Clinical presentation and management of patients with uncontrolled, severe hypertension: results from a public teaching hospital

Preston, Richard A.; Baltodano, Neyton M.; Cienki, John J.; Materson, Barry J.

doi:10.1038/sj.jhh.1000796

Cited by 49 publications

(29 citation statements)

References 19 publications

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“…A more recent 1999 study of 74 discharged ED patients at a teaching hospital who presented with a systolic or diastolic BP of at least 220 or 110 mm Hg, respectively, found that 13.5% of participants returned to the ED within three months with significant cardiovascular complications. 18 Several studies have assessed shortterm outcomes 19,20 and found very low frequencies of poor outcomes; however, hypertension is a disease that has significant long-term, rather than short-term, impact. 3 Large studies on the long-term outcomes are needed in order to guide these management decisions and, in turn, provide consistency of care to such patients across physicians.…”

Section: Discussionmentioning

confidence: 99%

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Cho

Austin

Atzema

2015

CJEM

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Introduction: Many patients are seen in the emergency department (ED) for hypertension, and the numbers will likely increase in the future. Given limited evidence to guide the management of such patients, the practice of one's peers provides a de facto standard. Methods: A survey was distributed to emergency physicians during academic rounds at three community and four tertiary EDs. The primary outcome measure was the proportion of participants who had a blood pressure (BP) threshold at which they would offer a new antihypertensive prescription to patients they were sending home from the ED. Secondary outcomes included patient-and providerlevel factors associated with initiating an antihypertensive based on clinical vignettes of a 69-year-old man with two levels of hypertension (160/100 vs 200/110 mm Hg), as well as the recommended number of days after which to follow up with a primary care provider following ED discharge. Results: All 81 surveys were completed (100%). Half (51.9%; 95% CI 40.5-63.1) of participants indicated that they had a systolic BP threshold for initiating an antihypertensive, and 55.6% (95% CI 44.1-66.6) had a diastolic threshold: mean systolic threshold was 199 mm Hg (SD 19) while diastolic was 111 mm Hg (SD 8). A higher BP (OR 12.9; 95% CI 7.5-22.2) and more patient comorbidities (OR 3.0; 95% CI 2.1-4.3) were associated with offering an antihypertensive prescription, while physician years of practice, certification type, and hospital type were not. Participants recommended follow-up care within a median 7.0 and 3.0 days for the patient with lower and higher BP levels, respectively. Conclusions: Half of surveyed emergency physicians report having a BP threshold to start an antihypertensive; BP levels and number of patient comorbidities were associated with a modification of the decision, while physician characteristics were not. Most physicians recommended follow-up care within seven days of ED discharge.

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Section: Discussionmentioning

confidence: 99%

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Cho

Austin

Atzema

2015

CJEM

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“…[1][2][3][4][5] Considering the severe organ damage that potentially follows hypertensive crises, identification of specific patients at increased risk is important. We performed a systematic literature search including all studies evaluating predictors for hypertensive crises and found no study evaluating such predictors in a prospective design.…”

Section: Introductionmentioning

confidence: 99%

Prediction of hypertensive crisis based on average, variability and approximate entropy of 24-h ambulatory blood pressure monitoring

Schoenenberger

Erné²,

Ammann

et al. 2007

J Hum Hypertens

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Approximate entropy (ApEn) of blood pressure (BP) can be easily measured based on software analysing 24-h ambulatory BP monitoring (ABPM), but the clinical value of this measure is unknown. In a prospective study we investigated whether ApEn of BP predicts, in addition to average and variability of BP, the risk of hypertensive crisis. In 57 patients with known hypertension we measured ApEn, average and variability of systolic and diastolic BP based on 24-h ABPM. Eight of these fiftyseven patients developed hypertensive crisis during follow-up (mean follow-up duration 726 days). In bivariate regression analysis, ApEn of systolic BP (Po0.01), average of systolic BP (P ¼ 0.02) and average of diastolic BP (P ¼ 0.03) were significant predictors of hypertensive crisis. The incidence rate ratio of hypertensive crisis was 14.0 (95% confidence interval (CI) 1.8, 631.5; Po0.01) for high ApEn of systolic BP as compared to low values. In multivariable regression analysis, ApEn of systolic (P ¼ 0.01) and average of diastolic BP (Po0.01) were independent predictors of hypertensive crisis. A combination of these two measures had a positive predictive value of 75%, and a negative predictive value of 91%, respectively. ApEn, combined with other measures of 24-h ABPM, is a potentially powerful predictor of hypertensive crisis. If confirmed in independent samples, these findings have major clinical implications since measures predicting the risk of hypertensive crisis define patients requiring intensive follow-up and intensified therapy.

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“…[5][6][7] Whether extreme hypertension is associated with increased release of circulating EMP and PMP has not been investigated.…”

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confidence: 99%

“…evere, uncontrolled hypertension is associated with high rates of target organ complications, [1][2][3][4][5][6] but the molecular mechanisms by which extreme blood pressure elevation leads to vascular injury are not well defined. Increasing evidence suggests that hypertension confers a prothrombic state, characterized by abnormalities of endothelial function and platelet activation.…”

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confidence: 99%

Effects of Severe Hypertension on Endothelial and Platelet Microparticles

et al. 2003

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Abstract-The molecular mechanisms by which extreme blood pressure elevation leads to vascular injury are not defined.To explore the hypothesis that activation of endothelium and platelets as manifested by increased concentrations of circulating endothelial microparticles and platelet microparticles could play a role in this target organ injury, we conducted a cross-sectional study of these markers in 3 groups: (1) untreated patients referred specifically for treatment of severe uncontrolled hypertension; (2) untreated patients with established mild hypertension; and (3) normotensive volunteer subjects. By ANOVA, endothelial (Pϭ0.002) and platelet (Pϭ0.01) microparticles were greatest in the severely hypertensive group. There was a significant correlation between both of these markers and blood pressure, even in the setting of multiple risk factors. Our results suggest that these markers may be useful and specific for pressure-induced endothelial and platelet activation in hypertension. Furthermore, because of the combined effects of endothelial and platelet microparticles on coagulation, leukocytes, and endothelium, it is possible that they may play a pathogenic role in mediating target organ injury in severe hypertension. Key Words: hypertension, arterial Ⅲ endothelium Ⅲ platelets Ⅲ endothelium-derived factors Ⅲ cell adhesion molecules S evere, uncontrolled hypertension is associated with high rates of target organ complications, 1-6 but the molecular mechanisms by which extreme blood pressure elevation leads to vascular injury are not well defined. Increasing evidence suggests that hypertension confers a prothrombic state, characterized by abnormalities of endothelial function and platelet activation. [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] This dysfunction is conferred by isolated systolic hypertension as well as simultaneous systolic and diastolic hypertension. 9 Consequently, investigative interest has recently focused on endothelial and platelet activation as important mediators of hypertensive vascular injury.Endothelial microparticles (EMP) are small membrane vesicles that are shed from the surface of endothelial cells in response to activation, injury, and/or apoptosis. EMP release can be caused by a number of cytokines such as interleukin-1 and tumor necrosis factor and by elevated shear pressure. [25][26][27][28][29][30] Assays for circulating EMP have recently been developed 25-26 as potential means of quantifying endothelial cell injury. EMP are also known to be elevated in thrombotic thrombocytopenic purpura, 26 a condition associated with endothelial injury, and in acute coronary syndromes. 27,30 Increased EMP release has also been associated with endothelial injury in patients with multiple sclerosis and lupus anticoagulant. 25,28 -29 Circulating platelet microparticle (PMP) concentration is a marker of platelet activation. [31][32][33] PMP are formed by platelet membrane vesicle formation and shedding. 31 PMP are known to possess procoagulant activity and are elev...

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Clinical presentation and management of patients with uncontrolled, severe hypertension: results from a public teaching hospital

Cited by 49 publications

References 19 publications

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Prediction of hypertensive crisis based on average, variability and approximate entropy of 24-h ambulatory blood pressure monitoring

Effects of Severe Hypertension on Endothelial and Platelet Microparticles

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