Outpatient Care Sufficient for Hypertensive Urgency

Veronica Hackethal, MD

June 16, 2016

Cardiovascular outcomes are not significantly better for patients admitted to the hospital with asymptomatic hypertensive urgency (systolic blood pressure, 180 mm Hg or greater; diastolic blood pressure, 110 mm Hg or greater) compared with those managed as outpatients, according to a study published online June 13 in JAMA Internal Medicine.

Results showed low rates of major cardiovascular events (MACE) in all patients with asymptomatic hypertensive urgency. However, two thirds of the patients still had uncontrolled hypertension at 6 months, suggesting the need for improved management.

"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 [emergency department] was associated with increased use of health care resources but not better outcomes," write Krishna Patel, MD, from the Cleveland Clinic in Ohio, and colleagues. "Finally, patients with hypertensive urgency are at high risk for uncontrolled hypertension as long as 6 months after the initial episode. Efforts to improve follow-up and intensify antihypertensive therapy should be pursued."

The study is the first to compare short-term outcomes of patients with hypertensive urgency based on treatment setting (inpatient vs outpatient).

Chronic high blood pressure can cause organ damage and result in myocardial infarction, heart failure, stroke, and kidney damage. However, severely elevated blood pressure, even for short periods, may raise concerns for end-organ damage.

Lack of research on the management of hypertensive urgency, however, may interfere with providing optimal care. Ambulatory patients with hypertensive urgency are often sent to the emergency department, admitted directly to the hospital, or sent home with medication changes. Whether hospital admission results in improved outcomes has been an open question.

The study included all patients who presented with asymptomatic hypertensive urgency to an office. The study excluded pregnant women and those with symptoms caused by conditions other than hypertension. The main outcome was MACE: acute coronary syndrome, stroke, transient ischemic attack, uncontrolled hypertension (≥140/90 mm Hg), and hospital admission.

The analysis included 2,199,019 office visits, of which 59,836 (4.6%) were for hypertensive urgency. The final analysis excluded 851 patients, yielding a final sample size of 58,535 (mean age, 63.1 years; 57.7% women; 76.0% white; average body mass index, 31.1 kg/m2; mean systolic blood pressure, 182.5 mm Hg; mean diastolic blood pressure, 96.4 mm Hg).

Just 0.7% of patients with hypertensive urgency were referred to the hospital for blood pressure management, whereas the remainder were sent home. Both groups had low rates of MACE within 7 days, 1 month, and 6 months (<1%).

Just 5.5% of tests in the emergency department had abnormal results, and 2.1% of the patients showed evidence of target organ injury. A large percentage of the patients were sent home (80.1%), and 82.9% had no change to their antihypertensive regimen.

Researchers used propensity matching to control for differences in blood pressure, demographics, and cardiovascular risk factors between those managed in the hospital (n = 426) and those sent home (n = 852). Results showed no significant differences in MACE between these two groups at 7 days (P = .11), 1 month (P = .11), and 6 months (P > .99).

A significantly higher percentage of those sent home vs those admitted had uncontrolled hypertension at 1 month (86.3% vs 81.9%; P = .04), but not at 6 months (64.6% vs 66.6%; P = .56).

However, 59.7% of patients still had uncontrolled hypertension at 6 months, with no differences between those admitted to the hospital and those sent home.

Because the study took place in a single healthcare system in Ohio and Florida, the results may not apply to other areas, the authors note. More than 20% of patients were lost to follow-up within 6 months, so the study could not include their outcomes.

In an invited commentary, Iona Heath, MB, BChir, FRCGP, FRCP, from the Royal College of General Practitioners, London, United Kingdom, emphasized that the term "hypertensive urgency" is "largely illusory" and causes a great deal of anxiety to patients and providers, but "does not require hospital admission and has a good prognosis."

"[P]eople are being admitted to hospital and treated with powerful medications, incurring unwarranted costs, and causing harm to patients in terms of needless fear, stress, and the adverse effects of medication," she stressed.

The problem highlights a disconnect in medical thinking between numbers and symptoms, she suggested. Bureaucratic procedures and the pressure to code for severity to ensure reimbursement may drive diagnosis.

"Perhaps the wise thing to do in the context of a very low incidence of major cardiac events recorded in this study, even in patients with markedly raised readings, is to move toward a concept of 'good enough' [blood pressure], in line with the values and aspirations of individual patients rather than the counsel of coercive perfection that permeates so many contemporary guidelines," she concludes.

The authors and Dr Heath have disclosed no relevant financial relationships.

JAMA Intern Med. Published online June 13, 2016. Article abstract, Commentary extract

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