Original ContributionHypertensive heart failure: patient characteristics, treatment, and outcomes☆
Introduction
Hypertensive crises, consisting of urgencies (without end-organ damage) and emergencies (with end-organ damage), are reported to account for 25% or greater of all emergency department (ED) medical emergencies [1] and may result in 3% of all ED visits. Overall, approximately 1% of patients who have long-term hypertension will experience a crisis in their lifetime [2]. If untreated, the 1-year mortality of uncontrolled hypertension is high [3], and in patients presenting with crises, the 5-year death rate is 26% [4].
Heart failure is a significant public health challenge. It is estimated that there are approximately 1.1 million annual US ED visits for HF [5], [6], of which 80% require hospitalization. Once hospitalized, the in-hospital HF mortality rate is 2% to 20% [7], [8]. After discharge, 11% die within 30 days, 44% require rehospitalization within 6 months, and 33% do not survive 1 year [7]. As an index event, ED HF presentations are associated with increased short-term mortality risk [9]. If admitted from the ED to the intensive care unit (ICU) for acute HF (AHF), in-hospital mortality exceeds 10% [8]. Finally, an ED presentation for acute pulmonary edema has a particularly poor prognosis; 12% die during their admission and greater than 40% within 1 year [10].
ED investigations report that 53% to 73% of all patients presenting with AHF have a history of hypertension [7], [10], with hypertension somewhat more prevalent in preserved (vs reduced) systolic function (76% vs 66%; P < .0001) [11]. More than 60% of patients with AHF have normal or elevated blood pressure (BP), and some report they have a lower mortality than patients with lower BP [12].
Hypertensive emergencies presenting as AHF have been poorly described. Our purpose was to describe the characteristics, treatment, and outcomes of patients presenting with severe hypertension complicated by AHF and compare them to the population presenting with severe hypertension without HF.
Section snippets
Methods
The Studying the Treatment of Acute HyperTension (STAT) registry is a US, multicenter, observational, cross-sectional survey of the management practices and outcomes for patients with acute, severe hypertension receiving parenteral antihypertensive therapy [13]. Its main objectives included describing outcomes of patients with acute severe hypertension by collecting characteristics of hospitalized patients, exploring practice patterns variation, resource use, and factors leading to treatment
Results
Overall, there were 1199 STAT registry patients. Their median age was 57 years, 48% were women, and 62% were African American. Most had a prior hypertension (92%), and 33% had a prior hospitalization for hypertension. From this cohort, 302 (25.2%) were defined as AHF. Acute HF and non-AHF had similar age and sex distributions. However, 75% of AHF were African American, vs 58% of non-HF group. The initial mean (±SD) systolic BP was clinically similar for AHF and non-HF, 210 ± 26 vs 205 ± 23 mm
Discussion
Both hypertensive emergencies and HF are common hospital presentations, often occur simultaneously, and represent an important health burden. We report results from the STAT registry from patients with acute severe hypertension, 25.2% who presented with AHF. Although other studies have identified hypertension at ED presentation to be a low-risk predictor of 30-day death and readmission in the HF population [15] and suggested that this population may be appropriate for early discharge, our
Conclusions
Acute HF patients with severe hypertension were similar to the non-HF acute hypertension cohort in age and sex but more commonly had a history of hypertension, renal insufficiency, and African American heritage. Excess resource use was required for a substantial proportion of AHF patients, as demonstrated by high rates of ICU admission, prolonged hospitalizations, and frequent 90-day readmissions. Finally, accurate BP control is critical, as declines below 120 mm Hg were associated with
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Cited by (33)
Management of Acute Hypertensive Heart Failure
2019, Heart Failure ClinicsCitation Excerpt :Heart failure patients were more likely to be admitted to the intensive care unit and require positive pressure ventilation. Patients with acute heart failure resulting from hypertensive emergency required more clinical resources than patients with severe hypertension without associated heart failure.4 Acute hypertensive heart failure is a rapidly progressive disorder characterized by hypertension and dyspnea.
Ischemic Evaluation in Patients Presenting with Hypertensive Emergency / Urgency and Acute Systolic Heart Failure: Is Coronary Angiography Required for all?
2019, Cardiovascular Revascularization MedicineCitation Excerpt :RWMA on echocardiography was a strong predictor of Obs-CAD also. Our data is also in line with studies supporting less incidence of Obs-CAD in African Americans [8,9,15]. The RANDS risk score we provide is simple to use and may be of help in deciding who needs to undergo coronary angiography after presenting with HF and uncontrolled HTN.
Acute blood pressure elevation: Therapeutic approach
2018, Pharmacological ResearchCitation Excerpt :The analysis of BP values in four cohorts of patients hospitalized for acute heart failure from 1995 to 2012 has shown that the portion of patients with SBP value higher than 160 mmHg significantly declined from one-third to one-fifth of the whole population [50]. Despite about 50% of patients with AHF have elevated BP at the ED admission, it is important to underline that SBP higher than 140 mmHg in patients hospitalized for acute heart failure is associated to a favorable survival, as shown by the ESC-HF-LT Registry [51]; on the opposite, the decline in BP below 120 mmHg during treatment is associated with an increased number of adverse events [52]. In patients presenting with dyspnea and the suspicion of acute heart failure, it should be considered, in addition to the ECG, an echocardiogram for the evaluation of left ventricular systolic and diastolic function and valvular regurgitation [30].
Hypertensive Emergency
2017, Medical Clinics of North AmericaCitation Excerpt :Additional work-up includes checking glucose level to rule out hypoglycemia and obtaining a brain computed tomography (CT) or MRI scan if readily available. The evolution of several cardiac emergencies, including acute heart failure, acute coronary syndrome, and aortic dissection, could be initiated by severe hypertension.19–21 The patient should be asked about a prior heart disease history, to include existing congestive heart failure or coronary artery disease as well as any potential cardiac-related complaints such as shortness of breath, weakness/fatigue, irregular heartbeat, coughing with production of pinkish phlegm, chest discomfort/pressure, referred jaw/ear/arm/epigastric discomfort, nausea/emesis, or a tearing chest or abdominal pain radiating to the back.
Hemodynamic profiles of ED patients with acute decompensated heart failure and their association with treatment
2014, American Journal of Emergency MedicineManagement of hypertensive crisis: British and Irish Hypertension Society Position document
2023, Journal of Human Hypertension
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Funding: STAT was supported by a research grant from the Medicines Company™.