Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting

Abstract

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.

Hypertensive Urgency—Is This a Useful Diagnosis?

“…The authors' very reasonable hypothesis is that "ambulatory patients with hypertensive urgency would have low rates of cardiovascular events in the short term and that referral to the hospital would not improve outcomes." 1 The study substantiates this conjecture. Perhaps unsurprisingly, patients who felt well turned out to be well, and experienced a very small number of serious sequelae.…”

Conditional prescriptions of oral antihypertensive drugs for the management of hypertension urgencies in the inpatient setting: An observational study

“…Finally, we found no evidence in the literature to support the initiation of antihypertension treatment for asymptomatic acute hypertension . Moreover, several studies have shown that hypertension urgencies are not associated with an elevated risk of major adverse cardiovascular events or intracerebral haemorrhage …”

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

“…In addition to implications for the ED, these data also have potential bearing on how patients with markedly elevated BP should be approached in non‐ED settings, suggesting that referral to the ED for fear of a hypertensive emergency may not be necessary in the vast majority of cases. Indeed, 1 retrospective study found that patients with hypertensive urgency treated in an office setting are not any more or less likely to have a major cardiovascular event compared to patients referred to the ED or hospital . Even among those actually admitted to the hospital, like those patients we defined as hypertensive emergency in the present analysis, charges for ED visits we characterized as hypertensive emergency have risen in the period from 2006 to 2013.…”