IMPORTANCEThe prevalence and short-term outcomes of hypertensive urgency (systolic blood pressure Ն180 mm Hg and/or diastolic blood pressure Ն110 mm Hg) are unknown. Guidelines recommend achieving blood pressure control within 24 to 48 hours. However, some patients are referred to the emergency department (ED) or directly admitted to the hospital, and whether hospital management is associated with better outcomes is unknown.OBJECTIVES To describe the prevalence of hypertensive urgency and the characteristics and short-term outcomes of these patients, and to determine whether referral to the hospital is associated with better outcomes than outpatient management. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study with propensity matching included all patients presenting with hypertensive urgency to an office in the Cleveland Clinic Healthcare system from January 1, 2008, to December 31, 2013. Pregnant women and patients referred to the hospital for symptoms or treatment of other conditions were excluded. Final follow-up was completed on June 30, 2014, and data were assessed from October 31, 2014, to May 31, 2015.EXPOSURES Hospital vs ambulatory blood pressure management. MAIN OUTCOMES AND MEASURESMajor adverse cardiovascular events (MACE) consisting of acute coronary syndrome and stroke or transient ischemic attack, uncontrolled hypertension (Ն140/90 mm Hg), and hospital admissions. RESULTSOf 2 199 019 unique patient office visits, 59 836 (4.6%) met the definition of hypertensive urgency. After excluding 851 patients, 58 535 were included. Mean (SD) age was 63.1 (15.4) years; 57.7% were women; and 76.0% were white. Mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 31.1 (7.6); mean (SD) systolic blood pressure, 182.5 (16.6) mm Hg; and mean (SD) diastolic blood pressure, 96.4 (15.8) mm Hg. In the propensity-matched analysis, the 852 patients sent home were compared with the 426 patients referred to the hospital, with no significant difference in MACE at 7 days (0 vs 2 [0.5%]; P = .11), 8 to 30 days (0 vs 2 [0.5%]; P = .11), or 6 months (8 [0.9%] vs 4 [0.9%]; P > .99). Patients sent home were more likely to have uncontrolled hypertension at 1 month (735 of 852 [86.3%] vs 349 of 426 [81.9%]; P = .04) but not at 6 months (393 of 608 [64.6%] vs 213 of 320 [66.6%]; P = .56). Patients sent home had lower hospital admission rates at 7 days (40 [4.7%] vs 35 [8.2%]; P = .01) and at 8 to 30 days (59 [6.9%] vs 48 [11.3%]; P = .009). CONCLUSIONS AND RELEVANCEHypertensive urgency is common, but the rate of MACE in asymptomatic patients is very low. Visits to the ED were associated with more hospitalizations, but not improved outcomes. Most patients still had uncontrolled hypertension 6 months later.

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AimsThe utility of combined assessment of both frailty and cognitive impairment in hospitalized heart failure (HF) patients for incremental post‐discharge risk stratification, using handgrip strength and Mini‐Cog as feasible representative parameters, was investigated.Methods and resultsA prospective, single‐centre cohort study of older adults (age ≥65) hospitalized for HF being discharged to home was performed. Pre‐discharge, grip strength was assessed using a dynamometer (Jamar hydrolic hand dynamometer, Lafayette Instruments, Lafayette, IN, USA) and was defined as weak if the maximal value was below the gender‐derived and body mass index‐derived cut‐offs according to Fried criteria. Cognition was assessed using the Mini‐Cog. The presence of impairment was defined as a score of <2. Outcome measures were all‐cause readmission or emergency department visit (primary) or all‐cause mortality (secondary) at 6 months. A total of 56 patients (mean age 77 ± 7 years, 73% male) were enrolled. The majority (n = 33, 59%) had weak grip strength, either with (n = 5) or without (n = 28) cognitive impairment. The highest risk for both readmission and mortality occurred in those with weak grip strength and cognitive impairment in combination (log‐rank P < 0.0001 and P = 0.01, respectively).ConclusionsPatients who are frail by grip strength assessment and cognitively impaired according to severely reduced Mini‐Cog performance show the worst midterm post‐discharge outcomes after HF hospitalization.

Background— Heart failure (HF) guidelines recommend screening for cognitive impairment (CI) but do not identify how. The Mini-Cog is an ultrashort cognitive “vital signs” measure that has not been studied in patients hospitalized for HF. The purpose of this study was to evaluate whether CI as assessed by the Mini-Cog is associated with increased readmission or mortality risk after hospitalization for HF. Methods and Results— We analyzed 720 consecutive patients who completed the Mini-Cog as a part of routine clinical care during hospitalization for HF. Our primary outcome was time between hospital discharge and first occurrence of readmission or mortality. There was a high prevalence of CI as quantified by Mini-Cog performance (23% of cohort). During a mean follow-up time of 6 months, 342 (48%) patients were readmitted, and 24 (3%) died. Poor Mini-Cog performance was an independent predictor of composite outcome (adjusted hazard ratio, 1.90; 95% confidence interval, 1.47–2.44; P <0.0001) and was identified as the most important predictor among 55 variables by random survival forest analysis. Inclusion of Mini-Cog performance in risk models improved accuracy (bootstrapped c -index, 0.602 versus 0.624) and risk reclassification (category-free net reclassification improvement, 27%; 95% confidence interval, 14%–40%; P <0.001). Secondary analysis of initial 30 days post discharge showed effect modification by venue of discharge, whereby patients with CI discharged to a facility had longer time to outcome as compared with those discharged home. Conclusions— Mini-Cog performance is a novel marker of posthospitalization risk. Discharge to facility rather than home may be protective for those patients with HF and CI. It is unknown whether structured in-home support would yield similar outcomes.