EVALUATION AND MANAGEMENT OF HYPERTENSIVE URGENCY IN PATIENTS IN A SINGLE LARGE TERTIARY CENTER

Background: Current guidelines recommend oral (PO) medications as first line therapy for management of hypertensive urgency. However, patients without end-organ damage who are symptomatic or have extremely high blood pressure (BP) may be classified as either “hypertensive urgency” or “emergency” by treating physicians.Objective: In a cohort of hospitalized patients with severe hypertension but no organ dysfunction, to compare characteristics and outcomes between those who received PO and those who received IV antihypertensive medications.

Methods: We identified patients admitted to a single tertiary care hospital with a principal diagnosis of hypertensive urgency (blood pressure [BP] of greater than 180/120 mmHg on admission) who could take medications by mouth. We excluded patients who met a recently published definition for hypertensive emergency. This definition uses evidence of organ dysfunction but does not use symptoms to identify hypertensive emergency. We used descriptive statistics and created generalized linear models with robust standard error and exchangeable correlation structure to evaluate within-subject BP changes over 24 hours.

Results: We identified 179 patients who met inclusion criteria. Most were women (58%); average age was 62-years-old; majority (165, 88%) had chronic hypertension, and 40.6% had chronic renal disease. Most presented with symptoms (176, 94%), most commonly headache (98, 56%), chest pain (74, 42%), and dyspnea (48, 27%). Average presenting BP was 206/98±17.4/21.5 mmHg. After admission, bradycardia occurred in 66 (35.3%) and new organ dysfunction in 43 (23.5%). Most patients (146, 81.6%) received IV medications, primarily labetalol (57.5%) and hydralazine (45.9%). Compared with those treated with PO medications, patients treated with IV medications had a greater number of chronic comorbid conditions and higher systolic BP on admission (190 mmHg [95% CI 187-192 mmHg] vs. 177 mmHg [95% CI 172-182 mmHg]. Median length of stay was longer in those treated with IV rather than PO medications (2.5 vs. 1.4, p=0.007), but rates of hypotension, orthostatic hypotension, bradycardia, and new organ dysfunction were similar. Most new organ dysfunction was seen in those treated with IV medications (38 [88%] vs. 5 [12%], p=0.259). We observed a more rapid initial decline in BP in those treated with IV medications, but BP was similar between the two groups after 12 hours.

Conclusions: IV medications were used frequently in a cohort of patients with severe hypertension but no evidence of organ dysfunction. Compared to patients who received PO medications, we observed more rapid BP lowering in patients who received IV medications, but no significant difference in BP control at 24 hours and no difference in other outcomes. Even when symptoms are present on admission, PO medications are likely a safe alternative to IV in patients who present with severe hypertension but no organ damage.