise, nausea, and vomiting. Magnetic resonance imaging, an echocardiogram, and a computed tomography scan of the brain are all clear. For the treatment of epistaxis, he received 1g of tranexamic acid intravenously three times a day for two days. He received intravenous labetalol, which was effective in treating his hypertensive urgency and rebound hypertension, utilizing repeated dosages of 5-20 mg. The patient's intravenous labetalol and previous enalapril were switched to captopril 25 mg orally three times a day for one month after starting drugs per os.

Discussion

The patient's hypertensive urgency is directly caused by forgetting to take his blood pressure medication and by not adhering to his previous antihypertensive drugs as prescribed. In this study, the patient's hypertension had been uncontrolled for the previous six months despite his treatment plan. Unaware that he had missed two doses of his antihypertensive medication, he was admitted to the emergency room with progressive anterior nose bleeding that persisted for four hours. The patient's elevated arterial blood pressure is what's causing the patient's nose to bleed.

Clinical Profile of Patients with Hypertensive Emergency Referred to a Tertiary Hospital in the Western Cape Province of South Africa

BACKGROUND

Despite advances in managing hypertension, hypertensive emergencies remain a common indication for emergency room visits. Our study aimed to determine the clinical profile of patients referred with hypertensive emergencies.

METHODS

We conducted an observational study involving patients aged ≥18 years referred with hypertensive crisis. A diagnosis of hypertensive emergencies was based on a systolic blood pressure (BP) ≥180 mmHg and/or a diastolic BP ≥110 mmHg, with acute hypertension-mediated organ damage (aHMOD). Patients without evidence of aHMOD were considered hypertensive urgencies. Hypertensive disorders of pregnancy and unconscious patients were excluded from the study.

RESULTS

Eighty-two patients were included, comprising 66 (80.5%) with hypertensive emergencies and 16 (19.5%) with hypertensive urgencies. The mean age of patients with hypertensive emergencies was 47.9 (13.2) years, and 66.7% were males. Age, systolic BP, and duration of hypertension were similar in the hypertensive crisis cohort. Most patients with hypertensive emergencies reported nonadherence to medication (78%) or presented de novo without a prior diagnosis of hypertension (36%). Cardiac aHMOD (acute pulmonary edema and myocardial infarction) occurred in 66%, while neurological emergencies (intracranial hemorrhage, ischemic stroke, and hypertensive encephalopathy) occurred in 33.3%. Lactate dehydrogenase (LDH) (P < 0.001), NT-proBNP (P=0.024), and cardiac troponin (P<0.001) were higher in hypertensive emergencies compared to urgencies. LDH did not differ in the subtypes of hypertensive emergencies.

CONCLUSION

Cardiovascular and neurological emergencies are the most common hypertensive emergencies. Most patients reported nonadherence to medication or presented de novo without a prior diagnosis of hypertension.

The Management of Hypertensive Emergencies-Is There a "Magical" Prescription for All?

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.

Differences in Diagnosis and Management of Hypertensive Urgencies and Emergencies According to Italian Doctors from Different Departments Who Deal With Acute Increase in Blood Pressure-Data from Gear (Gestione Dell'emergenza e Urgenza in ARea Critica) Study

Background: Diagnosis and treatment of hypertension emergency (HE) and urgency (HU) may vary according to the physicians involved and the setting of the treatment. The aim of this study was to investigate differences in management of HE and HU according to the work setting of the physicians. Methods: The young investigators of the Italian Society of Hypertension developed a 23-item questionnaire spread by email invitation to the members of Italian Scientific societies involved in the field of emergency medicine and hypertension. Results: Six-hundred and sixty-five questionnaires were collected. No differences emerged for the correct definitions of HE and HU or for the investigation of possible drugs that may be responsible for an acute increase in BP. The techniques used to assess BP values (p < 0.004) and the sizes of cuffs available were different according to the setting. Cardiologists more frequently defined epistaxis (55.2% p = 0.012) and conjunctival hemorrhages (70.7%, p < 0.0001) as possible presentation of HE, and rarely considered dyspnea (67.2% p = 0.014) or chest pain (72.4%, p = 0.001). Intensive care (IC) unit doctors were more familiar with lung ultrasound (50% p = 0.004). With regard to therapy, cardiologists reported the lowest prescription of i.v. labetalol (39.6%, p = 0.003) and the highest of s.l. nifedipine (43.1% p < 0.001). After discharge, almost all categories of physicians required home BP assessment or referral to a general practitioner, whereas hypertensive center evaluation or ambulatory BP monitoring were less frequently suggested. Conclusion: Management and treatment of HE and HU may be different according to the doctor’s specialty. Educational initiatives should be done to standardize treatment protocols and to improve medical knowledge.

Clinical Characteristics and Predictors of All-Cause Mortality in Patients with Hypertensive Urgency at an Emergency Department

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.

[Hypertensive urgencies and emergencies in pediatric patients]

Hypertensive crisis is a sudden rise in blood pressure that is significantly above normal values. Depending on the severity of symptoms, hypertensive crisis can be classified as hypertensive urgency, i.e. severe arterial hypertension (AH) without organ failure and damage with nonspecific symptoms (pain, dizziness, nosebleeds, nausea, vomiting), and hypertensive emergency, i.e. severe AH with organ failure and/or acute organ damage. The most common causes of hypertensive crisis in neonates and infants are vascular diseases (thrombus or stenosis of the renal artery, coarctation of the aorta) or renal parenchymal diseases, in older children kidney diseases and renal artery stenosis, in adolescents also intoxications or pregnancy. In neonates and infants, nonspecific symptoms caused by acute heart failure predominate, and in older children, symptoms from the central nervous system are most typical. Fast- and short-acting medications are used in the treatment of hypertensive urgencies and emergencies; a gradual normalization of blood pressure within 36-48 hours is recommended. Hypertensive emergencies are treated with intravenous drugs (e.g., labetalol, hydralazine), and hypertensive urgencies with intravenous or oral drugs such as nifedipine, clonidine, and minoxidil. Hypertensive emergencies are treated with intravenous drugs (e.g., labetalol, hydralazine), and hypertensive urgencies with intravenous or oral drugs such as nifedipine, clonidine, and minoxidil. Emergency conditions are treated with intravenous drugs (e.g., labetalol, hydralazine), urgent conditions with intravenous or oral drugs such as nifedipine, clonidine, and minoxidil. Some causes of hypertensive crisis require different management, e.g. alpha-blockers in pheochromocytoma. In all patients, evaluation of target organ damage and extensive diagnostics for secondary forms of hypertension is necessary.

Hypertensive Urgency: An Emergency Department Pipeline to Primary Care Pilot Study

BACKGROUND

Optimal triage of patients with hypertensive urgency (HU) in the emergency department (ED) is not well established. 2017 ACC/AHA hypertension (HTN) guidelines recommend treatment initiation and follow-up within 1 week. Objectives of our pilot study were to evaluate feasibility and impact of directly connecting ED patients with HU to outpatient HTN management on blood pressure (BP) control and ED utilization.

METHODS

ED patients with HU and no primary care physician were scheduled by a referral coordinator for an initial appointment in a HTN clinic embedded within a primary care practice. BP control and ED utilization over the subsequent 90 days were tracked and compared with BP at time of the referral ED visit, and ED utilization in the 90 days preceding referral.

RESULTS

Data are reported for the first 40 referred patients. Average time to first visit was 7.8 days. Mean age was 51 years (range 28-76), 75% were African-American, and mean pooled 10-year atherosclerotic cardiovascular disease (ASCVD) risk was 20.8%. Mean BP declined from 198/116 mm Hg at ED visit to 167/98 mm Hg at HTN clinic visit 1 to 136/83 by 6 weeks and was sustained at 90 days. Total ED visits for the group decreased from 61 in the 90 days prior to referral, to 18 in the 90 days after the first HTN clinic visit.

CONCLUSIONS

In this pilot study, coordinated referral between the ED and primary care provides safe, timely care for this high ASCVD risk population and leads to sustained reductions in BP and ED utilization.

Use of paediatric xylometazoline nasal drop is not a child's play in hypertensive patients on bisoprolol: A case report

Xylometazoline, a sympathomimetic agent, is considered safe in hypertensive patients as a relief measure for nasal congestion with intranasal application. In the present case, a 58-year old male patient, having ischemic heart disease, controlled hypertension on telmisartan and bisoprolol, experienced hypertensive urgency in a span of two hours of intranasal administration of the paediatric formulation of xylometazoline. The interaction with bisoprolol should be kept in mind while using xylometazoline.

Hypertensive Urgency in Tanzanian Adults: A 1-Year Prospective Study

BACKGROUND

Hypertensive urgency is associated with a high risk for cardiovascular events and mortality in the United States and Europe, but data from low-income countries and interventions to improve outcomes are lacking.

METHODS

We conducted a 1-year prospective study of the prevalence and outcomes of hypertensive urgency (blood pressure (BP) ≥180 mm Hg/120 mm Hg without end-organ damage) in a busy outpatient clinic in Tanzania.

RESULTS

Of 7,600 consecutive adult outpatients screened with 3 unattended automated BP measurements according to standard protocol, the prevalence of hypertensive crisis was 199/7,600 (2.6%) (BP ≥180 mm Hg/120 mm Hg) and the prevalence of hypertensive urgency was 164/7,600 (2.2%). Among 150 enrolled patients with hypertensive urgency, median age was 62 years (54-68), 101 (67.3%) were women, and 53 (35%) were either hospitalized or died within 1 year. In a multivariate model, the strongest predictor of hospitalization/death was self-reported medication adherence on a 3 question scale (hazard ratio: 0.06, P < 0.001); 90% of participants with poor adherence were hospitalized or died within 1 year.

CONCLUSIONS

Patients with hypertensive urgency in Africa are at high risk of poor outcomes. Clinicians can identify the patients at highest risk for poor outcomes with simple questions related treatment adherence. New interventions are needed to improve medication adherence in patients with hypertensive urgency.

Prevalence of Hypertensive Emergency and Associated Factors Among Hospitalized Patients with Hypertensive Crisis: A Retrospective Cross-Sectional Study

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.

Duloxetine-induced hypertensive urgency in type 2 diabetes mellitus with diabetic neuropathy

We present a case of hypertensive urgency in a diabetic patient with painful diabetic neuropathy on duloxetine treatment. The patient's blood pressure was high after taking 1-day dose of duloxetine and the patient was diagnosed with hypertensive urgency. The patient was managed with labetalol, leading to reduction in blood pressure. The patient's medication was switched to telmisartan and metoprolol, which leads to resolution of increased blood pressure. This case report is a possible case of hypertensive urgency after the initiation of duloxetine managed with antihypertensives and resolves with the discontinuation of the duloxetine.

Clinical Determinants of Myocardial Injury, Detectable and Serial Troponin Levels among Patients with Hypertensive Crisis

Introduction

There is a high prevalence of hypertensive crisis with myocardial injury, as evidenced by elevation in cardiac troponin levels. The risk factors predisposing patients to developing a myocardial injury, detectable troponin, and increase in serial troponin in this population are not known.

Methods

A retrospective study was designed to include all patients, presenting to the emergency room, diagnosed with hypertensive crisis, using International Classification of Diseases, 10^th revision, Clinical Modification (ICD-10-CM) codes between 2016-2018 (n=467). Logistic regression was used to determine the important predictors of myocardial injury evidenced by troponin elevation >99^th percentile of upper reference level (URL), detectable troponin (> 0.015 ng/ml), and increase in serial troponin levels.

Results

The 99^th percentile of the initial troponin level among all patients was 0.433 ng/ml. A total of 15% had a myocardial injury, and the significant risk factors associated with it were body mass index (BMI) < 30 kg/m2 (odds ratio [OR] 0.50, confidence interval [CI] 0.28-0.89), congestive heart failure (CHF; OR 4.28, CI 2.21-8.25) and prior use of aspirin (OR 1.98, CI 1.08-3.63). About 35% had detectable troponin, and BMI < 30 kg/m² (OR 0.62, CI 0.40-0.97), CHF (OR 3.49, CI 2.06-5.9), elevated creatinine (OR 1.17, CI 1.02-1.34) and age <61 years (OR 0.59, CI 0.38-0.94) were associated with it. The factors associated with an increase in serial troponin were BMI < 30 Kg/m2 (OR 0.56, CI 0.36-0.87), CHF (OR 1.78, CI 1.06-3.0), coronary artery disease (CAD; OR 2.08, CI 1.28-3.36) and non-Caucasian race (OR 0.52, CI 0.29-0.93).

Conclusion

About one-third of patients with the hypertensive crisis have detectable troponin. Still, among these, less than half have troponin levels >99^th percentile URL, and the majority of these patients have minimal changes in serial troponin. Low BMI was associated with higher initial and serial troponin levels, and this obesity paradox was stronger among females and older patients.

Hypertensive Crisis in Pediatric Patients: An Overview

Hypertensive crisis can be a source of morbidity and mortality in the pediatric population. While the epidemiology has been difficult to pinpoint, it is well-known that secondary causes of pediatric hypertension contribute to a greater incidence of hypertensive crisis in pediatrics. Hypertensive crisis may manifest with non-specific symptoms as well as distinct and acute symptoms in the presence of end-organ damage. Hypertensive emergency, the form of hypertensive crisis with end-organ damage, may present with more severe symptoms and lead to permanent organ damage. Thus, it is crucial to evaluate any pediatric patient suspected of hypertensive emergency with a thorough workup while acutely treating the elevated blood pressure in a gradual manner. Management of hypertensive crisis is chosen based on the presence of end-organ damage and can range from fast-acting intravenous medication to oral medication for less severe cases. Treatment of such demands a careful balance between decreasing blood pressure in a gradual manner while preventing damage end-organ damage. In special situations, protocols have been established for treatment of hypertensive crisis, such as in the presence of endocrinologic neoplasms, monogenic causes of hypertension, renal diseases, and cardiac disease. With the advent of telehealth, clinicians are further able to extend their reach of care to emergency settings and aid emergency medical service (EMS) providers in real time. In addition, further updates on the evolving topic of hypertension in the pediatric population and novel drug development continues to improve outcomes and efficiency in diagnosis and management of hypertension and consequent hypertensive crisis.

Hypertensive Urgency: An Undesirable Complication of a "Male Performance" Herbal Product

BACKGROUND

Hypertensive urgency is a clinical scenario that may be associated with herbal supplement use and that requires special consideration with regard to emergency department management.

CASE REPORT

A 49-year-old man presented to the emergency department with palpitations and severely elevated blood pressure without evidence of end organ dysfunction. Hypertension failed to be controlled with multiple doses of oral clonidine and intravenous labetalol. The patient later admitted to using an herbal supplement containing yohimbine, a selective ⍺2-adrenoreceptor antagonist specifically linked to cases of refractory hypertension. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Between 17-35% of the U.S. adult population may use herbal supplements on a sporadic or regular basis; pharmacologically active agents in herbal supplements may affect both a patient's presentation and response to treatment. Most patients do not mention over-the-counter and herbal products in their medication profile unless specifically asked, and therefore it is important for emergency physicians to be aware of the pharmacologic effects of herbal supplements in the evaluation and treatment of refractory severe hypertension.

Prevalence and risk factors for hypertensive crisis in a predominantly African American inner-city community

PURPOSE

A 3-year case control study was conducted to determine the prevalence of hypertensive crisis and its subtypes, hypertensive emergency and hypertensive urgency. The secondary objectives were to identify risk factors for hypertensive emergencies and to determine the odds of developing acute target organ damage among predominantly African American patients with a confirmed diagnosis of hypertension.

MATERIALS AND METHODS

Using emergency department medical records, patients with a confirmed diagnosis of hypertension were identified. From the pool of hypertensive patients, cases and controls were selected and matched 1:1 for age, gender and race. Cases were hypertensive patients with hypertensive crisis, defined as BP ≥ 200/120 mmHg. Controls had a diagnosis of hypertension and BP < 200/120 mmHg. Cases and controls, as well as cases with hypertensive emergencies and hypertensive urgencies were compared based on important demographic and clinical variables.

RESULTS

Almost 90% of study population were African Americans. The prevalence of hypertensive crisis was 11.4% and hypertensive emergencies was 3.2%. Hypertensive emergencies accounted for 28% of patients with crisis. The predictors for hypertensive emergencies were older age (p = .002), male gender (p < .007), anemia (p < .0001), history of coronary artery disease (p < .001), congestive heart failure (p < .001) and chronic renal insufficiency (p < .001). Having healthcare insurance and access to medical care did not reduce the odds of developing hypertensive emergencies. Race was not a significant risk factor in the progression from hypertensive crisis to hypertensive emergencies (p = .47).

CONCLUSIONS

The study highlights the high prevalence of hypertensive crisis and hypertensive emergencies in the predominantly African American urban population, which is 5 times the United States average. However, race is not a predictor of development of hypertensive emergencies and acute target organ damage in patients with already severely elevated blood pressure.

Hypertensive emergencies in diabetic patients from predominantly African American urban communities

Aim: The aim of this study was to identify risk factors for hypertensive emergencies in diabetic patients presenting with severely elevated blood pressure. Methods: Using electronic medical records, this study identified diabetic patients with hypertensive crisis who presented to the emergency department of Newark Beth Israel Medical Center, Newark, NJ from June 2013 to May 2016. Diabetic patients with hypertensive emergencies were compared with non-diabetic patients based on important demographic and clinical characteristics. Results: Patients with diabetes accounted for 52.27% of all hypertensive emergencies during the study period. There were 264 diabetic patients with hypertensive emergencies and 519 diabetic patients with hypertensive urgencies. The majority of patients were African Americans (88.6%). The odds of hypertensive emergencies were strikingly higher in diabetic patients with hyperlipidemia (OR 1.66, 95% CI 1.23-2.24), coronary artery disease (OR 2.95, 95% CI 2.15-4.05), congestive heart failure (OR 6.28, 95% CI 4.49-8.80), renal insufficiency (OR 2.84, 95% CI 2.10-3.86) and low hemoglobin (OR 0.9, 95% CI 0.84-0.97). Acute or worsening heart failure was the most frequent acute target organ injury (49.6%) followed by non-ST elevation myocardial infarction (41.7%). Diabetic and non-diabetic patients had similar rates of target organ injuries. Conclusion: The development of hypertensive emergencies in patients with diabetes was not because of diabetes per se but because of coexisting highly elevated blood pressure. Tight blood pressure control may decrease the risk of hypertensive emergencies in this patient population.

A Case of Recurrent Thrombotic Microangiopathy Caused by Hypertensive Urgency

A 26-year-old man presented to the emergency room with abdominal pain, nausea, and vomiting for four days. His medical history was significant for hypertension and end-stage renal disease managed with hemodialysis. He had been noncompliant with the antihypertensive regimen which included nifedipine, hydralazine, and spironolactone. At presentation, his blood pressure was 231/123 mmHg. Laboratory workup showed white blood count 17.3 × 109/L (normal range: 4.5 to 11.0 × 109/L), hemoglobin 7.8 gm/dL (normal range: 13.5 to 17.5 g/dL), platelet count 46 × 109/L (normal range: 150 to 400 × 109/L), reticulocyte count 7.8%, total bilirubin 1 mg/dL (normal range: 0.1 to 1.2 mg/dL), lactate dehydrogenase 1,235 U/L (normal range: 140 to 280 U/L), haptoglobin < 10 mg/dL, and a direct Coomb's test was negative. Numerous schistocytes were identified on the peripheral blood smear. The patient was diagnosed with thrombotic microangiopathy secondary to severe hypertension and was started on intravenous nicardipine. With appropriate blood pressure control, hematological parameters improved with normalization of the platelet count within 10 days. Notably, the patient had one similar episode of hypertension-induced thrombotic microangiopathy within a period of the last three months and ADAMTS-13 (a disintegrin and metalloprotease with thrombospondin type 1 motif 13) activity was normal on his previous admission.

Brain metastasis in colorectal cancer presenting as refractory hypertension

Background: Brain metastasis (BM) from colorectal cancer (CRC) is rare with the incidence ranging from 0.6% to 3.2%. There is also an increased incidence of BM with rectal primaries and is consistent with this patient’s presentation. Overall, there is scarce literature on the symptoms of patients who present with CRC BMs.

Objectives: We present a case of brain metastasis in colorectal cancer presenting with hypertensive urgency and severe headache.

Methods and results: This case highlights that neurological deficits are not necessary for BMs in patients with CRC and summarizes and reviews the associated literature regarding BM in CRC. A 57-year-old female with a past medical history of recently diagnosed stage IV moderately differentiated distal rectal adenocarcinoma with liver and lung metastasis was admitted with the primary complaint of hypertensive urgency, severe headache, intractable nausea and vomiting, and diarrhea. Magnetic resonance imaging brain showed a left cerebellar lesion measuring 3.6 × 3.2 × 2.9 cm, ipsilateral transtentorial herniation, and obliteration of the fourth ventricle. The patient was started on steroids and transferred for an urgent neurosurgical intervention to a tertiary care center.

Conclusions: Even though BMs are rare in CRC, clinicians should have a high index of suspicion with complaints like hypertensive urgency, headache, nausea, vomiting, vertigo, and blurring of vision triggering imaging studies to rule out BM. The approach to BM has become increasingly individualized as surgical and radiosurgical therapies have continued to evolve

Abbreviations: CRC: Colorectal cancer; BM: Brain metastasis; FOLFOX: Folinic acid, fluorouracil and oxaliplatin; CT: Computed tomography; IV: Intravenous; PO: By mouth; BAER: Brain auditory evoked response hearing testing; SSEP’s: Somatosensory evoked potentials; BMFI: Brain metastasis free interval; WBRT: Whole-brain radiation therapy; SRS: Stereotactic radiosurgery.

Pharmacologic Treatment of Hypertensive Urgency in the Outpatient Setting: A Systematic Review

BACKGROUND

Hypertensive urgency (HU), defined as acute severe uncontrolled hypertension without end-organ damage, is a common condition. Despite its association with long-term morbidity and mortality, guidance regarding immediate management is sparse. Our objective was to summarize the evidence examining the effects of antihypertensive medications to treat.

METHODS

We searched the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Cochrane Database of Systematic Reviews, Web of Science, Google Scholar, and Embase through May 2016.

STUDY SELECTION

We evaluated prospective controlled clinical trials, case-control studies, and cohort studies of HU in emergency room (ER) or clinic settings. We initially identified 11,223 published articles. We reviewed 10,748 titles and abstracts and identified 538 eligible articles. We assessed the full text for eligibility and included 31 articles written in English that were clinical trials or cohort studies and provided blood pressure data within 48 h of treatment. Studies were appraised for risk of bias using components recommended by the Cochrane Collaboration. The main outcome measured was blood pressure change with antihypertensive medications. Since studies were too diverse both clinically and methodologically to combine in a meta-analysis, tabular data and a narrative synthesis of studies are presented.

RESULTS

We identified only 20 double-blind randomized controlled trials and 12 cohort studies, with 262 participants in prospective controlled trials. However, we could not pool the results of studies. In addition, comorbidities and their potential contribution to long-term treatment of these subjects were not adequately addressed in any of the reviewed studies.

CONCLUSIONS

Longitudinal studies are still needed to determine how best to lower blood pressure in patients with HU. Longer-term management of individuals who have experienced HU continues to be an area requiring further study, especially as applicable to care from the generalist.

Effects of acute blood pressure elevation on biochemical-metabolic parameters in individuals with hypertensive crisis

Hypertensive crisis is a common clinical situation that presents a high rate of morbidity and mortality and it is characterized by symptomatic rise of blood pressure (BP), systolic (SBP) ≥ 180 mmHg and/or diastolic (DBP) ≥ 120 mmHg. It is classified as emergency (HE) or hypertensive urgency (HU). There is no description of laboratory findings in patients who present acute BP elevation. Thus, this study had the objective to assess the biochemical-metabolic parameters of patients with HC. We studied 74 normotensive individuals (NT), 74 controlled hypertensive patients (ContrHT), 50 subjects with HU, and 78 with HE for evaluating biochemical-metabolic parameters. HE occurs in older individuals and more frequently in those with known hypertension. More patients with HE had dyslipidemia than those with HU (58% vs. 38%). The diastolic BP and heart rate were higher in the HE group (120 mmHg and 87 bpm) compared to ContrHT (71 mmHg and 71 bpm; p < 0.0001) and NT groups (75 mmHg and 68 bpm; p < 0.0001). Glycemia was higher in HE vs. NT and ContrHT (p < 0.05). HDL cholesterol was lower in HE than NT (p = 0.0088). Potassium was lower in HE vs. NT, ContrHT and HU groups (p < 0.05). Creatinine was higher in the HC group vs. NT and ContrHT (p < 0.05). The GFR was significantly lower in HE group vs. HU, ContrHT and NT (p < 0.001). In conclusion, individuals with HC show biochemical alterations when compared to ContrHT and NT. Acute BP elevations are associated with hyperglycemia, dyslipidemia, and higher potassium and creatinine levels and lower renal function. Abbreviations BMI = body mass index BP = blood pressure CH = hypertensive crisis ContrHT = controlled hypertensive DBP = diastolic blood pressure GFR = glomerular filtration rate HbA1c = glycated hemoglobin HDLc = high-density lipoprotein cholesterol HE = hypertensive emergency HPLC = high-performance liquid chromatography HR = heart rate HU = hypertensive urgency JNC 7 = VII Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure LDLc = low-density lipoprotein cholesterol MDRD = Modification of Diet in Renal Disease NT = normotensive RASB = renin-angiotensin system blockers SBP = systolic blood pressure TC = total cholesterol TG = triglycerides.

Blood pressure management and guideline adherence in hypertensive emergencies and urgencies: A comparison between telemedically supported and conventional out-of-hospital care

Prehospital hypertensive emergencies and urgencies are common, but evidence is lacking. Telemedically supported hypertensive emergencies and urgencies were prospectively collected (April 2014-March 2015) and compared retrospectively with a historical control group of on-scene physician care in the emergency medical service of Aachen, Germany. Blood pressure management and guideline adherence were evaluated. Telemedical (n=159) vs conventional (n=172) cases: blood pressure reductions of 35±24 mm Hg vs 44±23 mm Hg revealed a group effect adjusted for baseline differences (P=.0006). Blood pressure management in categories: no reduction 6 vs 0 (P=.0121); reduction ≤25% (recommended range) 113 vs 110 patients (P=.2356); reduction >25% to 30% 13 vs 29 (0.020); reduction >30% 12 vs 16 patients (P=.5608). The telemedical approach led to less pronounced blood pressure reductions and a tendency to improved guideline adherence. Telemedically guided antihypertensive care may be an alternative to conventional care especially for potentially underserved areas.

Trends in the Incidence of Hypertensive Emergencies in US Emergency Departments From 2006 to 2013

Background

The incidence of hypertensive emergency in US emergency departments (ED) is not well established.

Methods and Results

This study is a descriptive epidemiological analysis of nationally representative ED visit‐level data from the Nationwide Emergency Department Sample for 2006–2013. Nationwide Emergency Department Sample is a publicly available database maintained by the Healthcare Cost and Utilization Project. An ED visit was considered to be a hypertensive emergency if it met all the following criteria: diagnosis of acute hypertension, at least 1 diagnosis indicating acute target organ damage, and qualifying disposition (admission to the hospital, death, or transfer to another facility). The incidence of adult ED visits for acute hypertension increased monotonically in the period from 2006 through 2013, from 170 340 (1820 per million adult ED visits overall) to 496 894 (4610 per million). Hypertensive emergency was rare overall, accounting for 63 406 visits (677 per million adult ED visits overall) in 2006 to 176 769 visits (1670 per million) in 2013. Among adult ED visits that had any diagnosis of hypertension, hypertensive emergency accounted for 3309 per million in 2006 and 6178 per million in 2013.

Conclusions

The estimated number of visits for hypertensive emergency and the rate per million adult ED visits has more than doubled from 2006 to 2013. However, hypertensive emergencies are rare overall, occurring in about 2 in 1000 adult ED visits overall, and 6 in 1000 adult ED visits carrying any diagnosis of hypertension in 2013. This figure is far lower than what has been sometimes cited in previous literature.

Evaluation and treatment of hypertensive crises in children

Hypertensive crises in children are medical emergencies that must be identified, evaluated, and treated promptly and appropriately to prevent end-organ injury and even death. Treatment in the acute setting typically includes continuous intravenous antihypertensive medications with monitoring in the intensive care unit setting. Medications commonly used to treat severe hypertension have been poorly studied in children. Dosing guidelines are available, although few pediatric-specific trials have been conducted to facilitate evidence-based therapy. Regardless of what medication is used, blood pressure should be lowered gradually to allow for accommodation of autoregulatory mechanisms and to prevent cerebral ischemia. Determining the underlying cause of the blood pressure elevation may be helpful in guiding therapy.

Therapy of acute hypertension in hospitalized children and adolescents

Acute hypertension (HTN) in hospitalized children and adolescents occurs relatively frequently, and in some cases, if not recognized and treated promptly, it can lead to hypertensive crisis with potentially significant morbidity and mortality. In contrast to adults, where acute HTN is most likely due to uncontrolled primary HTN, children and adolescents with acute HTN are more likely to have secondary HTN. This review will briefly cover evaluation of acute HTN and various age-specific etiologies of secondary HTN and provide more in-depth discussion on treatment targets, potential risks of acute HTN therapy, and available pediatric data on intravenous and oral antihypertensive agents, and it proposes treatment schema including unique therapy of specific secondary HTN scenarios.

Evaluation and management of pediatric hypertensive crises: hypertensive urgency and hypertensive emergencies

Hypertension (HTN) in the pediatric population is estimated to have a world-wide prevalence of 2%–5%. As with adults, pediatric patients with HTN can present with hypertensive crises include hypertensive urgency and hypertensive emergencies. However, pediatric blood pressure problems have a greater chance of being from secondary causes of HTN, as opposed to primary HTN, than in adults. Thorough evaluation of a child with a hypertensive emergency includes accurate blood pressure readings, complete and focused symptom history, and appropriate past medical, surgical, and family history. Physical exam should include height, weight, four-limb blood pressures, a general overall examination and especially detailed cardiovascular and neurological examinations, including fundoscopic examination. Initial work-up should typically include electrocardiography, chest X-ray, serum chemistries, complete blood count, and urinalysis. Initial management of hypertensive emergencies generally includes the use of intravenous or oral antihypertensive medications, as well as appropriate, typically outpatient, follow-up. Emergency department goals for hypertensive crises are to (1) safely lower blood pressure, and (2) treat/minimize acute end organ damage, while (3) identifying underlying etiology. Intravenous antihypertensive medications are the treatment modality of choice for hypertensive emergencies with the goal of reducing systolic blood pressure by 25% of the original value over an 8-hour period.

Pulsed and Tissue Doppler Echocardiographic Changes in Hypertensive Crisis with and without End Organ Damage

Background

Hypertensive crisis (HC) is a common medical emergency associated with acute rise in arterial blood pressure that leads to end-organ damage (EOD). Therefore, it is imperative to find markers that may help in the prediction of EOD in acute hypertensive crisis.

Aim

To assess the clinical presentations on admission; echocardiographic changes of pulsed and tissue Doppler changes in EOD patients compared with no EOD; and the risk of developing end organ damage for clinical and biochemical variables in hypertension crisis.

Material and Methods

The data of 241 patients with hypertensive crisis with systolic blood pressure (SBP) of >180 mmHg or diastolic blood pressure (DBP) >120 mmHg were extracted from patients files. Patients divided into hypertensive emergency (HE) with EOD, n = 62 and hypertensive urgency (HU) without EOD, n = 179. LV hypertrophy on ECG, echo parameters for wall thickness, left Ventricular mass index (LVMI), Body mass index (BMI), pulse Doppler ratio of early filling velocity E wave to late A wave (E/A) and ratio of E wave velocity to tissue Doppler Em to E wave (E/Em) were evaluated. Serum creatinine, hemoglobin, age, gender, body mass Index (BMI), history of diabetes mellitus, smoking, hypertension, stroke and hyperlipidemia were recorded. Multiple logistic regression analysis was applied for risk prediction of end organ damage of clinical variables.

Results

Patients with HE compared with HU were significantly older, with a significantly higher SBP on admission, high BMI and LVMI. Further there were significantly higher E/A ratio on Doppler echo and higher E/Em ratio on tissue Doppler echocardiogram. Multiple regression analysis with adjustment for age and sex shows positive predictive value with odds ratio of SBP on admission >220 mmHg of 1.98, serum creatinine > 120 µg/L of 1.43, older age > 60 year of 1.304, obesity (BMI ≥ 30) of 1.9, male gender of 2.26 and left ventricle hypertrophy on ECG of 1.92. The hemoglobin level, history of smoking, hyperlipidemia and DM were with no significant predictive value. The pulsed Doppler E/A ratio was ≥1.6, E/Em > 15, LVMI > 125 gm/m² in patients with EOD compared with those without.

Conclusion

In patients presented with hypertensive crisis, the echo indices of E/A ratio and E/Em ratio of tissue Doppler are significantly higher in patients with hypertensive emergency compared to hypertensive urgency. The left ventricle hypertrophy on ECG, high LV mass index of >125 gm/m², BMI > 30, old age > 60 year, male gender and history of hypertension and stroke were positive predictors of poor outcome and end organ damage.

Role of clevidipine butyrate in the treatment of acute hypertension in the critical care setting: a review

Acutely elevated blood pressure in the critical care setting is associated with a higher risk of acute end-organ damage (eg, myocardial ischemia, stroke, and renal failure) and perioperative bleeding. Urgent treatment and careful blood pressure control are crucial to prevent significant morbidity. Clevidipine butyrate (Cleviprex) is an ultrashort-acting, third-generation intravenous calcium channel blocker. It is an arterial-selective vasodilator with no venodilatory or myocardial depressive effects. Clevidipine has an extremely short half-life of approximately 1 minute as it is rapidly metabolized by blood and tissue esterases. These metabolites are then primarily eliminated through urine and fecal pathways. The rapid onset and the short duration of action permit tighter and closer adjustment of the blood pressure than is possible with other intravenous agents.

Parenteral clevidipine for the acute control of blood pressure in the critically ill patient: a review

Clevidipine is a new calcium channel blocker of the dihydropyridine class that is characterized by its ultra-short onset of action, vascular selectivity, small volume of distribution and extremely high clearance that coupled together result in an extremely short half-life of approximately 1 minute therefore permitting a rapid titration to the desired effect. Structurally similar to other dihydropyridines, clevidipine has an extra ester link that allows its rapid hydrolization to its inactive carboxylic acid metabolite in blood and extravascular tissues. Clevidipine’s metabolites are then primarily eliminated through urine and fecal pathways. Clevidipine does not affect cytochrome P450 (CYP) enzymes and no clinically significant drug interactions have been determined. In trials like the ESCAPE trials, ECLIPSE, and VELOCITY, clevidipine demonstrated a significant improvement in the management of acute hypertension when compared to placebo as shown in both ESCAPE trials. The ECLIPSE trial compared clevidipine to other drugs currently used in the management of acute hypertension, such as sodium nitroprusside, nitroglycerine and nicardipine; clevidipine was superior to all three agents; in providing blood pressure support, safety and tolerability clevidipine also showed a significant reduction in mortality rate (4.7% vs 1.7%, P =0.0445) when compared to sodium nitroprusside. In the VELOCITY trial clevidipine demonstrated a reduction in blood pressure of 6% at the 3 minute mark, 15% within 9.5 minutes and 27% at the 18 hour mark.

Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature

BACKGROUND

Hypertensive urgencies and emergencies are common clinical occurrences in hypertensive patients. Treatment practices vary considerably to because of the lack of evidence supporting the use of one therapeutic agent over another. This paper was designed to review the evidence for various pharmacotherapeutic regimens in the management of hypertensive urgencies and emergencies, in terms of the agents' abilities to reach predetermined "safe" goal blood pressures (BPs), and to prevent adverse events.

METHODS

medline was searched from 1966 to 2001, and the reference lists of all the articles were retrieved and searched for relevant references, and experts in the field were contacted to identify other relevant studies. The Cochrane Library was also searched. Studies that were eligible for inclusion in this review were systematic reviews of randomized control trials (RCTs) and individual RCTs, all-or-none studies, systematic reviews of cohort studies and individual cohort studies, and outcomes research. No language restrictions were used.

RESULTS

None of the trials included in this review identified an optimal rate of BP lowering in hypertensive emergencies and urgencies. The definitions of hypertensive emergencies and urgencies were not consistent, but emergencies always involved target end-organ damage, and urgencies were without such damage. Measures of outcome were not uniform between studies. The 4 hypertensive emergency and 15 hypertensive urgency studies represented 236 and 1,074 patients, respectively. The evidence indicated a nonsignificant trend toward increased efficacy with urapidil compared to nitroprusside for hypertensive emergencies (number needed to treat [NNT] for urapidil to achieve target BP, 12; 95% confidence interval [95% CI], number of patients needed to harm [NNH], 5 to NNT, 40 compared to nitroprusside). Several medications were efficacious in treating hypertensive urgencies, including: nicardipine (NNT for nicardipine compared to plabebo, 2 in one study [95% CI, 1 to 5] and 1 in another [95% CI, 1 to 1]); lacidipine (NNT, 2; 95% CI, 1 to 8 for lacidipine vs nifedipine) or urapidil (NNT for urapidil compared to enalaprilat and nifedipine, 4; 95% CI, 3 to 6); and nitroprusside and fenoldopam (all patients reached target BP in 2 studies). The studies reported 2 cases of cerebral ischemia secondary to nifedipine.

CONCLUSIONS

Many effective agents exist for the treatment of hypertensive crises. Because of the lack of large randomized controlled trials, many questions remain unanswered, such as follow-up times and whether any of the studied agents have mortality benefit.