Hypertensive Urgency in the Office Setting
For ambulatory patients presenting with hypertensive urgency, is referral to the hospital safer than routine outpatient management of blood pressure (BP)?
This retrospective cohort study with propensity matching included all patients presenting with hypertensive urgency to an office in the Cleveland Clinic Healthcare system from January 1, 2008, to December 31, 2013. Hypertensive urgency was defined as systolic BP (SBP) ≥180 mm Hg and/or diastolic BP (DBP) ≥110 mm Hg. Pregnant women and patients referred to the hospital for symptoms or treatment of other conditions were excluded. Final follow-up was completed on June 30, 2014, with uncontrolled BP at the end of a period defined as ≥140/90 mm Hg.
Of 1,299,019 unique patient office visits, 4.8% had a hypertensive urgency and 58,535 were included. Of the 426 patients with hypertensive urgency, 0.7% were referred to the hospital, of whom 39 were admitted directly. Mean (standard deviation) age was 63.1 (15.4) years, 57.7% were women, and 76.0% white. Mean sBP was 182.5 (16.6) mm Hg with 10% ≥200 mm Hg, and mean dBP 96.4 (15.8) mm Hg with 5.7% ≥120 mm Hg. The mean BP of those referred to the hospital was 16/11 mm Hg higher than that of patients sent home (p < 0.001). The 852 patients sent home were compared with the 426 patients referred to the hospital. A total of 496 patients experienced major adverse cardiac events (MACE) within 6 months (205 episodes of acute coronary syndrome and 301 episodes of stroke or transient ischemic attack). The rate of MACE within 7 days, 8-30 days (1 month), and 6 months was low (<1%) in both groups. Patients sent home were more likely to have uncontrolled hypertension at 1 month (735 of 852 [86.3%] vs. 349 of 426 [81.9%]; p = 0.04), but not at 6 months (393 of 608 [64.6%] vs. 213 of 320 [66.6%]; p = 0.56). Patients sent home had lower hospital admission rates at 7 days.
Hypertensive urgency is common, but the rate of MACE in asymptomatic patients is very low. Visits to the emergency department (ED) were associated with more hospitalizations, but not improved outcomes. Most patients still had uncontrolled hypertension 6 months later.
For patients presenting to the office with asymptomatic hypertensive urgency, efforts should focus on improving follow-up and serial BP control instead of referral to the hospital. However, for the busy practitioner with little time or experience, the choice of the ED or hospital may be more attractive.
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