Where Should Hypertensive Urgency Be Treated?
October 13th, 2016
CLEVELAND – When patients present to physician practices with hypertensive urgency — systolic blood pressure (BP) at least 180mm HG and diastolic BP at least 110 mm Hg — where should they be treated? At that outpatient location or referred to a hospital?
That is the question addressed recently in JAMA Internal Medicine. Background information in the article notes that physicians might be concerned about the potential for organ damage after severely elevated BP, even for a short time. On the other hand, few observational studies or randomized trials have reviewed the management of hypertensive urgency, which often is evaluated and treated in EDs.
To help formulate an answer, Cleveland Clinic researchers conducted a study of all patients presenting with hypertensive urgency to one of the healthcare system’s offices from 2008 through 2013.
The study's final sample included 58,535 patients, almost 58% of whom were women. Most were white, with an average BMI of about 31, and an average systolic BP of 182.5 mm Hg and an average diastolic BP of 96.4 mm Hg.
Of those, only 426 patients (0.7%) were referred to the hospital for blood pressure management, while the rest were sent home.
In an analysis that matched the 426 patients referred to the hospital with 852 patients who were sent home, no significant differences were uncovered in major adverse cardiovascular events in one week, one month, or in six months, results indicated.
Yet, patients who were sent home were more likely to have uncontrolled blood pressure at one month but not at six months. About two-thirds of all patients still had uncontrolled blood pressure at six months, however.
Patients who were sent home also had lower hospital admission rates at seven days, the study showed.
"Hypertensive urgency is common in the outpatient setting. In the absence of symptoms of target organ damage, most patients probably can be safely treated in the outpatient setting, because cardiovascular complications are rare in the short term,” the study authors concluded. “Furthermore, referral to the ED was associated with increased use of healthcare resources but not better outcomes.”
Finally, patients with hypertensive urgency are at high risk for uncontrolled hypertension as long as six months after the initial episode. Efforts to improve follow-up and intensify antihypertensive therapy should be pursued, the researchers concluded.