Hypertensive Emergency: Case Criteria, Sociodemographic Profile,and Previous Care of 100 Cases

NANCY M. BENNETT, MD, AND STEVEN SHEA, MD

Abstract: To study the frequency, cost, sociodemographicprofile, and previous care correlates of hospital admissions forhypertensive emergency, we used specific case criteria to identify aseries of 100 cases at Presbyterian Hospital in New York City.Approximately 58 cases were admitted per year. Mean length ofhospital stay was 1.8 days, 75 per cent of patients received intensivecare, and estimated annual hospital charges were $438,828 (1986dollars). Cases had severe hypertension on admission (mean systolicblood pressure, 229.8 mmHg; mean diastolic blood pressure, 143

IntroductionDespite major public health initiatives in the control of

hypertension,1 hypertensive emergency remains an impor-tant clinical problem. The causes of sudden severe hyper-tension are largely unknown2" but since the advent ofpharmacologic therapy for hypertension, these episodes arethought to be preventable by comprehensive care.5'6 Publichealth approaches to the comprehensive care of hypertensionutilize a sequential model that includes detection, patientawareness of the diagnosis, treatment, adherence, and bloodpressure control.7 Hypertensive emergency may occur as aresult of failure to achieve one or more of the goals of thissequence but no studies have identified the specific points offailure. In addition, no recent studies have characterized thepopulation at risk for this condition.

The lack of a generally accepted case definition and of aspecific International Classification of Disease8 code forhypertensive emergency has hindered epidemiologic inves-tigation that might have addressed these questions. Malig-nant hypertension, one category of hypertensive emergency,was originally described by Volhard and Fahr in 1914 as aclinical syndrome with pathologically distinct vascular le-sions.9 In 1928, Keith, et al, described hypertensive retinitis'0and in 1939 reported its prognostic significance." AlthoughKincaid-Smith described several cases of malignant hyper-tension without papilledema,21 the term "malignant hyper-tension" has generally been used since 1939 to describesevere hypertension with papilledema. 12-14 In 1955, Pereraintroduced the term "accelerated phase. " 15 Since then, manyinvestigators have defined accelerated hypertension by thepresence of retinal hemorrhages and exudates without papil-ledema, and malignant hypertension by the presence ofpapilledema.'6"17 Recently, the term "hypertensive emergen-cy" has been used to refer to a variety of clinical syndromesthat are caused or complicated by hypertension and requireimmediate treatment.'7-20 The International Classification ofDiseases, Revision 9 (ICD-9)8 classifies these entities asmalignant, benign, and unspecified hypertension (codes

From the Department of Medicine, College of Physicians & Surgeons andthe School of Public Health, Columbia University, New York, NY. Addressreprint requests to Nancy M. Bennett, MD, Division of General Medicine,Department of Medicine, College of Physicians & Surgeons, 622 West 168thStreet, New York, NY 10032. This paper, submitted to the Journal September3, 1987, was revised and accepted for publication December 3, 1987.Editor's Note: See also related editorial p 623 this issue.

© 1988 American Journal of Public Health 0090-0036/88$1.50

mmHg). Two-thirds had clinical evidence of acute arteriolitis. Caseswere predominantly young, male, Black or Hispanic, and of lowersocioeconomic status. At least 93 per cent of cases were previouslydiagnosed, and at least 83 per cent were aware of their diagnosis ofhypertension. Improved management of chronic hypertension ratherthan more intensive screening may be a useful strategy to reduce theincidence of hypertensive emergency. (Am J Public Health 1988;78:636-640.)

401.0, 401.1, 401.9); benign and malignant hypertensionspecified by the site of end-organ damage (codes 402-405);and hypertensive encephalopathy (code 437.2).

Recent epidemiologic data have been based on malignanthypertension alone. For example, the Statewide Planning andResearch Cooperative System (SPARCS),2' which reportshospital admission diagnoses in New York State, uses ICD-9codes and thus yields no information about the occurrence of"accelerated" hypertension or hypertensive emergency.Similarly, Lee and Alderman's study of declining mortalityfrom malignant hypertension in New York City between 1958and 1974 was based on death certificates specifying malignanthypertension.22

In this paper we report a case definition of hypertensiveemergency that includes cases without papilledema (malig-nant hypertension) and excludes other conditions complicat-ed by severe hypertension. We describe the clinical profileand sociodemographic background of 100 cases, and reportthat the great majority of cases occurred in previouslydiagnosed and treated hypertensives.

MethodsCase Definition and Ascertainment

Case criteria for hypertensive emergency, described inthe Appendix, were developed from a review of the litera-ture120 and revised in consultation with members of theDivisions ofNephrology and Cardiology in the Department ofMedicine, College of Physicians & Surgeons.

We used three methods of case ascertainment:* Admissions to Presbyterian Hospital in the years

1979-84 for malignant hypertension (ICD-9 codes 401.0,402.00, 402.01, 403.0, 404.0, 405.00 and 405.01) and hyper-tensive encephalopathy (437.2) were identified from comput-erized hospital discharge records. There were 145 suchadmissions among 140 patients with complete records avail-able for 128 (91.4 per cent) first admissions. Repeatedadmissions of five patients for hypertensive emergencyduring the study period were excluded from review. Of these128 first admissions coded for malignant hypertension orhypertensive encephalopathy, 67 met the case criteria forhypertensive emergency (Group I of the case series). Of the61 first admissions failing to meet case criteria, 53 weregrossly miscoded and eight did not meet our specific criteriafor hypertensive emergency. The most frequent coding errorwas coding cerebrovascular accidents in hypertensive pa-tients as hypertensive encephalopathy.

* We reviewed the charts of 48 randomly selected

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hospital admissions in 1979-84 with the primary diagnosis ofbenign hypertension (ICD-9 code 401.9). Eight of these 48admissions fulfilled our case criteria for hypertensive emer-gency (Group II of the case series).

* Cases were identified by surveillance of the MedicalService daily admission log from January through June 1986.There were 42 admissions among 40 patients for hyperten-sion. Two patients had second admissions for hypertensionduring the study period, but these second admissions wereexcluded from review. Complete records were obtained for36 (90 per cent) first admissions, and 25 met the case criteriafor hypertensive emergency (Group III of the case series).Three admissions were for reasons other than hypertension;eight other admissions failed to meet our case criteria.

These three case groups were combined for this caseseries. Homogeneity of the combined diagnostic categorywas assessed by examining differences among these threegroups with respect to resource utilization, demographic andsocioeconomic status, clinical characteristics, and previouscare indicators. We also compared cases with and withoutpapilledema regardless of method of ascertainment to see ifthe presence of classic malignant hypertension predictedclinical severity or utilization factors.

Data CollectionData were collected using a structured chart review

protocol.* Utilization-Length of hospital and intensive care unit

stays were ascertained from the chart. Hospital bills for 1986cases (Group III) were obtained from the PresbyterianHospital billing office. Total hospital charges for treatment ofhypertensive emergency at Presbyterian Hospital in 1986were calculated based on the estimated number of admissionsthat year and the average charge for each admission. Physi-cian charges were not available and therefore were notincluded in the total charge estimate.

* Clinical variables including blood pressure, grade ofretinopathy, and the presence of hematuria or encephalopa-thy (as defined in the Appendix) were obtained from chartreview. Grade III retinopathy was defined by the presence ofhemorrhages and exudates, and Grade IV by the presence ofpapilledema. Left ventricular hypertrophy on the admissionelectrocardiogram was defined by the Romhilt criteria.23Complications were defined as the onset after admission ofone of the following: renal insufficiency, new neurologicaldeficit, new cardiac ischemia, or hospital-acquired infection.

* Sociodemographic variables including age, race, lan-guage, employment and pay status, and category of admis-sion (ward vs. private) were obtained from chart review. Agewas defined as age at the time of admission. Language wasassumed to be English unless the chart indicated otherwise.To compare cases admitted in 1986 to the overall hospitalpayor mix, we obtained inpatient hospital payor mix datafrom the hospital billing office for 1986.

* Previous Care-Cases were classified as having pre-viously detected hypertension if the admitting history record-ed by the intern, resident, or attending physician stated thatthey had a history of diagnosed hypertension. Cases wereconsidered aware of the diagnosis of hypertension if thehistory indicated a previous hospital admission for hyper-tension-related disease or previous treatment withpharmacologic agents. Previous hospital admission for hy-pertension-related disease included prior admission forhypertensive emergency, malignant hypertension, or controlof blood pressure. Cases were classified as previously treated

if either the length of time of previous treatment or a specificantihypertensive medication was indicated in the admissionhistory. Mention in the admission note of a physician whofollowed the patient was considered evidence of a regularphysician. If no mention was made of a specific physicianwho had previously seen the patient (apart from emergencyroom visits), the patient was classified as having no regularphysician.

ResultsIn a six-month period in 1986, 25 of 36 (69 per cent)

admissions for hypertension for whom complete charts wereavailable met our case criteria. Based on the total of 42admissions for hypertension in this period, we estimateapproximately 58 (69 per cent of 84) admissions for hyper-tensive emergency per year or approximately 0.6 per cent ofthe 9,851 Medical Service admissions. The mean length ofstay of patients admitted for hypertensive emergency was14.4 days (range 1 to 154, SD = 19.6, median 10 days) (Table1). Seventy-five per cent of cases were admitted to intensivecare (Table 1).

Total hospital charges for the Group III (1986) admis-sions (n = 25) were $189,140 (average $7,566 per admission).Based on an estimated 58 admissions per year, total hospitalcharges for the treatment of hypertensive emergency at ourhospital in 1986 were $438,828 in 1986 dollars.Clinical Characteristics

Mean systolic blood pressure at admission was 229.8mmHg (SD = 33.6) and mean diastolic blood pressure was143 mmHg (SD = 18.9) (Table 2). Thirty-seven per cent ofcases had new hematuria, 58.9 per cent had Grade III or IVretinopathy, 34.4 per cent had Grade IV retinopathy, and 71per cent had evidence of left ventricular hypertrophy onadmission electrocardiogram. Of the 90 cases for whom theresults of both the funduscopic examination and theurinalysis were known, 60 (66.7 per cent) had acute arteri-olitis as evidenced by new hematuria or Grade III or IVretinopathy, and 24 (26.7 per cent) had both. Ofthe 100 cases,only 13 had a diastolic blood pressure of less than 130 mmHg;of these, two did not have clinical evidence of arteriolitis andwere entered into the study because they were admitted tothe intensive care unit for emergent lowering of bloodpressure in the absence of aortic dissection or primarypulmonary edema (see Appendix). Two patients died duringhospitalization from cerebrovascular accidents.

TABLE 1-Resource Utilization Characteristics of Cases

WeightedGroup Group II Group IlIl Average ± SD

Utilization (n = 67) (n = 8) (n = 25) (n = 100)

Intensive Care(% admitted) 83.6 50.0 60.0 75.0

Length of StayIntensiveCare (mean 3.5 1.8 2.8 3.3 ± 2.5days) (n = 56) (n = 4) (n = 15) (n =75)

Length of StayHospital(mean days) 17.0 8.0 9.7 14.4 ± 19.6

Group = Cases identified by ICD-9 codes for malignant hypertension andhypertensive encephalopathy in 1979-84.

Group II = Cases identified by review of randomly selected charts from those withICD-9 code for benign hypertension in 1979-84.

Group IlIl = Cases identified from Medical Service daily admission log in 1986.

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TABLE 2-Clinical Characteristics of Cases at Time of Admission

WeightedGroup Group II Group IlIl Average ± SD

Clinical Signs (n = 67) (n = 8) (n = 25) (n = 100)

Systolic BloodPressure (meanmmHg) 236.0 229.8 215.4 229.8 ± 33.6

Diastolic BloodPressure (meanmmHg) 146.2 143.8 139.2 143.0 ± 18.9

Hematuria (% present) 37.3 0 48.0 37.0Grade IlIl or IV

Retinopathy (% 63.5 28.6 55.0 58.9present) (n = 63) (n = 7) (n = 20) (n = 90)

Grade IV Retinopathy 39.7 14.3 25.0 34.4(% present) (n = 63) (n = 7) (n = 20) (n = 90)

Left VentricularHypertrophy (%present) 68.7 50.0 84.0 71.0

Complications (%developing duringhospitalization) 31.3 25.0 12.0 26.0

Demographic and Socioeconomic CharacteristicsMean age of cases was 52 years (range 22 to 87, SD =

14.9 years) (Table 3). Sixty-six of the 100 cases were male.There were 42 Black and 39 Hispanic cases. Eighty-two caseswere admitted to the ward service and 16 to the privateservice, although private service admissions account formore than half the medical admissions to the hospital. Thepercentages of cases who were Black on the private and wardservices were similar (43.8 per cent and 41.5 per cent) but 7per cent of the privately admitted cases as compared to 46.3per cent of the ward cases were Hispanic. Of the 89 cases forwhom occupational data were available, 50 (56 per cent) wereunemployed, disabled, or retired. Among males less than 65years old, 22 of 51 (43 per cent) were unemployed. Twenty-four per cent of the entire group spoke no English. Of the 98patients for whom insurance status was available, 58 (59 percent) were uninsured or had Medicaid, compared to 39 percent uninsured or Medicaid reimbursement for all Presbyte-rian Hospital admissions.

TABLE 3-Demographic Characteristics of Cases

WeightedGroup Group II Group IlIl Average ± SD

Demographics (n = 67) (n = 8) (n = 25) (n = 100)

Age (mean) 51.5 54.2 53.0 52.1 ± 15Sex (% male) 67.2 62.5 64.0 66.0Race (%non-White e.g.,Black, Hispanic,Asian) 82.1 62.5 88.0 82.0

Insurance (%Medicaid or 55.4 75.0 72.0 59.2uninsured) (n = 65)

Employment (%unemployedmales less than 43.3 60.0 33.3 42.065 years old) (n = 30) (n = 5) (n = 15) (n = 50)

Service (%admitted to 87.7 75.0 76.0 82.8ward service) (n = 65)

Language (%non-Englishspeaking) 19.4 25.0 36.0 24.0

Previous Care and Diagnosis of HypertensionOf the 91 patients whose past hypertension history was

documented, 85 (93 per cent) had been previously diagnosed(Table 4). Seventy-nine cases were known to have beenpreviously treated pharmacologically for hypertension, and26 had been previously admitted for hypertensive emergencyor for specific management of their hypertension. Thus, atleast 83 of the 100 cases were aware of their diagnosis(previous treatment or previous admission for hypertension-related diagnosis). Nonetheless, no source of regular carewas documented for 60 of the 100 cases, for 44 of the 83 (53per cent) cases aware of their diagnosis, or for 16 of the 26(61.5 per cent) cases previously admitted for hypertension.

TABLE 4-Previous Care Characteristics of Cases

WeightedGroup Group II Group IlIl Average t SD

Previous Care (n = 67) (n = 8) (n = 25) (n = 100)

Previous Detection ofHypertension (% of 90.0 100.0 100.0 93.4known) (n = 60) (n = 7) (n = 24) (n = 91)

Previous DocumentedTreatment (% of 78.8 71.4 78.6 78.0known) (n = 52) (n = 7) (n = 14) (n = 73)

Known Medications (% ofall cases) 61.2 62.5 68.0 63.0

Previously Treated (% ofall cases) 79.0 75.0 80.0 79.0

Previous HospitalAdmissions forHypertension (% of allcases) 25.4 0 36.0 26.0

Aware of Hypertension(% of all cases) 83.6 75.0 84.0 83.0

Known Primary Physician(% of all cases) 40.3 12.5 48.0 40.0

Known Primary Physician(% of cases aware of 48.2 16.7 52.4 47.0hypertension) (n = 56) (n = 6) (n = 21) (n = 83)

Medications on Day ofAdmission (% of 13.0 16.7 20.0 15.2previously treated) (n = 53) (n = 6) (n = 20) (n = 79)

Medications >30 DaysBefore Admission (% of 37.7 33.3 15.0 31.6previously treated) (n = 53) (n = 6) (n = 20) (n = 79)

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Of the 50 patients previously treated for hypertension and forwhom the last date of medication compliance was docu-mented in the chart, 25 (50 per cent) were noted to havestopped their medications more than 30 days prior to admis-sion and only 12 (24%) had taken any medication on the dayof admission to the hospital.Homogeneity of the Case Definition

Group I had slightly higher levels of resource utilization,systolic and diastolic blood pressure levels, and frequency ofretinopathy. Other indices of severity were greater in othergroups. The groups did not differ with regard to demographicor past medical history variables.

Comparison of cases with papilledema (malignant hy-pertension) to those with lesser grades of retinopathy or noretinopathy indicated that papilledema did not correlate withother clinical characteristics (data available upon request toauthor). Although admission to intensive care was associatedwith papilledema, lengths of stay in intensive care and in thehospital were the same for both groups.

DiscussionThere are several limitations to this case series. Because

the study comprises cases from a single institution, it may notbe generalizable to other settings. Second, previous care anddemographic data obtained by chart review may be lessaccurate than that obtained by patient interview. Third,without an appropriate control group it is not possible toestimate the strength of effects or test hypotheses formally.Finally, the absence of a denominator population makes theestimation of incidence impossible and raises the possibilitythat the sociodemographic correlates of hypertensive emer-gency found in this case series are due to patient self-selection, selective admission practices, or differential med-ical practices. With regard to patient self-selection, patientsof higher socioeconomic status cared for by private physi-cians affiliated with Presbyterian Hospital would be no lesslikely than those in the case series to seek care for hyper-tensive emergency at Presbyterian Hospital. In general, suchpatients actively seek admission to Presbyterian Hospitalunder the care of their private physicians. With regard toselective admission practices, private physicians at ourhospital rarely have admitting privileges at other institutions.With regard to differential medical practices, while it ispossible that the threshold for admission is higher for private,higher socioeconomic status patients who might be followedmore closely as outpatients, the lack of a correlation betweenthe level of blood pressure and socioeconomic status in ourdata does not support this possibility.

Despite these limitations, this case series indicates thathypertensive emergency remains an important clinical prob-lem in the inner-city population served by PresbyterianHospital, accounting for approximately 58 admissions or 0.6per cent of all medical admissions each year. Seventy-five percent of cases received intensive care, and calculated annualhospital charges, exclusive of physician charges, were over$400,000.

We found that the presence of papilledema (malignanthypertension) did not distinguish cases with regard to sever-ity of illness or short-term outcome in our series. While it ispossible that misclassification of retinopathy may have sup-pressed an association with other variables, cases withoutfully documented funduscopic examinations were not includ-ed in our analysis. We conclude that diagnostic distinctionsbased on the presence of papilledema as currently used in

ICD-9 may not be useful in predicting clinical outcome orutilization among patients with hypertensive emergency.

We found a number of coding errors in hospital diag-noses related to malignant hypertension. Many miscodedpatients had strokes complicated by severe hypertension.These coding inaccuracies may be addressed by recentMedicare requirements that physicians attest to the accuracyof discharge diagnoses. We also found that 8 of 48 (17 percent) admissions coded for hypertension alone met our casecriteria for hypertensive emergency. Approximately 60 percent of the admissions coded for malignant hypertension didnot have papilledema, although they did meet our criteria forhypertensive emergency. Since there is currently no ICDcode for hypertensive emergency, it is not surprising that thedischarge diagnosis for patients with hypertensive emergen-cy without papilledema would sometimes be coded as essen-tial hypertension and sometimes as malignant hypertension.These observations confirm that current diagnostic codingschema hinder case finding in the study of hypertensiveemergency. Revision of diagnostic codes to include codes forhypertensive emergency specified by site of end-organ dam-age would be helpful both for epidemiologic studies and forpublic health reporting.

Patients with hypertensive emergency in our series werepredominantly male and either Black or Hispanic. Malignanthypertension has been reported by others to occur morefrequently in young, Black males.'10"2-'4 To our knowledge,the incidence of malignant hypertension in Hispanic popu-lations has not been reported. The mean age ofour case serieswas similar to that of previously reported series of malignanthypertension. 10,12-14 Our findings suggest that hypertensiveemergency occurs primarily among patients of lower socio-economic status. Studies ofthe epidemiology ofhypertensionhave found an association between hypertension in generaland lower socioeconomic status.2F26 Therefore, without acomparison group of hypertensive patients, we cannot de-termine that lower socioeconomic status is a specific corre-late ofhypertensive emergency. However, comparison oftheinsurance status of our case series to overall hospital billingdata indicates that this demographic profile is not explainedby that of the general Presbyterian Hospital population.

Despite our conservative criteria for previous diagnosisof hypertension, more than 90 per cent of cases werepreviously diagnosed, and lack of patient awareness of thediagnosis was not the major obstacle to adequate manage-ment. The majority of cases were not adherent topharmacologic treatment and had no identifiable source ofregular medical care. These findings suggest preventionstrategies that improve adherence to therapy and that assureaccess to regular care.

APPENDIXCase Criteria for Hypertensive Emergency

1) Emergent admission priority for treatment of hypertensionand2) One or more of the following:* Diastolic blood pressure of 130 mmHg or greater on admission.* Evidence of arteriolitis present on admission (Keith-Wagner-Barker

retinopathy of grade III or IV, new microscopic hematuria, or an enceph-alopathy attributed to hypertension).

* Admission to an intensive care unit for emergent lowering of bloodpressure in the absence of aortic dissection or primary pulmonary edema.The first blood pressure recorded by the examining physician or registered

nurse at the time ofthe patient's presentation to the emergency room was used.When there was disagreement between the readings ofthe physician and nurse,the reading obtained by the physician was recorded.

The grade of retinopathy was based on the recorded examination of themost senior physician to examine the patient within the first 24 hours after

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admission. When an ophthalmologic consultation was obtained, this exami-nation was considered definitive.

Microscopic hematuria was defined as the presence of three or more redblood cells per high power field on microscopic examination of the first urineobtained after presentation to the emergency room.

Hypertensive encephalopathy was defined as the presence of an alteredmental status or level of consciousness at presentation that was attributed bythe examining physicians to the patient's elevated blood pressure. Patientswho had another documented explanation for their encephalopathy wereexcluded.

The patient was considered to have pulmonary edema secondary tohypertensive emergency and was included ifthe patient's ejection fraction wasgreater than 40 per cent and there was no evidence ofischemia on a subsequentexercise tolerance test.

REFERENCES1. National Heart, Lung, and Blood Institute, The Joint National Committee

on Detection, Evaluation, and Treatment of High Blood Pressure: The1984 Report of the Joint National Committee on Detection, Evaluation,and Treatment of High Blood Pressure. Arch Intern Med 1984;144:1045-1057.

2. Kincaid-Smith P, McMichael J, Murphy EA: The clinical course andpathology of hypertension with papilloedema (malignant hypertension). QJ Med 1958; 27:117-153.

3. Harrington M, Kincaid-Smith P, McMichael J: Results of treatment inmalignant hypertension. Br Med J 1959; 1:969-980.

4. Kincaid-Smith P: Malignant hypertension: Mechanisms and management.Pharmacol Ther 1980; 9:245-269.

5. Veterans Administration Cooperative Study Group on AntihypertensiveAgents: Effects of treatment on morbidity in hypertension. JAMA 1967;202:116-122.

6. National Heart, Lung, and Blood Institute, Hypertension Detection andFollow-up Program Cooperative Group: Five year findings of the hyper-tension detection and follow-up program. I. Reduction in mortality ofpersons with high blood pressure including mild hypertension. JAMA1979; 242:2562-2571.

7. National Heart, Lung, and Blood Institute, Hypertension prevalence andthe status of awareness, treatment, and control in the United States: Finalreport of the Subcommittee on Definition and Prevalence of the 1984 JointNational Committee. Hypertension 1985; 7:457-468.

8. US Public Health Service and Health Care Financing Administration:

International Classification of Diseases, 9th Rev. Clinical Modification.DHHS Pub. No. (PHS) 80-1260, Public Health Service. Washington, DC:Govt Printing Office, September 1980.

9. Volhard F, Fahr T: Die Brightsche Nierenkraukheit, Klinik, Pathologie,und Atlas. Berlin: Julius Springer, 1914.

10. Keith NM, Wagener HP, Kernohan JW: The syndrome of malignanthypertension. Arch Intern Med 1928; 41:141-188.

11. Keith NM, Wagener HP, Barker NW: Some different types of essentialhypertension: Their course and prognosis. Am J Med Sci 1939;197:332-343.

12. Derow HA, Altschule MD: Malignant hypertension. N Engl J Med 1935;213:957-960.

13. Mroczek W: Malignant hypertension. Angiology 1977; 28:444 453.14. Rabin E: Malignant hypertension. Can Med Assoc J 1978; 118:941-945.15. Pere GA: Hypertensive vascular diseases: Description and natural

history. J Chronic Dis 1955; 1:33-42.16. Vaziri ND: Malignant or accelerated hypertension. West J Med 1984;

140:575-582.17. Keith TA: Hypertensive crisis. JAMA 1977; 237:1570-1577.18. Ferguson RK, Vlasses PH: Hypertensive emergencies and urgencies.

JAMA 1986; 255:1607-1613.19. Alpert MA, Bauer JH: Hypertensive emergencies: Recognition and

pathogenesis. Cardiovasc Rev Rep 1985; 6:407-427.20. Koch-Weser J: Hypertensive emergencies. N Engl J Med 1974;

290:211-214.21. New York State Department of Health: Statewide Planning and Research

Cooperative System. Albany: NYSDH, 1984.22. Lee TH, Alderman MH: Malignant hypertension: Declining mortality rate

in New York City, 1958 to 1974. New York State J Med 1978;78:1389-1391.

23. Romhilt DW, Greenfield JC Jr, Estes EH Jr: Vectorcardiographic diag-nosis of left ventricular hypertrophy. Circulation 1968; 37:15-19.

24. Stamler J, Berkson DM, Lindberg HA, et al: Socioeconomic factors in theepidemiology of hypertensive disease. In: Stamler J, Stamler R, PullmanTN (eds): The Epidemiology of Hypertension. New York: Grune andStratton, 1967; 289-313.

25. National Heart, Lung, and Blood Institute, Hypertension Detection andFollow-up Program Cooperative Group: Race, education and prevalenceof hypertension. Am J Epidemiol 1977; 106:351-361.

26. Keil JE, Tyroler HA, Sandifer SH, Boyle E: Hypertension: Effects ofsocial class and racial admixture. Am J Public Health 1977; 67:634-639.

Ethics Committee Training Program: A Manual Available

A two-year project designed to educate new and prospective members of hospital ethics committeesin the New York area has just ended. As one of the outcomes, Dr. Ruth Macklin, the project director,has prepared a manual to assist others who would like to conduct similar training programs in theirregions. The manual includes agendas for the training sessions, a bibliography on ethics committees,evaluation instruments, and a narrative describing the program. Copies are available, free of charge,while supplies last.

For a copy of the manual, write to: Ruth Macklin, PhD, Professor, Department of Epidemiologyand Social Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461.Phone 212/430-2281 or -82.

A presentation about the training program described in the manual was made at the Bioethics Forumat the 1987 APHA annual meeting in New Orleans. The project was supported by Exxon Corporation,Morgan Guaranty Bank, the New York Community Trust, and the United Hospital Fund ofNew York.

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