Acute Target Organ Damage Research Articles

Abstract P302: Impact of Publication of Hypertension Guidelines on Inappropriate Use of Intravenous (IV) Antihypertensive Medications for Hypertensive Urgencies (HU)

Background: Hypertensive urgencies are common in hospitalized patients. In late 2017 and 2018, the publication of major U.S and European hypertension guidelines included specific recommendations against the use of IV antihypertensive medications for the management of severe acute BP elevations in the absence of acute target organ damage (HU). Aim: To study the impact of the publication of guidelines on local utilization of IV medications for HU. Methods and Results: We analyzed 224,265 non-ICU, non-obstetric, non-pediatric hospital admissions to 5 U.S. hospitals (total 2,681 beds) in a medium-sized U.S. healthcare system between January 2016 and March 2020. These included one large academic medical center with two campuses (Hosp A), one medium sized teaching community hospital (Hosp B), one small teaching community hospital (Hosp C), and two small non-teaching hospitals (Hosp D and E). Among all admitted patients, 22,929 (10.2%) developed HU (SBP>180 or DBP >110 mmHg sustained for at least 1 hour without evidence of acute target organ damage). A total of 2,914 HU patients (12.7%) received at least 1 intravenous medication within 6 hours of acute BP elevation, most commonly hydralazine (N 1473, 50.5%], labetalol (N 749, 25.7%) or metoprolol (N 632, 21.7%). The fraction of patients receiving IV antihypertensives decreased during the five years of the study across the five hospitals, but the absolute change was small (2016=13.7%, 2017=12.8%, 2018=12.5%, 2019=11.4%, 2020=11.7%, P value for overall change = 0.003). The Figure displays temporal trends for each hospital. There was significant heterogeneity across hospitals (P<0.0001). Trends were not related to teaching (vs. nonteaching) status of each hospital. Conclusion: In a medium sized U.S. hospital system, the publication of guidelines recommending against IV antihypertensive use in HU was temporally associated with very modest reductions in IV medication use in HU. Process improvement initiatives are needed to optimize guideline-congruent practice.

Prevention and management of hypertensive crises in children with pheochromocytoma and paraganglioma.

Hypertensive crises in pediatric patients are rare conditions. However, determining their precise prevalence is more challenging than in adults due to the heterogeneity in the definition itself. These crises frequently occur without a prior diagnosis of hypertension and may indicate an underlying cause of secondary hypertension, including pheochromocytoma/paraganglioma (PPGL). The mechanisms of hypertensive crises in the pediatric population with PPGL are directly related to different types of catecholamine excess. Noradrenergic tumors typically present with sustained hypertension due to their predominant action on α1-adrenoceptors in the vasculature. Conversely, adrenergic tumors, through epinephrine binding to β2-adrenoceptors in addition to stimulation of α1- and α2-adrenoceptors, more frequently cause paroxysmal hypertension. Furthermore, the biochemical phenotype also reflects the tumor localization and the presence of a genetic mutation. Recent evidence suggests that more than 80% of PPGL in pediatric cases have a hereditary background. PPGL susceptibility mutations are categorized into three clusters; mutations in cluster 1 are more frequently associated with a noradrenergic phenotype, whereas those in cluster 2 are associated with an adrenergic phenotype. Consequently, the treatment of hypertensive crises in pediatric patients with PPGL, reflecting the underlying pathophysiology, requires first-line therapy with alpha-blockers, potentially in combination with beta-blockers only in the case of tachyarrhythmia after adequate alpha-blockade. The route of administration for treatment depends on the context, such as intraoperative or pre-surgical settings, and whether it presents as a hypertensive emergency (elevated blood pressure with acute target organ damage), where intravenous administration of antihypertensive drugs is mandatory. Conversely, in cases of hypertensive urgency, if children can tolerate oral therapy, intravenous administration may initially be avoided. However, managing these cases is complex and requires careful consideration of the selection and timing of therapy administration, particularly in pediatric patients. Therefore, facing these conditions in tertiary care centers through interdisciplinary collaboration is advisable to optimize therapeutic outcomes.

The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association.

Over the past 3 decades, a substantial body of high-quality evidence has guided the diagnosis and management of elevated blood pressure (BP) in the outpatient setting. In contrast, there is a lack of comparable evidence for guiding the management of elevated BP in the acute care setting, resulting in significant practice variation. Throughout this scientific statement, we use the terms acute care and inpatient to refer to care received in the emergency department and after admission to the hospital. Elevated inpatient BP is common and can manifest either as asymptomatic or with signs of new or worsening target-organ damage, a condition referred to as hypertensive emergency. Hypertensive emergency involves acute target-organ damage and should be treated swiftly, usually with intravenous antihypertensive medications, in a closely monitored setting. However, the risk-benefit ratio of initiating or intensifying antihypertensive medications for asymptomatic elevated inpatient BP is less clear. Despite this ambiguity, clinicians prescribe oral or intravenous antihypertensive medications in approximately one-third of cases of asymptomatic elevated inpatient BP. Recent observational studies have suggested potential harms associated with treating asymptomatic elevated inpatient BP, which brings current practice into question. Despite the ubiquity of elevated inpatient BPs, few position papers, guidelines, or consensus statements have focused on improving BP management in the acute care setting. Therefore, this scientific statement aims to synthesize the available evidence, provide suggestions for best practice based on the available evidence, identify evidence-based gaps in managing elevated inpatient BP (asymptomatic and hypertensive emergency), and highlight areas requiring further research.

Rates of Acute Brain Injury Among Severely Hypertensive Patients Seen in the Emergency Department.

Identifying patients with acute brain injury among patients who present to the Emergency Department (ED) with severe hypertension can be challenging. We explored rates of brain injury in a cohort of ED patients with severe hypertension in whom acute target-organ damage was or was not initially suspected. We conducted a retrospective chart-review study at two different hospitals within the same urban health system. Consecutive adult patients seen from 10/1/2020 to 5/1/2022 with a systolic blood pressure ≥180mmHg or diastolic blood pressure ≥120mmHg were included. A total of 972 patients met our eligibility criteria. The average age was 59years (SD: 16.5), 454 (46.7%) were women, and 582 (59.9%) were non-White. A total of 186/972 (19.1%) patients were initially thought to have acute target-organ damage in the ED with 97/186 (52.2%) diagnosed with stroke or TIA. The remaining 786/972 (80.9%) patients were not initially diagnosed with target-organ damage (hypertensive urgency [HU]). Of the 786 patients with HU, a head CT was obtained in 216/786 (27.7%) and brain MRI in 74/786 (9.4%). Of the HU patients with a brain MRI, 23/74 (31.1%) had acute abnormalities; most abnormalities on brain MRI (17/23 [73.9%]) were not seen on preceding head CT. In a multicenter study of ED patients, nearly 1 in 5 patients though to have HU who eventually underwent brain MRI had unexpected acute neurological findings, though brain MR was obtained in only 9%.

A CLINICAL PROFILE OF HYPERTENSIVE EMERGENCIES WITH RESPECT TO TARGET ORGAN DAMAGE

Background: Hypertension is one of most common non-communicable disease affecting all age groups . Hypertensive emergency is characterized by an acute increase in blood pressure with systolic blood pressure greater than 180 or diastolic blood pressure greater than 110 . There is evidence of an acute target organ damage in hypertensive emergencies . The purpose of this study is to evaluate the clinical prole , and spectrum of target organ injury , as well as their prediction in patients with hypertensive crises. This is a hospital based prospective study done on 100 Methods: patients presenting with hypertensive emergencies to Department of General Medicine over a period of two years. The patients clinical and laboratory prole were evaluated. The results have shown that males have high Results: incidence of development of hypertensive emergencies and the average age of developing hypertensive emergencies is 62 years .Majority of population included are previously hypertensive .The most common presenting features include neurological decits , dyspnoea , chest pain , seizures , visual impairment .Type 2 Diabetes Mellitus and hyperlipidemia is associated with patients with hypertensive emergencies. Among the 100 patients , 93 were discharged and there were 7 mortalities. Hypertensive emergencies are associated with target or Conclusion: gan damage which can be life threatening , thus early idencation and strict control of blood pressure is must for all individuals

Prevalence of neurological complaints among emergency department patients with severe hypertension

ObjectiveSevere hypertension can accompany neurological symptoms without obvious signs of target organ damage. However, acute cerebrovascular events can also be a cause and consequence of severe hypertension. We therefore use US population-level data to determine prevalence and clinical characteristics of patients with severe hypertension and neurological complaints. MethodsWe used nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected in 2016–2019 to identify adult ED patients with severely elevated blood pressure (BP) defined as systolic BP ≥ 180 mmHg and/or diastolic BP ≥120 mmHg. We used ED reason for visit data fields to define neurological complaints and used diagnosis data fields to define acute target organ damage. We applied survey visit weights to obtain national estimates. ResultsBased on 5083 observations, an estimated 40.4 million patients (95% CI: 37.5–43.0 million) in EDs nationwide from 2016 to 2019 had severe hypertension, equating to 6.1% (95% CI: 5.7–6.5%) of all ED visits. Only 2.8% (95% CI: 2.0–3.9%) of ED patients with severe hypertension were diagnosed with acute cerebrovascular disease; hypertensive urgency was diagnosed in 92.0% (95% CI: 90.3–93.4%). Neurological complaints were frequent in both patients with (75.6%) and without (19.9%) cerebrovascular diagnoses. Hypertensive urgency patients with neurological complaints were more often older, female, had prior stroke/TIA, and had neuroimaging than patients without these complaints. Non-migraine headache and vertigo were the most common neurological complaints recorded. ConclusionIn a nationally representative survey, one-in-sixteen ED patients had severely elevated BP and one-fifth of those patients had neurological complaints.

Effect of intravenous antihypertensives on outcomes of severe hypertension in hospitalized patients without acute target organ damage.

Treatment of severe inpatient hypertension (HTN) that develops during hospitalization is not informed by guidelines. Intravenous (i.v.) antihypertensives are used to manage severe HTN even in the absence of acute target organ damage; however they may result in unpredictable blood pressure (BP) reduction and cardiovascular events. Our goal was to assess the association between i.v. antihypertensives and clinical outcomes in this population. This is a multihospital retrospective study of adults admitted for reasons other than HTN who develop severe HTN during hospitalization without acute target end organ damage. We defined severe HTN as BP elevation of systolic >180 or diastolic >110 mmHg. Treatment was defined as receiving i.v. antihypertensives within 3 h of BP elevation. We used overlap propensity score weighted Cox models to study the association between treatment and clinical outcomes during index hospitalization. Of 224 265 unique, nonintensive care unit hospitalizations, 20 383 (9%) developed severe HTN, of which 5% received i.v. antihypertensives and 79% were untreated within 3 h of severe BP elevation. In the overlap propensity weighted population, patients who received i.v. antihypertensives were more likely to develop myocardial injury (5.9% in treated versus 3.6% in untreated; hazard ratio [HR]: 1.6 [1.13, 2.24]). Treatment was not associated with increased risk of stroke (HR: 0.7 [0.3, 1.62]), acute kidney injury (HR: 0.97 [0.81, 1.17]), or death (HR: 0.86 [0.49, 1.51]). Intravenous antihypertensives were associated with increased risk of myocardial injury in patients who develop severe HTN during hospitalization. These results suggest that i.v. antihypertensives should be used with caution in patients without acute target organ damage.

Abstract 15577: Clinical Outcomes in Hypertensive Emergency: A Systematic Review and Meta-Analysis

Introduction: Despite the increasing rate of hypertensive emergency (elevated blood pressure with acute target organ damage) presentations in the emergency department (ED), subsequent morbidity and mortality data to support clinical decision making remains scarce. We aim to study the prevalence and prognosis of hypertensive emergencies and hypertension mediated organ damage (HMOD) in patients presenting to the ED. Methods: PubMed and Scopus were queried from their inception through the mid of November 2021. Studies were included if they reported the prevalence or prognosis of hypertensive emergencies in patients presenting to the ED. Data from each study was arcsine-transformed and pooled using a random-effects model. Results: Fourteen studies (n = 4370 patients) were included in our analysis. Pooled analysis demonstrates that the prevalence of hypertensive emergencies was 0.5% (95% CI: 0.40 - 0.60) in patients presenting to ED. Ischemic stroke 28.1% (95% CI: 18.7 - 38.6), was the most prevalent HMOD, followed by pulmonary edema/acute heart failure 24.1%, (95% CI: 19.0 - 29.7, hemorrhagic stroke 14.6%, (95% CI: 9.9 - 20.0), acute coronary syndrome 10.8%, (95% CI: 7.3 - 14.8), renal failure 8.0%, (95% CI: 2.9 - 15.5), subarachnoid hemorrhage 6.9%, (95% CI: 3.9 - 10.7), encephalopathy 6.1%, (95% CI: 1.9 - 12.4), and the least prevalent was aortic dissection 1.8%, (95% CI: 1.1 - 2.8) ( Figure ). Mortality rate among patients admitted to the hospital due to hypertensive emergency was 9.9% (CI: 1.4 - 24.6). Conclusions: Our findings demonstrate substantial morbidity and mortality amongst patients presenting to the ED with hypertensive emergency. Results of studies may help clinicians identify organs at highest risk of damage in patients with hypertensive emergency, aiding the work-up and therefore helping curb the burden of this disease.

Hypertensive Emergency In UMOD-Related Autosomal Dominant Tubulointerstitial Kidney Disease

Hypertensive emergency is characterized by an acute elevation in blood pressure with evidence of impending or progressive acute target organ damage. Management relies mainly on intravenous medications guided by the type of target-organ damage, but there is considerable variability in practice regarding the choice of medications and optimal therapy. Such variables include the choice of agent and the blood pressure goal, but also underlying medical conditions. We report a case of hypertensive emergency in a 39-year-old-male with a rare genetic condition, UMOD-related autosomal dominant tubulointerstitial kidney disease which gave rise to adolescent gout, worsening kidney function over decades and treatment-resistant hypertension.

Acil Servise Başvuran Hipertansif Hastalarda Serum Ürik Asit Düzeyleri

Objective: There is not enough information in the literature conducted about the importance of serum uric acid levels in hypertensive emergency patients. Our study aims to investigate the role of serum uric acid levels in patients admitted to the emergency department due to high blood pressure. Materials and methods: Hypertensive emergency with acute target organ damage with blood pressure 180/110 mmHg and above (group I), hypertensive urgency patients without acute target organ damage with blood pressure of 180/110 mmHg and above (group II), and the patients with uncontrolled hypertension with systolic blood pressure between 140-180 mmHg and diastolic blood pressure between 90-110 mmHg (group III). Results: One hundred twenty-four hypertensive patients (80 female, 44 male) were included. 33 patients (26.6%) were in group I, 19 (15.3%) in group II and 72 (58.1%) in group III. When compared in terms of serum uric acid level, it was found that there was a statistically significant difference between the groups (p = 0.001). The average serum uric acid level of patients in group I was higher compared to other groups (p <0.05). Conclusion: Serum uric acid levels in patients admitted to the emergency department with high blood pressure may be important in distinguishing hypertensive emergency.

A CLINICAL STUDY ON PRESENTATION OF HYPERTENSIVE EMERGENCIES IN TERTIARY CARE HOSPITAL

BACKGROUND:The clinical prole of hypertensive emergency patients presenting to hospitals in a developing country like ours is unknown. The current study sought to assess the modes of presentation, clinical prole, and spectrum of target organ damage in hypertensive emergency patients. AIM: Ÿ To evaluate the modes of presentations in patients with hypertensive emergencies. Ÿ To evaluate the modes of clinical prole. Ÿ To evaluate the modes of the spectrum of target organ damage in patients with hypertensive emergencies. MATERIALS AND METHODS: A six-month hospital-based prospective study was conducted in the Department of General Medicine, Santhiram Medical College, and General Hospital after approval from the Hospital Ethics and Research Committee. The study population included patients admitted to the hospital with severely elevated blood pressure and clinical evidence or laboratory evidence of acute target organ damage. The clinical prole and laboratory proles of fty of these patients were examined. RESULTS: Males were more likely than females to develop a hypertensive emergency. The most common symptoms were neurological decit, dyspnea, chest pain, convulsions, and vision loss. The vast majority of the patients had a history of hypertension. Higher blood pressure levels at presentation were linked to a poor outcome. Hyponatremia and hyperkalemia are two laboratory abnormalities observed in these patients. The most common type of target organ damage observed was intracerebral haemorrhage. In the current study, there was a 22% in-hospital mortality rate. CONCLUSION: Known hypertensives are more likely to present with acute target organ damage due to a hypertensive emergency. The most common mode of presentation is a neurological decit. The most common type of target organ damage in the current study was acute intracerebral haemorrhage

Excessive Blood Pressure Response to Clonidine in Hospitalized Patients With Asymptomatic Severe Hypertension.

There are limited and nonconcordant data on the rapidity and safety of blood pressure response to clonidine in the setting of asymptomatic severe hypertension. We evaluated the blood pressure response to clonidine in hospitalized patients with asymptomatic severe hypertension. We performed a review of hospitalized, noncritically ill patients receiving clonidine within 6 hours of developing asymptomatic severe hypertension (systolic blood pressure [SBP] >180 or diastolic blood pressure [DBP] >110 mm Hg in the absence of acute hypertension-mediated target organ damage). The incidence of mean arterial pressure (MAP) reduction by ≥30% at 4 hours after clonidine was the primary endpoint. We identified 200 relevant patient encounters (median age 63 years, 48.5% women). Median time to clonidine following asymptomatic severe hypertension was 2.8 hours. A total of 20 (10%) patients had ≥30% MAP reduction within 4 hours after clonidine, and 32 (16%) patients had ≥30% reduction in either SBP, DBP, or MAP. Older age, female sex, and preexisting vascular disease were associated with ≥30% MAP reductions (P < 0.05). Only patient sex and clonidine dose of 0.3 mg were significant in multivariable models. There were 14 adverse events observed within 24 hours of administration of clonidine; most (9) were acute kidney injury. There were no ischemic (myocardial, cerebrovascular) events. A substantial minority of hospitalized patients with asymptomatic severe hypertension experience precipitous blood pressure decline with clonidine, and though blood pressure declines more precipitously in women and those receiving higher doses (0.3 mg specifically), the response to clonidine is generally not predictable on clinical grounds.

C95. The electrocardiographic changes in a hypertensive COVID-19 patient who received beta-blocker and favipiravir: a case report

BackgroundVarious electrocardiographic manifestations have been reported in COVID-19 which either result from myocarditis or insult-induced re-emerging of pre-existing condition. Some antiviruses used off-labelly for COVID-19, including favipiravir, are considered to be proarrhythmic. Meanwhile, anti-hypertensive drugs such as beta-blocker may induce bradyarrhythmia.Case SummaryA 69-year-old male with confirmed COVID-19 and a history of uncontrolled hypertension presented with blood pressure of 216/111mmHg at admission. No sign and symptom of acute target organ damage had been reported. His electrocardiography showed normal sinus rhythm (heart rate [HR] 60bpm). The echocardiographic finding revealed normal heart function. He received favipiravir for 5 days, intravenous nicardipine (0.5mcg/kgBW/hour), and peroral amlodipine (1x10mg), candesartan (1x16mg), and bisoprolol (1x2.5mg). During hospitalization, the HR fluctuated between 52-109. On the sixth day, a total atrioventricular (AV) block with junctional escape rhythm (HR 66bpm) was present. Both favipiravir and bisoprolol were ceased simultaneously. The AV block persisted for 4 days then transformed into a junctional rhythm for the next 3 days and sinus bradycardia (HR 48bpm) thereafter. No pacing was performed.DiscussionThe possible differential diagnoses in this case include sick sinus syndrome (SSS), COVID-19-induced myocarditis, and drug-induced. The SSS might explain the wide variability of the HR. There were some reports presenting the sinus node dysfunction as a manifestation of SARS-CoV-2 infection. Further evaluation using Holter and/or electrophysiological study is warranted. Drug-induced cause may be excluded because the bradyarrhythmia remained after the cessation of both beta-blocker and favipiravir.

C95. The electrocardiographic changes in a hypertensive COVID-19 patient who received beta-blocker and favipiravir: a case report

BackgroundVarious electrocardiographic manifestations have been reported in COVID-19 which either result from myocarditis or insult-induced re-emerging of pre-existing condition. Some antiviruses used off-labelly for COVID-19, including favipiravir, are considered to be proarrhythmic. Meanwhile, anti-hypertensive drugs such as beta-blocker may induce bradyarrhythmia.Case SummaryA 69-year-old male with confirmed COVID-19 and a history of uncontrolled hypertension presented with blood pressure of 216/111mmHg at admission. No sign and symptom of acute target organ damage had been reported. His electrocardiography showed normal sinus rhythm (heart rate [HR] 60bpm). The echocardiographic finding revealed normal heart function. He received favipiravir for 5 days, intravenous nicardipine (0.5mcg/kgBW/hour), and peroral amlodipine (1x10mg), candesartan (1x16mg), and bisoprolol (1x2.5mg). During hospitalization, the HR fluctuated between 52-109. On the sixth day, a total atrioventricular (AV) block with junctional escape rhythm (HR 66bpm) was present. Both favipiravir and bisoprolol were ceased simultaneously. The AV block persisted for 4 days then transformed into a junctional rhythm for the next 3 days and sinus bradycardia (HR 48bpm) thereafter. No pacing was performed.DiscussionThe possible differential diagnoses in this case include sick sinus syndrome (SSS), COVID-19-induced myocarditis, and drug-induced. The SSS might explain the wide variability of the HR. There were some reports presenting the sinus node dysfunction as a manifestation of SARS-CoV-2 infection. Further evaluation using Holter and/or electrophysiological study is warranted. Drug-induced cause may be excluded because the bradyarrhythmia remained after the cessation of both beta-blocker and favipiravir.

Profile and management of hypertensive urgencies and emergencies in the emergency cardiology department of a tertiary hospital: a 12-month registry

Currently there are scarce epidemiological data regarding prevalence, clinical phenotype, and therapy of hypertensive urgencies (HU) and emergencies (HE). The aim of this article was to record the prevalence, clinical characteristics, and management of patients with HU and HE assessed in an emergency department (ED) of a tertiary hospital. The population consisted of patients presenting with HE and HU in the ED (acute increase in systolic blood pressure (BP) ≥ 180 mmHg and/or diastolic BP ≥120 mmHg with and without acute target organ damage, respectively). Of the 38 589 patients assessed in the ED during a 12-month period, 353 (0.91%) had HU and HE. There were 256 (72.5%) cases presented as HU and 97 (27.5%) as HE. Primary causes for both HU and HE were stress/anxiety (44.9%), increased salt intake (33.9%), and non-adherence to medication (16.2%). Patients with HU reported mainly dizziness/headache (46.8%) and chest pain (27.4%), whereas those with HE presented dyspnoea (67%), chest pain (30.2%), dizziness/headache (10.3%), and neurological disorders (8.2%). In HE, the underlying associated conditions were pulmonary oedema (58%), acute coronary syndrome (22.6%), and neurological disorders/stroke (7.2%). All HE cases were hospitalized and received intensive healthcare, including dialysis. This 1-year single-centre registry demonstrates a reasonable prevalence of HU and HE contributing to the high volume of visits to the ED. Stress, increased salt intake and non-adherence were main triggers of HE and HU. Dizziness and headache were the prevalent symptoms of HU patients while heart failure was the most common underlying disease in patients with HE.

Comparison of cardiovascular events and estimation of hazard ratio for hypertensive patients with and without hypertensive urgencies after a 12-month follow up

Abstract Background Few epidemiological data show a worst prognosis of hypertensive emergencies compared with hypertensive urgencies (HU). To the best of our knowledge, there is even fewer published evidence comparing prognosis of hypertensive patients (HP) with and without HU. Purpose The purpose of our prospective study was to record the prevalence and clinical characteristics of patients with HU assessed in the emergency department (ED) in a tertiary Hospital and to compare them with HP without urgencies for new events and hard-end points for a 12-month follow-up. Methods The study population consisted of 256 patients presenting at the ED with acute increase in blood pressure (BP) (systolic BP≥180mmHg and/or diastolic BP≥120mmHg) with absence of acute hypertension-mediated target organ damage in a period of one year. Each of these participants were matched one-to-one by age, gender and history of hypertension with HP with either controlled, grade 1 or grade 2 hypertension attending our Hypertension excellence center the same period. However, 78 of HU did not conclude the follow up and 5 could not be matched with HP for the above covariates and were therefore excluded. Both groups, 173 of HU and 173 of controls, concluded 12 months follow up for fatal and non fatal cardiovascular events, including acute coronary syndrome, stroke, newly diagnosed heart failure or deterioration of NYHA class, and composite end points such as stroke-myocardial infarction and overall cardiovascular disease outcome. Results The mean age of all patients was 64.9±12.5 years (64±12.2 for controls and 65.7±12.7 for HU), 48.8% were males (49.1% of controls and 48.6% of HU) and 26.6% had a history of smoking (22.5% of controls and 30.6% of HU). Overall, 15 (5.5%) patients had nonfatal clinical cardiovascular events and 4 (1.2%) had fatal cardiovascular events. Cox regression models were adjusted for age, gender, smoking, previous cardiovascular disease, diabetes mellitus and the population. The frequency of the composite stroke-myocardial infarction event was statistically significant higher in HU (5 vs 4, p&amp;lt;0.0001, Hazard Ratio for HU 181.7, 95% Confidence Intervals 19.7–1677.2) adjusted for the rest covariates. In addition, there was a higher trend for stroke in the group of HU (p=0.067) and in patients with a history of diabetes mellitus irrespective of group (p=0.055). Finally, the Cox regression analysis identified age (p=0.035) and history of cardiovascular disease (p=0.038) as independent predictors for death, and smoking (p=0.035) as independent predictor for overall cardiovascular events. Conclusions Our study emphasizes the higher trend for cardiovascular outcomes, especially stroke, in the group of HU compared with HP without urgencies, while it highlights the necessity for more intensive follow-up for the first group and the need for further research in this pathological entity. Funding Acknowledgement Type of funding sources: None.

CE: Hypertensive Emergencies: A Review.

While acute blood pressure elevations are commonly seen in the ED, not all require emergency treatment. True hypertensive emergencies are characterized by a rapid elevation in blood pressure to a level above 180/120 mmHg and are associated with acute target organ damage, which requires immediate hospitalization for close hemodynamic monitoring and IV pharmacotherapy. Recognizing the clinical signs and symptoms of hypertensive emergency, which may vary widely depending on the target organ involved, is critical. High blood pressure levels that produce no signs or symptoms of target organ damage may be treated without hospitalization through an increase in or reestablishment of previously prescribed oral antihypertensive medication. However, all patients presenting with blood pressure this high should undergo evaluation to confirm or rule out impending target organ damage, which differentiates hypertensive emergency from other hypertensive crises and is vital in facilitating appropriate emergency treatment. Drug therapy for hypertensive emergency is influenced by end-organ involvement, pharmacokinetics, potential adverse drug effects, and patient comorbidities. Frequent nursing intervention and close monitoring are crucial to recuperation. Here, the authors define the spectrum of uncontrolled hypertension; discuss the importance of distinguishing hypertensive emergencies from hypertensive urgencies; and describe the pathophysiology, clinical manifestations, and management of hypertensive emergencies.

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.

Risk factors for hypertensive crisis in adult patients: a systematic review.

The objective of this review was to examine the best available evidence on the risk factors for hypertensive crisis in adult patients with hypertension. Hypertensive crisis is an acute severe elevation in blood pressure, which can present as hypertensive urgency or emergency. In contrast to hypertensive urgency, which is a markedly elevated blood pressure without acute target organ damage, hypertensive emergency is associated with equally high blood pressure in the presence of potentially life-threatening target organ damage, such as myocardial infarction, stroke, pulmonary edema, or acute kidney injury. Hypertensive crisis results in adverse clinical outcomes and high utilization of health care. This review considered studies of non-modifiable factors (age, sex, ethnicity) and modifiable factors such as socioeconomic factors (lack of medical insurance, lack of access to medical care), adherence to medical therapies, presence of comorbidities (diabetes, hyperlipidemia, coronary artery disease, history of stroke, chronic kidney disease, congestive heart failure), and substance abuse in persons of either sex, older than 18 years with a diagnosis of hypertension. A search of four databases, seven gray literature sites, and relevant organizational websites revealed 11,387 titles. After duplicates were removed, 9183 studies were screened by the title and abstract for eligibility. Forty full-text articles were retrieved, and each was assessed for eligibility. Twenty-one articles were excluded. The remaining 19 full-text studies were critically appraised and included in this review. The risk of hypertensive crisis was higher in patients with a history of comorbid cardiovascular conditions, such as chronic kidney disease (odds ratio [OR] 2.899, 95% confidence interval [CI] 1.32, 6.364), coronary artery disease (OR 1.654, 95% CI 1.232, 2.222), or stroke (OR 1.769, 95% CI 1.218, 2.571). Patients with hypertensive emergency had higher mean systolic blood pressure (mean difference [MD] 2.413, 95% CI 0.477, 4.350) and diastolic blood pressure (MD 2.043, 95% CI 0.624, 3.461). Hypertensive emergency was more common in men (OR 1.390, 95% CI 1.207,1.601), older patients (MD 5.282, 95% CI 3.229, 7.335), and those with diabetes (OR 1.723, 95% CI 1.485, 2.000) and hyperlipidemia (OR 2.028, 95% CI 1.642, 2.505). Non-adherence to antihypertensive medications (OR 0.939, 95% CI 0.647,1.363) and hypertensive diagnosis unawareness (OR 0.807, 95% CI 0.564, 1.154) did not increase the risk of hypertensive emergency. Comorbid cardiac, renal, and cerebral comorbidities (coronary artery disease, congestive heart failure, cerebrovascular disease, and chronic kidney disease) increase the risk of hypertensive crisis. The risk of hypertensive crisis is higher in patients with unhealthy alcohol and recreational drug use. Systolic and diastolic blood pressure are marginally higher in patients with hypertensive emergency compared to patients with hypertensive urgency. Since these differences are small and not clinically significant, clinicians should rely on other symptoms and signs to differentiate between hypertensive urgency and hypertensive emergency. The risk of hypertensive emergency is higher in older adults. The coexistence of diabetes, hyperlipidemia, and chronic kidney disease increases the risk of hypertensive emergency. PROSPERO (CRD42019140093).

A descriptive study on the hypertensive crisis in Visakhapatnam, Andhra Pradesh, India

Objective: The objective of the present study, A Descriptive study on Hypertensive Crisis inVisakhapatnam, India was to evaluate the modes of presentations, clinical profile, and spectrum oftarget organ damage in patients with hypertensive emergencies. Material and Methods: The studypopulation included patients admitted in this hospital with severely elevated blood pressure withclinical or laboratory evidence of acute target organ damage. Result: The clinical and laboratoryprofile of 50 of these patients were evaluated. Males had higher chances of developing ahypertensive emergency compared to females. The commonest presenting symptoms were chestpain, dyspnoea, and neurological deficit. The majority of the patients have known hypertensives.Higher levels of blood pressure at presentation were associated with an adverse outcome. Acute LVFwas the commonest target organ damage observed. In-hospital mortality of 14% was observed inthe present study. Conclusion: Known hypertensives are at a higher risk of presenting with acutetarget organ damage associated with chest pain. Acute LVF is the commonest form of target organdamage encountered in the present study.