EMERGENCY HYPERTENSION.
WHAT ARE THE MISSING DATA?
Maria Lorenza Muiesan
- TRUE PREVALENCE OF HYPERTENSIVE EMERGENCIES (INCLUDING
ACUTE HYPERTENSIVE MICROANGIOPATHY OR MALIGNANT HT)
- «HYPERTENSIVE URGENCY» VS «UNCONTROLLED HT»
- IMPACT OF ACUTE HYPERTENSION-MEDIATED ORGAN DAMAGE ON
FUTURE CARDIOVASCULAR RISK
- OPTIMAL TREATMENT STRATEGY FOR MOST HYPERTENSIVE
EMERGENCIES
- OPTIMAL FOLLOW-UP
Hospital Admissions for Hypertensive Emergencies and Urgencies
<
Pinna et al , 2014
Trends in the Incidence of Hypertensive Emergencies in US Emergency Departments From 2006 to 2013
J Am Heart Assoc. 2016;5:e004511
incidence of 1640 per million adult ED visits in 2013, yielding an estimated rate increase of 13.9% per year
35%
Monthly hospitalizations of patients diagnosed with malignant hypertension, hypertensive
encephalopathy, essential hypertension, and the 3 series combined in the United States
(Nationwide Inpatient Sample, 2000–2011).
Linnea A. Polgreen et al. Hypertension. 2015; 65:1002-1007
The dramatic increase in the number of hospital admissions for hypertensive encephalopathy and malignant hypertension should have resulted in dramatic increases in morbidity, but it did not. The change is most likely related to changes in coding related to diagnostic-related groups that occurred in 2007.
)Incidence of malignant hypertension in the Amsterdam multiethnic population
(August 1993- 2005)
The annual incidence of all-cause mortality is 2.6 per 100 patient-years compared with normotensive (0.2) and hypertensive (0.5) controls (both P<.01)Amraoui et al J Clin Hypertension 2014
Van den Born J Hypertens 2006
Journal of Hypertension 2017, 35:2310–2314
351 patients who had at least 5-year
history of malignant hypertension
West Birmingham Malignant Hypertension Registry
An Italian survey: progetto GEAR (Gestione dell’Emergenza e urgenza in ARea critica)
Submitted
667 questionnaires
Hypertension emergencies are situations in which severe hypertension (grade 3) is associated with acute HMOD, which is often lifethreatening and requires immediate but careful intervention to lower BP, usually with intravenous(i.v.) therapy.
Stratification of hypertensive emergencies according
to the condition or target organ involved
van den Born BH et al, Eur Heart J Cardiovasc Pharmacother. 2018
The term ‘hypertension urgency’ has also been used to describe severe hypertension in patients presenting to the emergency department in whom there is no clinical evidence of acute HMOD. Whilst these patients require BP reduction, they do not usually require admission to hospital,and BP reduction is best achieved with oral medication according to the drug treatment algorithm. However, these patients will require urgent outpatient review to ensure that their BP is coming under control
Asymptomatic uncontrolled hypertensionSBP or DBP >180 or >110 mmHg, respectively, in which OD is excluded
van den Born BH et al, Eur Heart J Cardiovasc Pharmacother. 2018
van den Born BH et al, Eur Heart J Cardiovasc Pharmacother. 2018
Key target organs :the aorta, heart, brain, retina & kidneys
Acute BP increase (>180/110)
Absence of organ damage Presence of organ damage
Author NCV risk/ year
(approximated)
Vlcek M, 2008 384 6 %
Merlo C, 2012 50 6 %
Patel KK, 2016 58.535 1,8 %
Guiga H, 2017 285 8,9%
Author NCV risk/ year
(approximated)
Keith NM, 1939 200 78%
Guiga H, 2017 385 39%
Event-rate in emergencies and urgencies
(events/100pts/yrs)
14,5
11,8
7,5
42,7
4,33,5
0
5
10
15
Emergencies
4.53.6
1.9 1.70.9
1.7 2.3
0
5
10
15
Urgencies
Clinica Medica Università di Brescia & DEA Spedali Civili di Brescia, Muiesan et al ESH 2011
Cardiovascular event-rate during FU
Event-rate in emergencies and urgencies
(events/100pts/yrs)
14,5
11,8
7,5
42,7
4,33,5
0
5
10
15
Emergencies
4,53,6
1,9 1,7 0,9 1,7 2,3 2,380,9
0
5
10
15
Urgencies
Clinica Medica Università di Brescia & DEA Spedali Civili di Brescia, Muiesan et al ESH 2011
Cardiovascular event-rate during FU
diagnostic studies in patients withsuspected hypertensive emergency
For all
On indication
Patient evaluation
Katz JN et al Am Heart J 2009
STAT registry(Studying The Treatment
of Acute hyperTension)
1,588 patients from 25 sites
Median age 58 years
49% women
56% African-American
Traditional ophtalmoscope Smartphone small optical device (D-Eye, Si14 S.p.A.)
Muiesan Ml et al J Hypertens 2017
2 observers (1 trained not expert, 1 expert ophtalmologist )
•ESH/ESC guidelines 2018 and ESC/ESH position paper Eur Heart J Cardiovasc Pharmacother. 2018
•ESH/ESC guidelines 2018 and ESC/ESH position paper Eur Heart J Cardiovasc Pharmacother. 2018
Critical Care 2011
Among patients with initial hospitalization for acute hypertensive emergency 17,8 % were hospitalized again within 30 days of the index admission.
Two prevalent conditions: acute HF, CKD
Kumar N et al. Thirty-day readmissions after hospitalization for hypertensive emergency. Hypertension. 2019
Need for a follow-up
• patients with hypertensive emergencies may have this condition because they are not adherent to their medications
• follow-up will allow for educating the patient about home BP monitoring that may improve hypertension control
• medications may not be enough to improve BP
• some patients with acute hypertensive emergencies may have a secondary cause for hypertension and an investigation for secondary hypertension is needed
An Italian survey: progetto GEAR (Gestione dell’Emergenza e urgenza in ARea critica)
Are you aware of a protocol
for the management of
hypertensive
emergencies/urgencies ?
Are you using a fast-track for short
term re-evaluation of patients with
hypertensive emergencies/urgencies by
an hypertension specialist in your
hospital?
Yes No I don’t know Yes No
Submitted
An Italian survey: progetto GEAR (Gestione dell’Emergenza e urgenza in ARea critica)
Visita specialistica
ABPM
Controllo PA domiciliare
Valutazione del MMG
Visita presso centro ipertensione
0
20
40
60
80
100
<25% dei casi Nel 50% dei casiNel 75% dei casiNel 100% dei casi
Park SK et al, J Hypertens 2017;35:1474-1480
CLINICAL EFFICACY OF RESTING VS ANTI-HYPERTENSIVE
TREATMENT IN HYPERTENSIVE URGENCIES
N.138 patients with hypertensive urgency randomized to resting vs resting + telmisartan 80 mg
EPISTASSI
✓60% della popolazione
✓PRIMARIE / SECONDARIE
✓Anteriori / posteriori
American Journal of the Medical Sciences: July 1930 - Volume 180 - Issue 1 - ppg 47-58
Epistaxis and hypertension
Kikidis D et al Eur Arch Otorhinolaryngol 2014;271(2):237-43.
Studies evaluation the relationship between epistaxis and hypertension
BP and epistaxis
Systolic BP Diastolic BP
*
126 subjects (84 M, age range 15-93 yrs march 2014-february 2015
Personal data, 2015
Conclusions The presence of high arterial blood pressure during the actual episode of nasal bleeding cannot establish a causative relationship with epistaxis, because of confounding stress and possible white coat phenomenon, but may lead to initial diagnosis of an already installed arterial hypertension.
Target BP
mmHg
Timeline for BP
reduction
Baseline BP
Acute aortic dissection SBP < 120 ( lower if
tolerated)
+ HR < 60bpm
Minutes >150
Acute pulmonary
edema
SBP < 140 Minutes >160
Coronary ischemia
(ACS)
SBP < 140 Minutes- slow >160
Severe pre-
eclampsia/HELLP
SBP / DBP < 160/105 Minutes/hours >160/105
Hypertensive
encephalopathy
< 180
MAP 20-25 %
Minutes >220 /120
Ischemic stroke 15 % MAP 1 hour >220/120
Ischemic stroke +
Thrombolysis
SBP< 185 first 24 hours
SBP< 180 after
thrombolysis
1 hour >185
Acute hemorrhagic
stroke
SBP< 180 to < 140 Minutes >180
Malignant hypertension SBP < 180
MAP 20-25 %
Hours >220
ESH/ESC guidelines 2018
Cerebral edema consequenceof an acute hyperperfusion
Symptoms : severe hypertensionseizures, lethargy, cortical blindness and coma, in the absence of an alternative explanation
Histopathological changes :cerebral oedema, microscopichaemorrhages and infarctionsPosterior reversible encephalopathysyndrome (PRES)
Hypertensive encephalopathy
10 % patients with malignant hypertension
Uncontrolled hypertension (>180/110)
Absence of organ damage Presence of organ damage
Author NCV risk/ year
(approximated)
Vlcek M, 2008 384 6 %
Merlo C, 2012 50 6 %
Patel KK, 2016 58.535 1,8 %
Guiga H, 2017 285 8,9%
Author NCV risk/ year
(approximated)
Keith NM, 1939 200 78%
Guiga H, 2017 385 39%
Shah M et al. Am J Hypertens. 2016
Trends in hospitalization for hypertensive emergency
2002–2012 nationwide inpatient sample database to identify patients with HTNE129,914 admissions, 630 (0.48%) patients died during their hospital stay
Presence of acute cardiorespiratory failure, stroke/TIA, chest pain, and aortic dissection were most predictive of higher hospital mortality.
Prospective analysis
77154 patients admitted to ED
University Hospital Brescia
during the year 2010
1728 (2.2%)
patients with hypertensive
emergencies or urgencies
1551 (90%)
20%
80%
Emergencies
Urgencies
Age 70 ± 14 yrs,
range 18-102
M 44 %; females 56 %
Clinica Medica Università di Brescia & ED Spedali Civili di Brescia, Muiesan ML et al abst ESH 2011
Clinica Medica University of Brescia & ED Spedali Civili Brescia,
Cardiovascular events*
Follow up (days)
Log Rank (Mantel-Cox) p<0.001
Emergencies
Urgencies
Emergencies
Urgencies
Log Rank (Mantel-Cox) p<0.0001
* Acute coronary syndromes, cerebrovascular events or hospitalizations for heart failure
0
4
8
12
16
20
Urgencies Emergencies
Events/100 patients/years
Muiesan et al, J Hypertens 2011 (abst)
The optimum therapy, treatment is dictated by consensus on the basis of:- particular presentation of the clinical situation- end-organ complications
-not on the absolute value of blood pressure
BP lowering target/timing in hypertensive emergency
European Society of Hypertension &European Society of Cardiology , 2013
• Reduce blood pressure by <25% during ‘‘first hours’’ and then subsequent cautious reduction.
• Intravenous agents most usually employed: labetalol, sodium nitroprusside, nicardipine, nitrates, and furosemide.
AHA/ACC , 2017• For adults with a compelling condition (i.e., aortic dissection, severe
preeclampsia or eclampsia, or pheochromocytoma crisis), SBP should be reduced to less than 140 mm Hg during the first hour and to less than 120 mm Hg in aortic dissection.
• For adults without a compelling condition, SBP should be reduced by no more than 25% within the first hour; then, if stable, to 160/100 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours.
• In adults with a hypertensive emergency, admission to an intensive care unit is recommended for continuous monitoring of BP and target organ damage and for parenteral administration of an appropriate agent
van den Born BH et al, Eur Heart J Cardiovasc Pharmacother. 2018
Drug of choice Alternative
Acute aortic dissection Nitroprusside/NTG + esmolol Labetalol, Metoprolol
Verapamil or diltiazem
Acute pulmonary edema Furosemide
NTG/nitroprusside / CPAP
Urapidil
Clevidipine
Coronary ischemia (ACS) NTG
Labetalol
Clevidipine
Urapidil
Hypertensive
encephalopathy
Labetalol
Nicardipine
Nitroprusside
Ischemic stroke Labetalol
Nicardipine
Nitroprusside
Ischemic stroke +
Thrombolysis
Labetalol
Nicardipine
Nitroprusside
Acute hemorrhagic
stroke
Labetalol
Nicardipine
Urapidil
Malignant hypertension
with or without ARF
Labetalol
Nicardipine
Nitroprusside, Urapidil,
fenoldopam , clevidipine
Severe pre-
eclampsia/HELLP
Labetalol
Nicardipine + Magnesium sulphate
Consider delivery
ESH/ESC guidelines 2018
ULTIMA DIAPOSITIVA
Congresso Nazionale AcEMC 2018 - Pisa
Treatment aspects of hypertensive emergencies and urgencies vary widely according to a patient’s clinical conditions and are largely based on consensus from clinical experience , observations and comparisons of intermediate outcomes
Further research is needed to assess the impact of acute hypertension-mediated organ damage on future cardiovascular risk and its therapeutic consequences in these patients
Flow chart for acute BP elevation
[
]
Muiesan ML et al ESH Manual of Hypertension 2018
Treatment aspects of hypertensive emergencies and urgencies vary widely according to a patient’s clinical conditions and are largely based on consensus from clinical experience , observations and comparisons of intermediate outcomes
Further research is needed to assess the impact of acute hypertension-mediated organ damage on future cardiovascular risk and its therapeutic consequences in these patients
Conclusions