'Hypertensive urgency' may cause unnecessary alarm

By Eleanor McDermid

Patients with a very high blood pressure (BP) reading in the absence of other symptoms are highly unlikely to have a major adverse cardiovascular event (MACE) within the next 6 months, researchers report.

Such patients should not be referred to hospital, say Krishna Patel (Cleveland Clinic Foundation, Ohio, USA) and study co-authors. They found that hospitalisation increased use of healthcare resources without improving outcomes.

"Disappointingly, most patients with hypertensive urgency still had uncontrolled hypertension 6 months later", they write in JAMA Internal Medicine, adding "Efforts to improve follow-up and intensify antihypertensive therapy should be pursued."

The team identified 58,535 patients who presented to outpatient clinics within the Cleveland Clinic Healthcare System with hypertensive urgency, that is, with systolic BP of at least 180 mmHg or diastolic BP of at least 110 mmHg. But less than 1% of these patients had a MACE within the following 6 months.

Just 0.7% of patients were referred to hospital. These patients tended to have higher BP than those sent home and more often had a history of hypertension and of chronic kidney disease. They had slightly higher rates of MACE than those sent home at 7 days (0.5 vs 0.1%) and 6 months (0.9 vs 0.8%), but the differences were not significant after the patients were matched on their propensity for hospital referral.

Most patients referred to hospital were sent to the emergency department, where they underwent tests including blood tests, urinalysis, chest radiography and computed tomography of the head. These tests were rarely abnormal, with the most frequent finding being haematuria. Just eight of these 387 patients had evidence of target-organ damage.

In a related commentary, Iona Heath (Royal College of General Practitioners, London, UK) observes that, in the absence of symptoms, hypertensive urgency "turns out to be largely illusory". Yet, she says, "people are being admitted to hospital and treated with powerful medications, incurring unwarranted costs, and causing harm to patients in terms of needless fear, stress, and the adverse effects of medication."

Patients initially referred to hospital were significantly more likely than those sent home to be hospitalised within 30 days, but their BP was just as likely to remain uncontrolled after 6 months. At 6 months, 66.6% of hospitalised patients and 60.2% of those sent home still had uncontrolled BP.

However, Heath notes how difficult it can be to meet BP targets, and advocates a pragmatic approach, "in line with the values and aspirations of individual patients rather than the counsel of coercive perfection that permeates so many contemporary guidelines."

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