emergency hypertension. what are the missing … term ‘hypertension urgency’ has also been used...

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



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%


(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

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


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


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

http://journals.lww.com/amjmedsci/toc/1930/07000

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


(approximated)

Vlcek M, 2008 384 6 %

Merlo C, 2012 50 6 %

Patel KK, 2016 58.535 1,8 %

Guiga H, 2017 285 8,9%


(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

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

emergency hypertension. what are the missing … term ‘hypertension urgency’ has also been used...

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