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#183 What is Urgent About Hypertensive Urgency?

What are the risks for asymptomatic patients who present with significantly elevated blood pressure?

Patients with markedly elevated blood pressures (BPs) (mean 186/121 mmHg) have ~40% risk of cardiovascular disease (CVDat 18 months if untreated. The risk for treated patients ranges from 14% at one month to 1.2% at six months. Outcomes influenced by presenting BPs (and measurement accuracy)patient co-morbidities, follow-up, socio-economic status and ethnicity. For most asymptomatic patients with BPs >180/110 mmHg, addition or initiation of oral agents at presentation with close outpatient follow-up is reasonable.  

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Randomized Controlled Trial (from 1967):  
  • 143 hospitalized males (mean BP 186/121 mmHg) randomized to hydrochlorothiazide, reserpine, and hydralazine versus placebo.1  
    • At 18 months, death, CVD, intracerebral/retinal hemorrhage: 3% versus 39% (placebo): Number Needed to Treat=3. 
Cohort studies of treated patients: 
  • 58,535 American outpatients (mean BP 185/96 mmHg)73% known hypertensive, ~60% on ≥2 BP meds, ~25% known CVD.2  
    • At six months, CVD, stroke or transient ischemic attack=1.2%.  
      • No difference between in- or out-patient management. 
    • Limitation: 4.6% of ~2 million office visits had BP>180/110 mmHg – suspect BP measurement inaccuracies. 
  • 384 Austrians (BP >220/120 mmHg) recruited after receiving oral treatment in emergency department (ED).3 Patients had numerous investigations/follow-up. 
    • At four years, CVD, heart failure (HF), or atrial fibrillation=23%. 
  • 164 Swiss primary care outpatients (mean BP 198/101 mmHg).4 90% asymptomatic or ‘urgent’ (had non-specific symptoms: Headache, dizziness). 
    • At one year, CVD, HF or peripheral vascular disease=12.8%. 
    • Limitation: Treating physician reported outcomes. 
  • 91 inner city African/Hispanic patients in ED (mean BP 209/128 mmHg).5 Non-specific symptoms (example headache, dizziness) in ~66%50% known CVD.  Majority treated with oral agents (clonidine), most had no follow up.  
    • At one month, CVD, HF, or encephalopathy=14%. 
  • Definition of hypertensive urgency varies between studies. 
  • While optimal speed of BP lowering remains unknown,6 rapid reduction in asymptomatic patients is discouraged.7 
  • Most hypertensive urgencies occur in known hypertensives,2,4,8,9 often due to medication non-adherance.2,5,10  
  • Hypertension with acute end-organ damage (example: CVD, aortic dissection, encephalopathy)11 requires immediate intravenous treatment.9 

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  • Cian Hackett BSc MD
  • Michael R Kolber BSc MD CCFP MSc

1. Veterans Administration Cooperative Study Group on Antihypertensive Agents. JAMA. 1967; 202(11):1028-34.

2. Patel K, Young L, Howell E, et al. JAMA Intern Med. 2016; 176(7):981-8.

3. Vlcek M, Bur A, Woisetschlager C, et al. J Hypertens. 2008; 26(4):657-62.

4. Merlo C, Bally K, Tschudi T, et al. Swiss Med Wkly. 2012; 142:w13507.

5. Preston R, Baltodano N, Cienki J, et al. J Hum Hypertens. 1999; 13:249-55.

6. Cherney D, Straus S. J Gen Intern Med. 2002; 17:937-45.

7. Grossman E, Messerli FH, Grodzicki T, et al. JAMA. 1996; 276:1328-31.

8. Levy PD, Mahn JJ, Miller J, et al. Am J Emerg Med. 2015; 33: 1219-24.

9. Marik PE, Varon J. CHEST. 2007; 131:1949-62.

10. Saguner AM, Dür S, Perrig M, et al. Am J Hypertens. 2010; 23:775-80.

11. Daskalopoulou SS, Rabi DM, Zarnke K, et al. Can J Cardiol. 2015; 31:549-68.

Authors do not have any conflicts of interest to declare.