European Journal of Cardiovascular Medicine

The clinical profiles of patients presenting with hypertensive emergencies in the emergency department of developing countries are not well documented. This study evaluated the presentation mode, clinical profile, prognosis and spectrum of target end-organ damage within the first 48 hours. Hypertensive emergencies account for over 25% of all medical emergencies. Common symptoms include chest pain (27%), headache (22%), dyspnea (22%), epistaxis (17%), faintness and psychomotor agitation (10%)¹,². Associated end-organ damage includes cerebral infarction (24%), acute pulmonary edema (23%), hypertensive encephalopathy (16%) and cerebral hemorrhage (4.5%)²,³.

Hypertensive crisis, classified as urgencies or emergencies, require distinct therapeutic strategies³. Emergencies, marked by acute end-organ damage and severe blood pressure elevations, demand immediate intervention 4,5, whereas urgencies, without end-organ damage, require blood pressure reduction within 24 hours 6,7. The JNC VII report indicates that hypertension affects one billion people globally and classifies hypertensive crisis into urgencies and emergencies¹. Urgencies are more common and hypertension prevalence is expected to rise due to population growth and aging²,³. According to the Framingham study, normotensive individuals at 55 years face a 90% lifetime risk of developing hypertension4.

In the early 20th century, malignant hypertension led to severe complications such as renal and retinal damage4,5. Advances in treatment have significantly lowered mortality rates 6,7. A 1967 VA cooperative study highlighted that antihypertensive drugs reduced cerebrovascular morbidity and mortality 8,9. Hypertension doubles the risk of cardiovascular diseases, including coronary artery disease, heart failure, stroke and peripheral arterial disease. Its prevalence is rising globally, with projections estimating 1.5 billion cases by 2025 due to increasing obesity and aging populations². High blood pressure is responsible for 54% of stroke cases and 47% of ischemic heart disease cases worldwide, half of which occur in hypertensive patients9. The asymptomatic nature of hypertension delays diagnosis. Effective management requires continuous care, which is often inadequate among low-income minorities and men 10. Non-adherence to treatment, influenced by pill burden, costs and side effects is common. Despite advancements, less than one-third of patients achieve blood pressure control below 140/90 mmHg, even in high-income countries. In India, the prevalence of hypertension varies widely. Regional surveys report rates between 6.15% to 36.36% in men and 2% to 39.4% in women in urban areas and from 3% to 36% in men and 5.80% to 37.2% in women in rural areas ¹¹,¹². Hypertensive emergencies require intravenous anti-hypertensives in intensive care for safe management. Hypertensive urgency is often treated with rapid BP-lowering drugs, though evidence for this practice is lacking and long-term blood pressure control is crucial for preventing recurrent hypertensive emergencies and enhancing overall prognosis 18, 19.

This study was therefore designed to evaluate the clinical profiles of patients experiencing hypertensive emergencies.

Aim of the Study

This study aims to evaluate the modes of presentation, clinical profiles, spectrum of target end-organ damage and prognosis of hypertensive emergencies, which constitute over one-fourth of all medical emergencies, during the first 48 hours of presentation in an emergency department.

Objectives

1. To examine the various presentation methods, clinical characteristics and range of target organ damage
2. To facilitate rapid diagnosis and efficient management of hypertensive emergencies
3. To enhance the outcome of hypertensive crisis

This investigation focused on individuals who sought emergency care for high blood pressure at SSIMSRC, Davangere, India between December 2012 and June 2014.

Study Design: Prospective Observational Research

Participant Count: 100 Individuals

Timeframe: December 2012 to June 2014

Location: Emergency Medicine Unit, SSIMSRC, Davangere.

Statistical Analysis: Z test, 1.96 for 95% confidence interval. A 'p' value <0.05 was deemed statistically significant in this research.

Inclusion Criteria

Participants were required to meet at least two of the following conditions:

• Age exceeding 18 years
• Systolic blood pressure above 180 mmHg or diastolic blood pressure surpassing 110 mmHg
• Clinical or laboratory evidence of target organ damage

Exclusion Criteria

The study excluded:

• Individuals under 18 years of age
• Patients with congenital valvular heart disease or chronic kidney disease
• Cases of gestational hypertension, preeclampsia or eclampsia

Study Protocol

Data was collected from 100 patients admitted to the emergency department of SSIMSRC, Davangere, India from December 2012 to June 2014, spanning one and a half years. The study included patients presenting with significantly elevated blood pressures, defined as systolic blood pressure (SBP) ≥180 mmHg or diastolic blood pressure (DBP) ≥110 mmHg, along with symptoms or laboratory evidence indicating acute target organ damage. A comprehensive history was obtained from each patient, focusing on symptomatology, hypertension related history and drug compliance. This information was systematically recorded using a structured proforma, a copy of which is provided in the annexure.

Blood pressure was measured using a mercury column sphygmomanometer to ensure accuracy. Measurements were taken at multiple intervals: upon admission, one hour later, 24 hours later and at the time of discharge. These repeated measurements allowed for the monitoring of blood pressure trends during the patient's hospital stay, facilitating the evaluation of treatment effectiveness and progression. The study aimed to analyze the clinical presentation, progression and management outcomes of patients with hypertensive emergencies, contributing valuable insights into the acute management of hypertension and associated complications in a high-risk population. The collected data was analyzed to derive meaningful conclusions about patient profiles and outcomes.

The following points were noted while recording the blood pressure

1. The key to the reservoir was turned open
2. The mercury meniscus was at zero
3. The calibrated glass tube was ensured clean.
4. An appropriately sized cuff was used (The bladder length should encircle at least 80% of the circumference while the width should be at least 40% of the circumference of arm. Standard bladder size is 13 cm x 24 cm).
5. The inflation deflation bulb was ensured to function properly. (Failure to achieve a pressure of 40 mmHg above the estimated SBP or 200 mmHg after 3–5 seconds of rapid inflation. The inability of the equipment to deflate smoothly at a rate of 1 mmHg per second or at each pulse beat).
6. Auscultatory measurement of systolic and diastolic pressures.

The following technique was followed for the measurement of BP using a sphygmomanometer.

1. Patients were adequately rested and seated with their arms supported.
2. The cuff and the mercury reservoir were kept at the level of the heart.
3. SBP was initially estimated via palpation. While palpating the brachial/ radial artery, the cuff is inflated until the pulse disappears. The cuff was then inflated to a further 20 mmHg. The cuff is then slowly deflated and the pressure at where the pulse is palpable, is the estimated SBP.
4. The bladder is again inflated to 20 mmHg above the previously estimated SBP and the pressure reduced at 1-2 mmHg per second, while auscultating with the diaphragm of the stethoscope. The point at which repetitive, clear tapping sounds first appears (Korotkoff Phase I) provides SBP.
5. Phase I sounds sometimes disappear as pressure is reduced and reappears again at a lower reading (Auscultatory gap), resulting in an underestimation of the SBP.
6. The complete disappearance of sound (Korotkoff Phase V) was considered a diastolic reading.

In patients with prolonged Korotkoff sounds, Phase IV was used to determine diastolic BP. BP was measured in both arms, taking the higher reading and discrepancies >20/10 mmHg indicated potential arterial anomalies. Detailed systemic and fundoscopic examinations were performed. Blood tests included Hb%, total/differential counts, ESR, blood sugar, renal function tests, electrolytes, lipid profile and urinalysis. Chest X-rays, ECGs and additional imaging (CT brain, echocardiography, renal sonogram) were conducted based on clinical findings. Data were analyzed using Microsoft Excel.

Computed Tomography Brain in Neurological Deficit Patient

Hypertensive haematomas. (A) Axial non-contrast CT scans show hyperdense acute intra-cerebral haematomas in the region of right external capsule/lentiform nucleus, (B) Left thalamus, (C) Pons and (D) Right cerebellar hemisphere.

Demographical parameters

Gender-wise distribution: Maximum number of patients enrolled in the study were males 70% and females were 30%.

Age-wise distribution: In the 30-39 age group, there were 5 males and 3 females; in the 40-49 age group, 15 males and 5 females; in the 50-59 age group, 20 males and 8 females; in the 60-69 age group, 16 males and 10 females; and in those aged above 70 years, 14 males and 4 females (Table-1). The age range was 38-80 years for males and 43-75 years for females, with a mean age of 57.65 years for males and 63.33 years for females.

Table 1. Age-wise distribution of the patients

Among the patients with blood pressure (BP) > 220/120 mmHg, 16 were males and 6 females; 20 males and 12 females presented with a BP of 210/110 mmHg; 14 males and 4 females exhibited a BP of 200/110 mmHg; and 20 males and 8 females demonstrated a BP of 180/110 mmHg upon admission, out of the 100 patients included in the study (Figure-1).

In a cohort of 100 patients, 50 patients presented with neurological deficits (38 males and 12 females), 25 with dyspnoea (15 males and 10 females), 14 with chest pain (10 males and 4 females), 7 with epistaxis (5 males and 2 females) and 4 with headache (3 males and 1 female).

Distribution of Patients Based on Neurological Deficit

Among the 50 patients, 24 experienced altered sensorium, 20 had hemiparesis, 3 exhibited visual deficits, 2 had convulsions and 1 presented with monoparesis (Fig-3).

Distribution Based on Hypertensive Status: Among the 100 patients, 60 were previously diagnosed with hypertension. Of these known hypertensive individuals, 42 adhered to their antihypertensive medication regimens, while 18 discontinued treatment.

In the present study, out of 100 patients, 12 had diabetes and 36 presented with dyslipidaemia.

Table-2: Distribution of Systolic and Diastolic Blood Pressure measurements in the study

The mean systolic blood pressure at the time of admission was 216 mmHg, at 1 hour was 197 mmHg, at 24 hours was 163 mmHg and at the time of discharge was 136 mmHg. The mean diastolic blood pressure at the time of admission was 125 mmHg, at 1 hour, 111 mmHg, at 24 hours was 96 mmHg and 85 mmHg at discharge.

Electrocardiogram Changes : Out of 100 patients, 26 had ST segment or T wave changes (16 males & 10 females), 10 had ECG voltage criteria of LVH (8 males & 2 females), 2 had both changes (both males) and rest 62 were normal.

Fundus examination: Fundus was normal in 32 patients, 22 exhibited grade I changes, 12 presented with grade II changes, 4 demonstrated grade III changes and 24 showed evidence of papilloedema.

Chest Radiography: Among the 100 patients, seven presented with cardiomegaly, eight exhibited pulmonary oedema and the remaining 85 were within normal limits.

Echocardiography: A total of 39 patients presented with chest pain (14) & dyspnoea (25), underwent 2D ECHO, wherein 30 demonstrated LVF and the remaining 9 had normal ECHO results.

Renal Function Tests: Among the 100 patients, 24 exhibited elevated blood urea, 18 presented with elevated serum creatinine, 10 demonstrated elevations in both parameters and 48 were within the normal range.

Distribution of Patients Based on Ultrasound Abdomen

Patients with deranged RFT (52) were subjected to renal sonogram, 12 had grade I (23.07%), 8 had grade II (15.38) & remaining 30 were normal (61.53%)

Computed Tomography of Brain: Neurological evaluation (50) in symptomatic patients with computed tomography of brain revealed acute intra-cerebral haemorrhage in 28 patients, acute ishaemic stroke in 10 cases,

subarachnoid hemorrhage in 8 cases and normal study of the brain in remaining 4 cases.

Target End Organ involvement: Target end organ damage in the present study comprised intracranial haemorrhage in 36 patients, left ventricular failure in 30 patients, ischaemic stroke in 10 patients, hypertensive encephalopathy in 24 patients, papilloedema in 24 patients and nephropathic changes in 20 patients.

Among the 24 patients who presented with hypertensive encephalopathy, all 24 exhibited signs of papilloedema upon fundoscopic examination and 20 demonstrated nephropathic changes on renal sonography.

Outcome and ‘P’ value of the study: In a study of 100 patients, 78 achieved full recovery, whereas 22 experienced in-hospital mortality. All 22 deceased patients had been admitted with blood pressure exceeding 200/110 mmHg and exhibited target end-organ damage : 14 with intracerebral haemorrhage (ICH) and 8 with left ventricular failure (LVF). The 22 patients comprised 16 males and 6 females. Every male patient had a history of hypertension and half of them were diagnosed with diabetes. Similarly, all six females were known to have hypertension, but only four had pre-existing diabetes.

In the current investigation, the calculated p value of 0.0485 fell below the 0.05 threshold, indicating statistical significance. This result demonstrates a notable disparity in mortality rates amongst individuals presenting with elevated blood pressure levels.

The present clinical study of hypertensive emergencies and its clinical presentation was performed at the tertiary care hospital SSIMSRC Davangere from December 2012 to June 2014 over a period of one and half years.

In the present study, the number of males presenting with hypertensive emergencies was greater than that of females. 70% of the patients were males and 30% were females. In a study on hypertensive crisis, 55% of patients were males among patients with hypertensive emergencies13. The proportion of males in hypertensive emergencies was also higher in another study3. This is probably due to the increased susceptibility of males compared with females to hypertension related target end-organ damage. The decade-wise distribution of age shows that the largest groups belong to the fifth and sixth decades at the time of presentation, with 28% and 26% respectively. This possibility was revealed in the Framingham study, which showed that the incidence of coronary artery disease in men increased in an almost linear manner as age increased. The proportion of males was higher when studying the group of patients aged < 50 years. The majority of female patients belonged to the postmenopausal age group which shows susceptibility of postmenopausal age to end organ damage. This is also due to the fact that postmenopausal female haemodynamics is not very much different from the male profile with regard to blood pressure 15, 16. Analyzing the presenting symptoms, the largest group of patients in the present study presented with the neurological deficit (50%), followed by dyspnea (25%) and chest pain (14%). This was similar to the study by Martin et al., who reported presenting symptoms of neurological deficits, dyspnoea and chest pain in 48%, 25% and 18% of their patients 13. Another report also indicated that more patients presented with chest pain (27%), dyspnoea (22%) and neurological deficits (21%) 3. Neurological deficits in the present study included hemiparesis (40%), altered sensorium(48%), convulsions (6%) and visual deficits (4%). Altered sensorium, followed by hemiparesis, accounted for the largest group of patients with neurological deficits. Most patients in the present study had previously.

known hypertension (60%). Martin et al noticed a large number of patients (83%) in their study to be previously diagnosed hypertensives 13. It has also been reported that a large proportion (92%) of known hypertension prevails among patients. This evidence confirms that the number of hypertensive emergencies was higher in patients with previously known hypertension 3. This also shows that patients with hypertension are at a higher risk of developing a hypertensive emergency if they do not adhere to antihypertensive therapy. In the present study, 40% of the known hypertensives ignored their hypertensive status and discontinued antihypertensive medications which would have put them at a higher risk for acute target end-organ damage and hypertensive emergencies. Diabetes mellitus and dyslipidaemia were other risk factors in the present group of patients. In this study, 12% and 36% of the patients had diabetes mellitus and dyslipidaemia, respectively. The percentage of patients with diabetes mellitus was 26% in a previous reported study 13. These risk factors could have added to premature atherosclerosis and coronary artery disease, predisposing them to acute target end-organ damage. The prevalence of arterial hypertension in diabetic patients (40-50%) is greater than that in non-diabetic patients (20%) 17. Metabolic abnormalities ( hyperglycaemia, hyperinsulinaemia and dyslipidaemia) may play a role in the pathogenesis and complications of arterial hypertension, as observed in the present study. The highest recorded SBP was 280 mm Hg, with a mean SBP of 216+25 mmHg. The highest recorded DBP was 180 mmHg, with a mean of 126+18 mmHg. This is in conformity with the findings of Martin et al., who reported a mean SBP of 193+26 mmHg in their patients and a mean DBP of 129+12 mmHg 13. The mean reduction in blood pressure one hour after admission to the hospital was 19 mmHg for SBP and 14 mmHg for DBP. Blood pressure levels at admission were higher in the group of patients who died than in those who were discharged from the hospital. Higher blood pressure levels would have added to more severe target organ damage in these patients with adverse outcomes. This indicates a worse prognosis with higher blood pressure at presentation. Evaluation of the fundus revealed changes ranging from hypertensive retinopathy to papilloedema in 68% of the patients. Papilloedema was observed in 24% of the patients which is evidence of ongoing target organ damage in these patients. Renal dysfunction in the form of elevated serum urea and creatinine levels was observed in 24% and 18% of patients respectively. Renal changes amounting to hypertensive target end-organ damage were seen in five patients. Hyponatremia was observed in 32% of patients, 12% of the patients had hypokalemia compared to 4% with hyperkalemia, reflecting secondary aldosteronism from increased rennin secretion induced by intra renal ishaemia. Microalbuminuria was seen in 36% of the patients which puts these patients at a higher risk for hypertension-related renal disease than patients without proteinuria. Computed tomography of the brain showed intracerebral haemorrhage (56%) as the most common cause of neurological target organ damage, followed by cerebral infarction (16%) and subarachnoid haemorrhage (10%). Voltage criteria suggestive of left ventricular hypertrophy on ECG were seen in 38% of the patients and 76% had left ventricular hypertrophy on echocardiography. A study conducted by Lip et al. on complications and survival of 315 patients with malignant hypertension found a low median survival time in patients with proteinuria and high serum urea & creatinine levels at presentation and if left ventricular hypertrophy was detected on echocardiogram14. These findings in a patient in a hypertensive emergency may help in prognosticating these patients.

Evaluation of target organ damage in the present study showed intracerebral haemorrhage as the common cause (25%), followed by left ventricular failure (20%), unstable angina (12%), acute myocardial infarction (10%), acute ischaemic stroke (10%), subarachnoid haemorrhage (8%), malignant hypertension (6%), acute myocardial infarction with left ventricular failure (4%) and hypertensive encephalopathy (16%). Zampglione et al in their study observed target end organ damage in the form of intracerebral haemorrhage (45%), left ventricular failure (23%), acute ishaemic stroke (24%) in their patients 3. Another study revealed intracerebral haemorrhage (17%), left ventricular failure (25%), acute ischaemic stroke (39%) and acute myocardial infarction 8% in patients13.

The present study showed an in-hospital mortality rate of 22% in these patients. Among the 22 patients, 16 were males and 6 females. Of the 16 males, all were known hypertensives and 8 were diabetic patients. Of the six females, all were known to have hypertension and only four had diabetes mellitus.

This prospective observational study contributes to the insightful knowledge about hypertensive emergencies characterized by SBP ≥180 mmHg or DBP ≥110 mmHg with acute target organ damage. Clinical history, blood pressure trends, systemic examinations, biochemical tests, imaging and outcomes were evaluated. Most patients were males aged >50 years, with 60% having pre-existing hypertension, 36% dyslipidemia and 12% diabetes. Neurological deficits (50%) and intracerebral hemorrhage (56%) were the common presentations. Severe blood pressure levels correlated with worse outcomes, including a 22% in-hospital mortality rate. Effective management focuses on prompt BP reduction to prevent further organ damage.

SUMMARY

Hypertensive emergencies, over a quarter of medical emergencies, involve acute organ damage, requiring immediate BP reduction to prevent further harm. Hypertension, a key modifiable risk factor for major diseases, demands timely treatment, healthy lifestyle promotion and preventive strategies to reduce its 

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