Pharmacological blood pressure control and outcomes in patients with hypertensive crisis discharged from the emergency department

Abstract

Pharmacological blood pressure (BP) intervention for high blood pressure is controversial for a wide spectrum of hypertensive crisis in the emergency department (ED). We evaluated whether medical control of BP altered the short- and long-term outcomes among patients with hypertensive crisis who were discharged from the ED under universal health care. This retrospective cohort comprised 22 906 adults discharged from the ED of a tertiary hospital with initial systolic BP ≥ 180 mmHg or diastolic BP ≥ 120 mmHg between 2010 and 2016. The main exposure was the use of antihypertensive medication during the ED stay. Clinical endpoints were revisits to the ED or inpatient admission (at 7, 30, and 60 days), cardiovascular mortality (at 1, 3, and 5 years), and incident stroke (at 1, 3, and 5 years). The associations between pharmacological intervention for BP and outcomes were evaluated using multivariable Cox proportional-hazards models. Of the patient data analyzed, 72.2% were not treated pharmacologically and 68.4% underwent evaluation of end-organ damage. Pharmacological intervention for BP was significantly associated with a 11% and 11% reduced risk of hospital revisits within 30 or 60 days of discharge from ED, respectively, particularly among patients with polypharmacy. No association between pharmacological intervention for BP and incident stroke and cardiovascular mortality was observed. A revision of diagnostic criteria for hypertensive crisis is essential. Although pharmacological intervention for BP may not alter the long-term risk of cardiovascular mortality, it significantly reduces short-term health care utilization.

Hypertensive emergencies and urgencies: a preliminary report of the ongoing Italian multicentric study ERIDANO

“…To our knowledge, our study is currently the only one that prospectively and systematically assesses short-term (72 hours) BP control in office setting after ED discharge, except for a small study on 21 hypertensive patients in which 24h-ABPM immediately after discharge from the ED [ 47 ]. Approximately 90% of patients in our study were discharged from the ED with BP < 180/110 mmHg, thus no longer meeting the criteria for HU, for those without organ damage; a similar rate has been described in recent studies [ 48 , 49 ]. In about one-third of the cases, normal office BP was present at 72 hours after ED discharge; similar outcome than that reported, of about 20% at 2 weeks after discharge, in a retrospective study conducted in the Thai population [ 49 ], but very different from the previously cited Israeli report in which 17 out of 21 patients remained with a SBP > 180 mmHg 24 hours after ED discharge [ 47 ].…”

A 6-Months Outcome of Hypertensive Crisis According to Risk Factors

“…Our sample also had a significant proportion of patients with dyslipidemia (39.5%), which aligns with expectations given local dietary habits though it contrasts with findings from other studies conducted in Italy [5]. Blood pressure values at admission were similar in our study compared to other reports [5,8].…”

“…While we found a slight predominance of women (50.6%), some studies reported significantly higher percentages of men [7]. Additionally, the number of patients with a history of diabetes varied across different studies (6,7,8), possibly due to differences in therapy, lifestyle habits, ethnicity, and sample selection. The prevalence of smokers in our sample (29.6%) fell between the percentages reported in other studies, which could reflect differences in anti-smoking campaigns and patient reporting accuracy.…”

Treatment of Hypertensive Urgencies

“…Major organ systems included the central nervous, cardiovascular, renal, and gravid uterus. Activation of the renin-angiotensin aldosterone system seems to be significant in the pathophysiology of severe hypertension [11][12][13][14][15][16][17].…”