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Most cases of hypertensive urgency can be safely treated in outpatient setting
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Hospitalization does not improve outcomes for patients presenting with hypertensive urgency, according to new data published in JAMA Internal Medicine.
“The rate of [major adverse CV events] in all patients was low. Referral to the hospital was associated with increased hospitalizations, but not with better outcomes. Disappointingly, most patients with hypertensive urgency still had uncontrolled hypertension 6 months later,” the researchers wrote.
The researchers evaluated 58,535 patients (mean age, 63 years; mean systolic BP, 182.5 mm Hg; mean diastolic BP, 96.4 mm Hg; 58% women) who presented with hypertensive urgency, defined as systolic BP 180 mm Hg and/or diastolic BP 110 mm Hg, to a Cleveland Clinic office from 2008 to 2013. Endpoints of interest were major adverse CV events, uncontrolled hypertension and hospital admissions. Uncontrolled hypertension was defined as a reading of systolic BP 140 mm Hg/diastolic BP 90 mm Hg.
Baseline characteristics
Among the cohort, 426 patients (0.7%) were sent to the hospital for management of BP, and the rest were sent home. Compared with those sent home, those sent to the hospital were more likely to have systolic BP 200 mm Hg (51.2% vs. 9.9%; P < .001), to have a history of hypertension (96.2% vs. 73%; P < .001) and to have chronic kidney disease (16.7% vs. 10.4%; P < .01), according to the researchers.
The researchers constructed a propensity model (C-statistic, 0.83) and conducted a propensity-matched analysis of the 426 patients sent to the hospital vs. 852 patients sent home.
According to the propensity-matched analysis, there were no significant differences between the groups in major adverse CV events at 7 days (home group, 0%; hospital group, 0.5%; P = .11), 8 to 30 days (home group, 0%; hospital group, 0.5%; P = .11) or 6 months (0.9% vs. 0.9%; P > .99).
Uncontrolled hypertension was more frequent in patients sent home than in hospitalized patients at 1 month (86.3% vs. 81.9%; P = .04), but not at 6 months (home group, 64.6%; hospital group, 66.6%; P = .56).
Hospital admission rates were lower in the home group at 7 days (4.7% vs. 8.2%; P = .01) and at 8 to 30 days (6.9% vs. 11.3%; P = .009), according to the researchers.
The researchers wrote hypertensive urgency is common in the outpatient setting and that “in the absence of symptoms of target organ damage, most patients probably can be safely treated in the outpatient setting because [CV] complications are rare in the short term.”
‘Good enough’ BP
In an accompanying editorial, Iona Heath, MD, BChir, FRCGP, FRCP, of the Royal College of General Practitioners in London, wrote that the BP targets in the study were hard to achieve, with more than 80% of the patients having a higher BP than the target at 1 month and more than 60% at 6 months despite many of them being on two or more antihypertensive medications.
“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’ BP, in line with the values and aspirations of individual patients rather than the counsel of coercive perfection that permeates so many contemporary guidelines,” Heath wrote. – by Tracey Romero
Disclosure: The researchers and Heath report no relevant financial disclosures.
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