Written by Chris Thom
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This was a multi-hospital retrospective study of patients who presented to the emergency department with severe hypertension without end organ damage. The authors found that the 1 year rate of major adverse cardiovascular events (MACE) was 15.5%.
Watch out for that blood pressure
This was an analysis of 12,044 patients over an 18-month period at eight hospitals in Michigan. Eligible patients were all adults who presented to the ED with an initial systolic blood pressure (SBP) of 180 to 220 and absence of end organ damage (EOD). Researchers used a clinical diagnosis of acute coronary syndrome, heart failure, stroke, or acute kidney injury as definition of EOD.
Chart review was performed to assess for the rate of MACE at 1 year amongst various patient characteristics and presenting complaints. In addition, researchers compared 30-day MACE rates between patients discharged with a SBP ≤ 160 versus those discharged with a SBP > 160.
The incidence of MACE within 1 year was 15.5% (1865 patients). Several characteristics were identified that were associated with increased rates of MACE, including presentation with chest pain, altered mental status, or dyspnea, as well as treatment with intravenous antihypertensives. Referral into the ED for hypertension was not associated with increased risk of MACE. There was no difference in 30-day MACE between patients discharged with SBP ≤ 160 versus > 160 (OR 0.99, 95%CI 0.78-1.25).
How will this change my practice?
On one hand, this study adds to the growing body of work demonstrating that the practice of acutely lowering blood pressure of ED patients with no end organ damage does not provide benefit and should be avoided. Chasing a lower blood pressure value for the sake of a more palatable number is not evidence-based in the absence of EOD. However, the study also seems to suggest that patients with severely elevated blood pressure are overall at high risk of MACE at 1 year. There are a few caveats that cloud this conclusion, including the high likelihood of significant confounding variables and the inclusion of patients with altered mental status, as hypertensive encephalopathy is often described as evidence of EOD. The main takeaway is, ensure good discharge instructions and outpatient follow-up planning for patients who present with severe hypertension.
Editor’s note: After yesterday’s AHA statement, I don’t want us to be too cavalier and ignore elevated BP in the ED. Though this article suggests very high 1-year MACE, I would also encourage you to read an article from 2016, a huge study with >200,000 patients which found excellent short-term safety outcomes for patients with ED visits solely for elevated BP, with 90-day mortality <1% and “hospitalizations for stroke, heart failure, acute myocardial infarction, atrial fibrillation, renal failure, hypertensive encephalopathy, and dissection were less than 1% at 30 days.” Hypertension often coexists with other cardiac risk factors, so we need to take each patient presentation seriously and ensure close follow-up care for these patients. ~Clay Smith
Source
Emergency Department Blood Pressure Treatment and Outcomes in Adults Presenting with Severe Hypertension. West J Emerg Med. 2024;25(5):680-689.
Does the study address lack of compliance with medications or lack of outpatient follow up? I would hate to be liable for outcomes one year later when there are so many confounding factors. Wouldn’t imagine that argument would hold up but curious.