Hypertensive Urgency Research Articles

One-year risk of all-cause death and major cardiovascular events in patients presenting with hypertensive crisis. A report from a global federated research health network

Abstract Background Few data are available about the clinical course of patients presenting with hypertensive crisis who are discharged alive from hospital. Purpose To assess the long-term risk of adverse events in patients with hypertensive crises. Methods Retrospective study utilizing a research health network. Based on the ICD-10-CM codes recorded between 2000 and 2022, from 85 health care associations mainly located in the United States, patients with hypertensive crisis were subdivided into hypertensive urgencies (I16.0) and hypertensive emergencies (I16.1). In those with hypertensive emergencies, the type of target organ damage was reported, ie. central nervous system (ischemic stroke, hypertensive encephalopathy, intracerebral hemorrhages), cardiovascular (CVS: myocardial infarction (MI), heart failure (HF), aorta dissection (AD)), or renal (acute kidney failure). Primary outcomes were the one-year risks of all-cause death, and major cardiovascular events (MACE: MI, stroke, cardiac arrest, AD, and HF). Secondary outcomes were the risks for each type of MACE. Cox regression analysis after propensity score matching (PSM) 1:1 was used to produce hazard ratios (HRs) and 95% Confidence Intervals (95%CIs). Results Overall, we identified 25 294 patients with hypertensive emergency (age 62.4±15.7, 46.1% females) and 21,737 patients with hypertensive urgency (age 63.5±17.2, 55.5% females). Patients with hypertensive emergency were more likely males, Black or African American origin and showed a higher prevalence of chronic hypertensive-related complications, vs. those with hypertensive urgency. After PSM, patients with hypertensive emergency showed a higher risk of all-cause death (HR, 1.34, 95%CI 1.25-1.44) and MACE (HR 4.09, 95%CI 3.87-4.33), vs. those with hypertensive urgency. Of the secondary outcomes, patients with hypertensive emergency had increased risks of MI (HR 3.33, 95%CI 3.03-3.67), stroke (HR 4.73, 95%CI 4.33-5.17), cardiac arrest (HR 1.30, 95%CI 1.07-1.58), AD (HR 5.49, 95%CI 3.90-7.73), and HF (HR 3.01, 95%CI 2.74-3.14). All the different types of organ involvement during the hypertensive emergency were each associated with similar long-term risks of adverse events (Figure 1). Conclusion Patients with hypertensive emergency have a high long-term risk of MACE and all-cause death. Preventing the onset of target organ damage in patients with hypertensive crisis is crucial to mitigate their long-term risk of adverse events.

More hypertensive crises in women than in men in a single emergency department

Abstract Introduction Hypertensive crises are a common presenting complaint in the emergency department. A hypertensive crisis includes hypertensive urgencies defined as a systolic and/or diastolic blood pressure greater than 180/120 mmHg and hypertensive emergencies with additional hypertension-mediated organ damage (HMOD). In the literature there is very little data regarding the distribution between men and women in hypertensive crises. Most data suggest a balanced distribution or a higher frequency in men, especially compared to premenopausal women. Methods We retrospectively analysed patient data in our hospital information system from 2022 using ICD-10 diagnoses at discharge. We included inpatient as well as outpatient cases that presented to our emergency department between 01/01/2022 and 31/12/2022 with one of the following ICD-diagnoses at discharge: - I10.01, Benign essential hypertension With mention of hypertensive urgency - I10.91, Essential hypertension, unspecified With mention of hypertensive urgency - I11.01, Hypertensive heart disease with (congestive) heart failure With mention of hypertensive urgency - I11.91, Hypertensive heart disease without (congestive) heart failure With mention of hypertensive urgency - R03.0, Elevated blood-pressure reading, without diagnosis of hypertension Then we compared the difference of the median age at presentation between men and women using the independent t-test. Results We identified 397 patients with a hypertensive crisis in the year of 2022. Overall the percentage of women in the collective of patients with any type of hypertensive crisis diagnosis was 73.0 % and thus a lot higher than the percentage of men. Women were on average 7.7 years older at presentation (p < 0.0001). Discussion: On the basis of the available data the causes for the distribution between men and women in hypertensive crises can only be speculated. On the one hand women may measure their blood pressure more frequently than men and the urge to call an ambulance or seek medical attention may be higher. On the other hand it could be possible that arterial hypertension in general has differences in the course and underlying mechanism with a higher frequency in blood pressure peaks, symptoms at lower blood pressure values and antihypertensive medication could be less effective depending on the type of drug. Also arterial hypertension may be underdiagnosed in women. The difference in the age at presentation is probably due to a later hormonal adjustment after the menopause as shown in the literature. The findings of this small observational study should be further investigated in larger trials.

Hospital and one-year outcomes following a hypertensive urgency or emergency: a major challenge

Abstract Introduction Hypertension is an important issue, and recommendations are constantly evolving based on the latest research findings and directions. Hypertensive emergencies are defined as a severe elevation of blood pressure associated with organ damage. End organ damage was defined as the presence of one of the following findings: encephalopathy, ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, acute heart failure, acute coronary syndrome, or aortic dissection. Furthermore, malignant hypertension is a HE characterized by small artery fibrinoid necrosis in the kidney, retina and brain. All these definitions are confusing, but what about their evolution? Objective:The present study aims to analyze the mortality in the short and long term (12months), the survival of the hypertensive patients, the frequency of malignant hypertension and hypertensive retinopathy. Methods For this purpose, we conducted a prospective study including all patients who followed or were diagnosed with hypertension and admitted to the emergency department for hypertensive urgency/emergency, from January to March 2023; after that, we studied the evolution of these patients for one year until January 2024. Demographic data, disease history, blood pressure, clinical presentation on admission, target organ involvement, ophthalmological examination and evolution during hospitalization were studied. Statistical analysis was performed using SPSS software. Preeclampsia and chronic renal failure were excluded.Result: Our work brought together 300 patients, mainly female, with an average age of 63.4. One hundred fifteen were admitted for HE and 185 for HU. The most common presenting symptoms at admission were headache, focal neurologic deficit and dyspnea. Malignant hypertension was identified in 9 patients based on optical coherence tomography angiography by identifying subclinical microvascular damage, and investigation is still in progress searching for hypertensive retinopathy grade III-IV Keith-Wagner in the second group. Patients were mainly hospitalized for hypertensive emergencies. Regarding their therapeutic management, except for the acute lowering of blood pressure in stroke, there was no consensus initially; ideally was to determine which organs are affected to assess the need for specific intervention other than lowering blood pressure. Overall, 49 had died from HE n=44/115(vs n=5/185 for HU). Of these, 33 have died at the Hospital (mortality was higher for HE and attributable to neurovascular emergencies rather than cardiovascular emergencies) and ten at 12 months. Conclusion Properly managing patients who come to the Emergency Department for BP elevation faces many difficulties. Can we still talk about hypertensive emergencies/urgency, discuss retinal lesions, and the importance of hypertension monitoring? However, all those definitions can be potentially life-threatening; these results justify better follow-up and treatment for these patients.

Risk and causes of hospital admission in patients with atrial fibrillation on treatment with oral anticoagulants

Abstract Background Atrial fibrillation (AF) is associated with an increased risk of hospitalisation, although the main reasons for hospital admission and the role of antiarrhythmic drugs are not clarified. Objective The aim of our study was to assess the incidence rate and the factors associated with all-cause, cardiovascular and AF-related causes of hospitalisation in patients suffering from AF. Methods This is a prospective single-centre ongoing study (ATHERO-AF cohort) which included 2782 patients affected by non-valvular AF on oral anticoagulants. The primary endpoints were all-cause, cardiovascular and AF-related hospitalisation. Cardiac hospitalizations were defined as (non-AF) arrhythmias, acute coronary syndromes, heart failure (HF), systemic embolism, hypertensive urgency, vascular/cardiac surgery. The AF-related hospitalisation was defined as a recurrence of AF in paroxysmal pattern or as a high-rate symptomatic AF episode in persistent/permanent patterns. Multivariable Cox proportional hazards regression analysis was used to calculate the hazard ratio (HR) with 95% Confidence interval (95%CI) for each factor in relation to risk of hospitalisation. Results Overall, 43.5% of patients were women with a mean age of 74.6±9.1year. Patients were followed for a mean of 31±26.8 months. We registered 1205 (12.1%/year) hospitalisations for any reason, 533 (5.7%/year) for cardiovascular causes and 180 (2.0%/year) were AF-related hospitalisations (Central illustration). Among the anti-arrhythmic drug use, we highlighted that flecainide and propafenone were associated with AF-related hospitalisations in paroxysmal and in persistent/permanent patterns (HR 1.861, 95%CI 1.116-3.101 and HR 1.947, 95%CI 1.069-3.548, respectively). Amiodarone (HR 3.012, 95%CI 1.835-4.943) and verapamil or diltiazem (HR 2.067, 95%CI 1.117-3.825) were associated with an increased risk of AF-related hospitalisations in persistent/permanent AF pattern. Furthermore, cancer was associated (HR 1.802, 95%CI 1.057-3.070) with increased risk of hospitalisation due to AF-related causes. Conversely, beta-blockers and digoxin were not associated with increased risk of hospital admission. Conclusions Hospitalisations of patients with AF are frequent for both cardiovascular and non-cardiovascular causes. Among the AF-related ones, the use of antiarrhythmic drugs emerged as associated with increased risk of hospitalisations, hypothesizing their poor effect in preventing AF episodes. For these reasons, we suggest carefully considering their use, reserving them for symptomatic patients with frequent AF recurrences.Central Illustration

HYPERTENSIVE CRISES: HYPERTENSIVE EMERGENCY AND CRISIS MANAGEMENT DURING ANESTHESIA

Introduction: hypertensive crisis is characterized by an acute and massive increase in blood pressure. Hypertensive crises encompass several clinical situations with different severity and prognosis, including hypertensive urgency and hypertensive emergency. The difference between the latter depends on whether the situation is life-threatening for the affected individual. Objective: to detail current information related to hypertensive crises, especially hypertensive emergency, definition, differentiation, etiology, epidemiology, pathophysiology, histology, clinical history, physical examination, management, differential diagnosis, prognosis and complications. Methodology: a total of 28 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 15 bibliographies were used because the other articles were not relevant to this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: hypertensive crises, hypertensive emergencies, hypertensive emergencies, arterial hypertension. Results: approximately 1-2% of adults with hypertension suffer hypertensive crises. Multiple case series show that short-term treatment of hypertensive emergencies has good results; however, long-term results are unknown. The main drawback is that follow-up of individuals is lost and the medication regimen is frequently modified. Untreated hypertensive emergencies have very high morbidity and mortality and if the patient does not receive adequate education about the severity of hypertension, this trend is likely to continue. Conclusions: given the high prevalence of hypertension, it is crucial that health care professionals are able to differentiate between hypertensive emergencies and hypertensive emergencies to provide appropriate and timely treatment. Rapid blood pressure reduction is critical in the treatment of hypertensive emergencies. The choice of medications should consider both efficacy and safety to avoid further complications. A detailed clinical evaluation can help identify the underlying cause and guide treatment, highlighting the importance of an individualized approach. Lack of timely treatment can lead to severe consequences, emphasizing the need for proper management in critical situations. Constant training in the management of hypertensive emergencies is essential to reduce the morbidity and mortality associated with this condition.The management of hypertension during anesthesia is critical, as its prompt detection and control are fundamental to prevent serious complications. Despite the lack of specific criteria to suspend surgery in hypertensive patients, it is essential to evaluate each case individually, prioritizing target organ damage over blood pressure levels. KEY WORDS: crisis, emergency, urgency, hypertension.

Characterizing myocardial edema and fibrosis in hypertensive crisis with cardiovascular magnetic resonance imaging.

A hypertensive crisis is associated with an increased risk of cardiovascular events. Although altered cardiac structure, function, and myocardial architecture on cardiovascular magnetic resonance (CMR) have been associated with increased adverse events in hypertensive patients, the studies did not include patients with hypertensive crisis. Our study aimed to determine myocardial tissue characteristics in patients with hypertensive crisis using CMR imaging. Participants underwent comprehensive CMR imaging at 1.5T. The imaging protocol included cine-, T2-weighted-, contrasted- and multi-parametric mapping images. Blood and imaging biomarkers were compared in hypertensive emergency and hypertensive urgency. Predictors of myocardial edema was assessed using linear regression. The predictive value of T1- and T2 mapping for identifying hypertensive emergency (from urgency) was assessed with receiver operator characteristics curves. Eighty-two patients (48.5 ± 13.4 years, 57% men) were included. Hypertensive emergency constituted 78%. Native T1 was higher in patients with LVH compared to those without (1056 ± 33 vs. 1013 ± 40, P < 0.001), and tended to be higher in hypertensive emergency than urgency (1051 ± 37 vs. 1033 ± 40, P = 0.077). T2-w signal intensity (SI) ratio and T2 mapping values were higher in hypertensive emergency (1.5 ± 0.2 vs. 1.4 ± 0.1, P = 0.044 and 48 ± 2 vs. 47 ± 2, P = 0.004), and in patients with than without LVH (1.5 ± 0.2 vs. 1.4 ± 0.1, P = 0.045 and P = 0.030). A trend for higher extracellular volume was noted in hypertensive emergency compared to urgency (25 ± 4 vs. 22 ± 3, P = 0.050). Native T1 correlated with T2 mapping (rs = 0.429, P < 0.001), indexed LV mass (rs = 0.493, P < 0.001), cardiac troponin (rs = 0.316, P < 0.001) and NT-proBNP (rs = 0.537, P < 0.001), while T2 correlated with cardiac troponin (rs = 0.390, P < 0.001), and NT-proBNP (rs = 0.348, P < 0.001). Non-ischemic LGE pattern occurred in 59% and was 21% more prevalent in the hypertensive emergency group (P = 0.005). Our findings demonstrate that hypertensive crisis is associated with distinct myocardial tissue alterations, including increased myocardial edema and fibrosis, as detected on CMR. Patients with hypertensive emergency had a higher degree of myocardial oedema than hypertensive urgency. Further research is necessary to explore the prognostic value of these findings.

6402 Unsuspected Bladder Mass Turns Out To Be A Paraganglioma

Abstract Disclosure: S. Lamichhane: None. A. Flowers: None. D.T. Price: None. A. Kaur: None. Background: Urinary bladder (UB) paragangliomas are extremely rare tumors comprising of less than 0.05% of all bladder neoplasms and 10% of all paragangliomas. The diagnosis is usually suspected based on clinical features of painless hematuria, episodic headaches, hypertension, palpitations associated with micturition or bladder and confirmed biochemically by elevated urinary and/or plasma fractionated metanephrines (MN). Here, we present a case of a UB mass that was initially diagnosed on biopsy and subsequent biochemical workup revealed elevated MN. Case Report: A 64-year-old man with type 2 diabetes and hypertension, admitted for revision surgery of subdural hematoma was incidentally found to have a 3.3 x 3.4 x 3.9 cm polypoid heterogenous hyper enhancing UB mass attached to the anterior wall on CT abdomen done for abdominal pain. Cystoscopy and TURBT were complicated by hypertensive urgency. Pathology turned out to be paraganglioma. Detailed history at this time revealed a long-standing history of frequency, urgency, nocturia 4 times nightly, recurrent urinary tract infections, an episode of gross hematuria 1-2 years ago, and difficulty controlling blood pressure on 4 anti-hypertensives. Subsequently, labs showed plasma free MN of 97 pg/ml (ref range &amp;lt;=57), free normetanephrine (NMN) of 2392 pg/ml (ref range &amp;lt;=148), and total MN of 2489 pg/ml (ref range &amp;lt;=205). Genetic panel was negative for SDHA, SHD, AF2, SDHB, SHDC, SDHD, VHL, RET, TMEM127. He received 6 doses of Lantreotide due to suspicion of metastasis based on abdominal, pelvic, and inguinal lymphadenopathy seen on DOTATATE scan. After preparation with alpha and beta blockers, he underwent uneventful robot-assisted cystectomy with lymph node resection that resulted in a well-differentiated paraganglioma negative for margins, lymph node involvement, and extra bladder extension. A week later, MN reduced, plasma free MN 37 pg/ml, free NMN 178 pg/ml, and total plasma MN 215 pg/ml. His BP improved, and micturition-induced palpitations resolved. Conclusion: Due to the rarity of UB paraganglioma, the diagnosis can be missed and delayed. This has a serious implication due to the risk of hypertensive crisis during the surgery and increased risk of cardiovascular complications. This case highlights the need for awareness among physicians of the clinical presentation associated with UB paraganglioma, its early recognition and management. Presentation: 6/2/2024

12315 Unveiling A Paraganglioma: Catecholamine-Induced Hyperglycemia Masquerading As Type 2 Diabetes Mellitus

Abstract Disclosure: S. Salman: None. M. Hussine: None. J. Tibaldi: None. Background: Excessive catecholamines have been demonstrated to exert adverse effects on insulin homeostasis and carbohydrate metabolism, potentially resulting in the onset of secondary DM. We present a case of a patient who had been previously misdiagnosed with T2DM for an extended period. Clinical Case: A 34-year-old woman with history of T2DM, HTN, and chronic tachycardia on beta blockers, presented with complaints of palpitations, headaches, and abdominal pain for two weeks. Upon admission, she was found to be in DKA, necessitating transient administration of insulin drip. Furthermore, she exhibited persistent tachycardia and intermittent episodes of hypertensive urgency. Notably, thyroid levels revealed euthyroidism. Although DKA resolved, her fasting blood sugar levels remained elevated and refractory to escalating insulin therapy. CT abdomen with contrast revealed a large enhancing mass in the RUQ. MRI abdomen confirmed an 8.1 cm heterogeneously enhancing T2 hyperintense mass located in the RUQ, abutting the right hepatic lobe, right adrenal gland, extrahepatic biliary ducts, and adjacent vessels. Given suspicions of a neuroendocrine tumor, she was transferred to the surgical service for tumor excision. Hormonal analysis revealed elevations in plasma metanephrines (620 pg/mL, n 0-88 pg/mL), plasma normetanephrines (9954 pg/mL, n 0-210.1 pg/mL), 24-hr urine normetanephrines (10,952 μg/24hr, n 110-720 μg/24hr) and 24-hr urine metanephrines (1406 μg/24hr, n 35-278 μg/24hr). Additionally, she exhibited elevated 24-hr urine epinephrine fraction (218 μg/g Cr, 0-20 μg/g Cr) and 24-hr urine norepinephrine fraction (2775 μg/g Cr, 0-45 μg/g Cr). Preoperatively, appropriate alpha and beta blockade were administered, followed by successful retroperitoneal tumor resection. Postoperatively, her glucose levels normalized without the need for further insulin therapy, and no episodes of hypoglycemia were reported. Histopathological examination of the excised mass revealed an 11 cm sympathetic paraganglioma with retention of SDHB staining. Genetic testing for SDHB, SDHD, VHL, and RET mutations is pending. Conclusion: This case underscores the potential oversight of pheochromocytomas and paragangliomas due to their nonspecific symptomatology, often mimicking more prevalent conditions, thereby presenting diagnostic challenges. The catecholamines secreted by these tumors can lead to both impaired insulin secretion and increased insulin resistance, resulting in clinically significant manifestations. The exact mechanism underlying the glycemic dysregulation remains controversial, necessitating further investigation through large-scale multicenter prospective studies to enhance understanding and inform diagnostic and therapeutic strategies for these tumors, which can manifest with severe and potentially fatal glycemic disturbances. Presentation: 6/1/2024

6409 Successful Treatment Of Severe Ectopic ACTH-dependent Cushing’s Syndrome With Osilodrostat

Abstract Disclosure: K.A. Lee: None. C. Mendes Pessoa: None. W. Huang: Consulting Fee; Self; WH, Honoraria from Consulting and Speaking received from Recordati Rare Disease. Background: Cushing’s syndrome due to ectopic ACTH secretion is rare and may progress rapidly, making treatment very challenging. Previous case reports have described therapeutic options including adrenal steroidogenesis inhibitors, bilateral adrenalectomy (BAL), and adrenal embolization with success. Clinical Case: A 27-year-old woman with metastatic neuroendocrine tumor presented with sudden onset and rapidly progressing symptoms of fatigue, muscle weakness, acne and weight gain within two weeks. Laboratory findings confirmed severe Cushing’s syndrome due to ectopic ACTH secretion: AM cortisol 173.4 µg/dL (5-25), ACTH 1425 pg/mL (7.2-63.3), 24 hour urine cortisol 29,498 mcg/24hr (4-50), DHEA-Sulfate 1314 µg/dL (65 - 380), and testosterone 133 ng/dL (0-100). She was also found to have severe hypokalemia, hypocalcemia and hyperglycemia (despite an HbA1C of 6.2 at 2 weeks before presentation). CT- scan showed diffuse thickening of the bilateral adrenal glands. Due to widely metastatic disease in the peritoneum, BAL was considered non-feasible. The patient was admitted to hospital and initiated on osilodrostat at 20mg twice daily (after correction of hypokalemia) with close monitoring of her electrolytes, cortisol, EKG and steroid withdrawal symptoms. There was a rapid improvement of cortisol levels in response to osilodrostat. During treatment, she developed steroid withdrawal symptoms for which she was started on medium dose hydrocortisone. Bilateral adrenal arterial embolization was attempted but ultimately needed to be converted to right only adrenal gland embolization due to a hypertensive urgency and difficulty with catheterization. Her symptoms of Cushing’s syndrome significantly improved with the treatment. During her hospitalization, her hypokalemia was managed with spironolactone and potassium supplement, hypocalcemia with calcium supplement, and hyperglycemia with basal and bolus insulins. With significant improvement of cortisol levels, her hypocalcemia and hyperglycemia resolved and required no further treatment. Her potassium levels normalized and spironolactone was stopped. She remains on potassium supplement to keep K level at upper half of normal range to avoid long QTc. After discharge, her morning cortisol levels (before morning dose of hydrocortisone) continued to decrease and her osilodrostat dose was gradually tapered to 5mg once daily at night. Hydrocortisone was continued as part of the block-and-replace regimen. Conclusion: This case described a unique sudden onset and rapid progression of ectopic ACTH dependent Cushing’s syndrome and successful utilization of a block-and-replace approach by using the steroidogenesis inhibitor osilodrostat in prompt control of the hypercortisolism and related comorbidities. We also explored the feasibility of adrenal embolization for definitive management in the context of unfeasible BAL. Presentation: 6/2/2024

Efficacy and safety of fenoldopam for the treatment of hypertensive crises in children with kidney disease: a retrospective study.

Hypertensive crises in children represent critical medical situations characterized by severe hypertension and potential organ damage. Fenoldopam, a dopaminergic medication, offers a viable therapeutic option for managing such clinical scenarios. We aimed to evaluate efficacy and safety of fenoldopam in the management of hypertensive urgencies and emergencies. This retrospective analysis focused on pediatric patients affected by acute or chronic kidney disease, aged 1month-18years, admitted to the Pediatric Nephrology and the Pediatric Intensive Care Unit at University-Hospital of Padua, Italy, who presented witha hypertensive crisis treated with fenoldopam between March 2010 and December 2022. The study included 74 patients with median age 10years (interquartile range [IQR] 4-15years) who received 102 fenoldopam infusions. Seventy-two percent were already receiving antihypertensive treatment before admission. In all cases, fenoldopam was associated with a reduction of blood pressure (BP) after 8h of treatment, but in 87% of patients reduction of the initial mean arterial pressure (MAP) was higher than 25% of calculated drop pressure. MAP normalized in 26% of cases after 24h and in35% after 48h. Occurrence of hypotension was 7%, while hypokalemia was observed in 13% of cases. Patients who presented a MAP reduction not exceeding 25% of calculated drop pressure received a lower median fenoldopam dose (0.2 mcg/kg/min; IQR 0.1-0.2) compared with patients having a MAP reduction > 25% of calculated drop pressure (0.4 mcg/kg/min; IQR 0.2-0.6; p = 0.002). Fenoldopam seems effective and safe for the treatment of hypertensive crises in children with kidney disease, at a starting dose of 0.2 mcg/kg/min. Strict BP monitoring is required to identify possible excessive drop pressure in the first hours of infusion.

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&gt;180 or DBP &gt;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&lt;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.

P150 HYPERTENSION URGENCY: GUIDELINES INDICATIONS AND IMPLEMENTATION IN CLINICAL PRACTICE

Background and objective: Unreasonable admissions to hospital increase costs of the health care system. The maximum transfer of medical care to outpatient setting is a trend in modern medicine. Hypertension urgency (HU) is not accompanied by acute hypertension-mediated target organ damage and is not an indication for hospitalization of the patient. In 2018-2020 ISH/ESH Guidelines have revised the term “HU” for “uncontrolled hypertension”, approaches to its diagnosis and treatment. The purpose of the study is to evaluate the implementation of the Guidelines in real clinical practice. Methods: A single-center retrospective study was conducted in a private family medicine clinic, which has been observing a large number of patients of different age and gender for more than 30 years. The clinic has an emergency department, a hospital with 60 beds. Medical records of consecutive patients aged ≥18 years admitted to hospital in 2018 and 2023 with systolic blood pressure at admission ≥180 mmHg and/or diastolic blood pressure ≥110 mmHg were collected and analyzed. Results: The prevalence of patients admitted according to the chosen criteria was 0.8% (n=25) in 2018 and 0.9% (n=26) in 2023. According to the clinical characteristics and signs of acute damage to target organs (acute coronary syndrome, acute stroke, pulmonary embolism), 4% and 7.7% of cases in 2018 and 2023, respectively, were considered as hypertension emergencies. HU was diagnosed in other cases — 96% and 92.3%. HU was the direct cause of admission in 23.1% of cases in 2018 and in 28% of cases in 2023, in other cases - 69.2% (2018) and 64% (2023) hospitalization was due to another disease (pneumonia, neurological diseases, etc.). The probable causes of HU were patient non-compliance with antihypertensive drug therapy- 50% (2018) and 57% (2023), resistant hypertension, stress. Conclusions: The prevalence of patients admitted due to HU has not significantly changed. The most probable cause of HU is non-compliance with antihypertensive treatment, self-termination of treatment.

Abstract P399: Defining A Negative Space: A Scoping Review of Hypertension

Study Objectives: This scoping review seeks to examine the existing body of literature to reveal consensus or absence thereof regarding the definition and management strategies for asymptomatic hypertension. Methods: The review was conducted using Joanna Briggs Institute guidelines. We searched the CINAHL (EBSCO), Scopus, Ovid EMBASE, and PubMed (MEDLINE) databases using keywords and index terms (“hypertension”, “high blood pressure”, “elevated blood pressure”, “asymptomatic”, “symptomless”, “symptom free”, “emergenc*”, “urgent”) to identify adult patients with hypertension in an emergency or outpatient setting. After review and quality assessment, we retained 35 texts for inclusion. Results: The definition of “asymptomatic hypertension” varied widely between the texts. There was significant variation in which society or academic guideline served as the reference and what the blood pressure cut offs were; all specified a lack of end-organ damage. A majority included a definition for hypertensive urgency, most commonly based on elevated blood pressure with vague symptoms. End-organ damage was poorly defined – studies instead described the absence of hypertensive emergency. The most common emergencies mentioned were myocardial infarction, renal failure, and hypertensive encephalopathy. Of the texts which provided recommendations, all recommended a thorough history and physical examination. Only one study recommended additional testing for asymptomatic patients – an ECG and creatinine test. Treatment recommendations for asymptomatic patients relied predominantly on ACEP clinical policy, with a majority of studies advocating for gradual reduction of blood pressure rather than an immediate one, as well as referral for outpatient management. Conclusion: There is a need for unified guidelines on the definition and management of asymptomatic hypertension to ensure effective and consistent patient care. Additionally, there is no consensus for further diagnostic testing in patients with a negative history and physical exam, and there is strong agreement that rapid blood pressure decrease in asymptomatic patients can be detrimental. Addressing this gap in guideline consistency and evidence base could enhance clinical outcomes and streamline healthcare processes across different settings. Future research should focus on establishing consensus and developing management strategies that are adaptable to both emergency and primary care environments.

A Curriculum on Advanced Topics in Hypertension for Internal Medicine Residents.

Hypertension (HTN) affects nearly half of US adults. Our multi-institutional survey revealed that Internal Medicine residents lack proficiency in advanced HTN topics. We developed a curriculum to address knowledge gaps in these topics and aimed to assess the effects of the curriculum on residents' confidence, desire for future training, and knowledge in advanced HTN topics. HTN experts taught four advanced topics in HTN: conducting a workup for secondary HTN, managing HTN in chronic kidney disease, managing HTN in patients who are or may become pregnant, and managing hypertensive urgency (severe asymptomatic HTN) in the outpatient setting. The setting of the curriculum was an ambulatory educational half-day, during which residents rotated through small-group sessions dedicated to each HTN topic. We developed pre-, immediate post-, and 8 weeks postcurriculum surveys assessing residents' confidence and desire for future training in the four topics (4-point Likert scales), and multiple-choice quizzes to assess changes in knowledge. We used repeated-measures analysis of variance to compare means between time points for surveys and quizzes. A total of 112 Internal Medicine residents participated in the curriculum. The mean confidence scores for all four topics increased from 1.79 to 2.61 precurriculum to 2.90 to 3.45 immediately postcurriculum (all P < 0.001) and remained higher (2.53-3.18) than precurriculum at 8 weeks postcurriculum (all P < 0.02). The mean desire for future training scores decreased from 2.74 to 2.96 precurriculum to 2.06 to 2.36 immediately postcurriculum (all P < 0.001 except for managing HTN in patients who are or may become pregnant, which was P = 0.17) and remained lower (2.08-2.36) than precurriculum at 8 weeks postcurriculum (all P ≤ 0.003). The mean knowledge score increased from 48% precurriculum to 62% immediate postcurriculum (P < 0.001) and remained higher (55%) than precurriculum at 8 weeks postcurriculum (P = 0.015). A curriculum on advanced HTN topics produced durable gains in confidence and knowledge and partially satisfied the desire for future learning among Internal Medicine residents.

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.

Serum Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand and the Cardiovascular Disease Continuum: Insights from Hypertensive Urgencies and Acute Heart Failure Events

Background: Although TRAIL is a potent propapoptotic factor, its role in cardiovascular disease (CVD) remains unclear. This pilot exploratory study investigated serum TRAIL changes along the CVD continuum. We focused on two successive phases of this spectrum (systemic arterial hypertension and heart failure), with emphasis on acute cardiac events due to their immediate clinical significance. Methods: The study population included 90 age- and sex-matched patients hospitalized with hypertensive urgencies (HTUs) or acute decompensation episodes (ADHF). Key echocardiographic, endothelial, cardiometabolic, renal, and liver markers were assessed alongside TRAIL levels. Results: ADHF patients showed significantly elevated TRAIL concentrations, suggesting a progressive rise in TRAIL levels along the CVD continuum. They exhibited worse cardiac, hematologic, and renal profiles, with longer hospital stays and the cachexic phenotype. TRAIL correlated directly with asymmetric dimethylarginine, C-reactive protein, and admission potassium in ADHF patients. In hypertensive subjects, it correlated directly with asymmetric dimethylarginine and inversely with erythrocyte size variability. TRAIL may, thus, serve as a compensatory mechanism in HF, with potential as a biomarker for acute cardiovascular events. Conclusions: TRAIL dynamics provide valuable insights into CVD pathophysiology, particularly in acute settings, warranting further investigation to clarify its role in the broader context of apoptosis and cardiovascular health.

Comparison of clevidipine vs nicardipine in the treatment of hypertensive urgency and emergency in critically ill patients.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Evidence has suggested that clevidipine may provide faster blood pressure (BP) reduction with less volume than nicardipine in stroke and cardiothoracic surgery patients, but its use in hypertensive crises has not been well established. The primary objective of this study was to compare the treatment success of clevidipine and nicardipine in hypertensive crisis. This was a multicenter, retrospective cohort study including patients who received either clevidipine or nicardipine for treatment of hypertensive crisis. The primary outcome was the time from infusion start to attainment of goal BP, defined as the higher value of the guideline-directed 25% reduction in BP or the physician-ordered goal. Secondary outcomes were the time from infusion start to guideline-directed 25% reduction in BP, drug and total volume intake, the time from order entry to BP goal attainment, the number of BP and heart rate excursions, intensive care unit (ICU) length of stay, and study medication cost. In total, 182 patients were included in the study (103 receiving nicardipine and 79 receiving clevidipine). Time to goal BP was similar between the groups (35 vs 33 minutes for clevidipine vs nicardipine, respectively; P = 0.37). Time to guideline-directed 25% reduction was also similar (P = 0.42). Volume from study drug was significantly less with clevidipine (222 vs 518mL; P = 0.01); however, the total volume received in the ICU was similar (3,370 vs 3,383mL; P = 0.43). Percent time in the goal BP range was similar (43.1% vs 42.3%). The cost of clevidipine was $199.37 per vial (based on the average wholesale price as of June 2023). This cost was 682% higher than that for a bag of nicardipine. Time to goal BP was similar for clevidipine and nicardipine in this population. Any decreases in medication-associated volume with clevidipine were no longer evident when all volume sources were considered. These results show that clevidipine may not provide meaningful benefit in this heterogenous population. The difference in cost does not seem justified given the lack of improvement in clinically relevant outcomes.

Nursing Care for Mrs. W Diagnosed with Hypertensive Urgency using Foot Massage Therapy in the Emergency Department

Hypertensive emergency is a hypertensive crisis characterized by a sudden increase in blood pressure of 180/110 mmHg without organ damage. Hypertensive disease has increased every year due to low awareness of compliance in taking medication and maintaining a healthy lifestyle in hypertensive patients. The purpose of this case study is to provide nursing care to patients experiencing hypertension urgency. This research method uses a qualitative approach with case studies as the main method, using observation sheets, interviews, and documentation studies. This case study chose one patient as the research subject, namely a patient with hypertensive urgency in the emergency room of Gunung Jati Hospital, Cirebon City. Nursing care management is based on meeting the needs of patients carried out in 1 day. The results of the case study showed that after being given nursing care there was a decrease in blood pressure from 195/110 mmHg to 187/104 mmHg. The conclusion is that the nursing care provided is effective in emergency hypertension patients and meets the needs of patients. The implication of this study is the importance of nursing care in managing hypertension emergencies, which can help in the effective monitoring and management of this disease. In addition, this study also strengthens the understanding of the importance of patient compliance in managing hypertension to prevent complications that can arise.

Drugs for hypertension.

American College of Cardiology/American Heart Association (ACC/AHA) guidelines for treatment of hypertension were last published in 2018.1 Treatment of hypertensive urgencies and emergencies is not discussed here.

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%.