Hospital or outpatient care when patients present with hypertensive urgency?

Do ambulatory patients who present in office settings with hypertensive urgency -- systolic blood pressure (BP) at least 180mm HG and diastolic BP at least 110 mm Hg -- do better when they are referred to the hospital or when they have their BP managed in an outpatient setting?

Krishna K. Patel, M.D., of the Cleveland Clinic, and coauthors examined that question in a new study published online by JAMA Internal Medicine.

Organ damage can result from increased blood pressure over time, so physicians may be concerned about the potential for organ damage after severely elevated BP, even for a short time. However, the management of hypertensive urgency is complicated by a lack of observational studies or randomized trials. Some patients with hypertensive urgency are evaluated and treated in emergency departments.

To help inform management of hypertensive urgency, the authors conducted a study of all patients presenting with hypertensive urgency to a Cleveland Clinic office from 2008 through 2013.

Of nearly 2.2 million patient visits, 59,836 (4.6 percent) met the definition of hypertensive urgency. The study's final sample included 58,535 patients. Almost 58 percent of those patients were women, most were white, they had an average body mass index of about 31, and they had an average systolic BP of 182.5 mm Hg and an average diastolic BP of 96.4 mm Hg.

The authors report only 426 patients (0.7 percent) were referred to the hospital for blood pressure management and the rest (n=58,109) were sent home.

In an analysis that matched the 426 patients referred to the hospital with 852 patients who were sent home, there was no significant difference in major adverse cardiovascular events in a week, in a month or in six months, the study showed.

Patients who were sent home were more likely to have uncontrolled blood pressure at one month but not at 6 months. However, about two-thirds of all patients still had uncontrolled blood pressure at six months. Patients who were sent home also had lower hospital admission rates at seven days, according to the results.

"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. Furthermore, referral to the ED was associated with increased use of health care 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 study concludes.

Source:

Michael B. Rothberg, MD, MPH et al. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA Intern Med, June 2016 DOI: 10.1001/jamainternmed.2016.1509