Dissertation committee:
Πέτρος Νιχογιαννόπουλος, Ομότιμος Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Γεώργιος Στεργίου, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Κωνσταντίνος Τσιούφης, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Χαράλαμπος Βλαχόπουλος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Κωνσταντίνα Αγγέλη, Καθηγήτρια, Ιατρική Σχολή, ΕΚΠΑ
Αναστάσιος Κόλλιας, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Ευστάθιος Μανιός, Αναπληρωτής Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Summary:
Clinical profile, management and outcomes of hypertensive crises in the emergency department of a tertiary Hospital: A 12-month registry and 1-year follow-up study.
Aims: Currently there are few data regarding prevalence, clinical phenotype, therapy, as well as prognosis of patients with hypertensive urgencies (HU) and emergencies (HE). The purpose 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. Following, our study aimed to compare cardiovascular (CV) outcomes of HE, HU, and Hypertensive patients without urgencies or emergencies (HP) during a 12-month follow-up period, while examining predisposing factors i.e. sex.
Methods: The population consisted of patients presenting with HE and HU in the ED (acute increase in systolic blood pressure ≥ 180mmHg and/or diastolic blood pressure ≥120mmHg with and without acute target organ damage, respectively). The registered patients were subsequently referred to our hypertension center for follow-up. After completing scheduled follow-up visits, patients with HU were retrospectively matched one-to-one by age, sex, and hypertension history with HP patients who attended our hypertension center during the same period. Primary outcomes were a) recurrent hypertensive crisis (HC) and b) fatal and non-fatal cardiovascular (CV) events (coronary heart disease, stroke, heart failure, or CV interventions), while secondary outcomes were a) all-cause death, b) non-CV death, and c) hospitalization for any cause. Events were prospectively registered for all three groups. Finally, after stratification of HC for sex one-year outcomes were determined in these patients after hospital discharge.
Results: Out of 38,589 patients assessed in the ED during a 12 month-period, 353 (0.91%) had HC, 256 (72.5%) cases presented as HU and 97 (27.5%) as HE. Primary causes for all HC 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 dyspnea (67%), chest pain (30.2%), dizziness/headache (10.3%) and neurological disorders (8.2%). In HE, the underlying associated conditions were pulmonary edema (58%), acute coronary syndrome (22.6%), and neurological disorders/stroke (7.2%). All HE cases were hospitalized receiving intensive health care, including dialysis, while 2 of them died. During the 12-month follow-up, 81 patients were excluded for not completing the visits. Among eligible patients (HE, n=94; HU, n=178), a total of 90 hospitalizations and 14 deaths were recorded; HE registered greater CV morbidity, when compared with HU (29 vs 9, ΗR 3.43, 95% CI 1.7 - 6.9, p=0.001), and increased CV mortality (8 vs 1, ΗR 13.2, 95% CI 1.57 - 110.8, p=0.017). When opposing HU to HP, events did not differ substantially. After stratification of the HE by sex, men recorded more events than women (27 vs. 13, HR 2.2, 95% CI 1.03-4.7, p=0.042). Cox regression models were adjusted for age, sex, CV and chronic kidney disease, diabetes mellitus, smoking.
Conclusions: This one-year single-center 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 reported triggers of HC. Dizziness and headache were the prevalent symptoms of HU patients while heart failure was the most common underlying disease in patients with HE. During 1-year follow-up the prognosis of HU was better than HΕ, but not different compared to HP. In addition, our study raises the hypothesis that male sex in HE patients is independent risk factor for CV outcomes. These results highlight the need for improved care of HE and the HU phenotype, especially men.
Keywords:
Hypertensive emergencies, Hypertensive urgencies, Hypertensive patients, management, sex, outcomes, prognosis
