Hypertension Raises Red Flags in Busy ERs

Acute severe hypertension (ASH) accounts for up to 25% of all patients seen in “busy urban emergency departments,” according to the results a recent study published in Hospitalist News, but the condition has an unusually high recurrence rate, as well as high morbidity and mortality rates.

Led by Dr. Christopher B. Granger, a cardiologist at Duke University, the study (Studying the Treatment of Acute Hypertension, or STAT) looked at 1,588 patients who received intravenous antihypertensive agents for ASH within 24 hours of going to the hospital, at any of 25 participating U.S. hospitals. Of patients studied, 56% were African-American,nearly one-half were women, and more than 25% had previously been admitted to a hospital for ASH.

Rates of mortality for patients still in the hospital were about 7%; rates of mortality within 90 days were 11%; average time to bring down systolic blood pressure below 160 mm Hg was 4 hours; six different anti-hypertensives were used among the patients, all of which were administered at varying times; and about 65% of patients were not documented as having scheduled or attended a follow-up appointment.

“The thing that jumps out at me is the extraordinarily low rate of follow up,” said Dr. Jeffrey S. Borer, session co-chair, on the Hospitalist News website. “It would be so easy to blame the doctor, but my guess is that’s not what happened. My guess is that it has to do with a lack of effort on part of the patient. Perhaps they don’t realize how important it is to follow up.”

Two analyses of STAT are still ongoing, which aim to identify risk factors for recurrence of ASH and the most effective treatments for lowering blood pressure with serious damage to the kidneys or other organs.

Granger also discussed how incredibly busy emergency departments are in the United States and how that might relate to findings discussed in the STAT registry about emergency room visits for ASH.“I think the problem relates largely to the fact that in the [United States]—and this may be an issue worldwide as well—the emergency departments where acute severe hypertension is largely being managed are really overburdened and unable to deal with the issues of long-term care, follow-up, and prevention of recurrence,” he said.

Federal law requires that emergency rooms must stabilize a patient, but afterward the patients may be transported to other hospitals. This may contribute to what Dr. Granger discussed, in that ASH can be treated with medication, making a patient stable and thus allowed to legally be released from the hospital. The problems is that for those with underlying heart conditions or other chronic illnesses, much more than stabilizing care is needed, as Dr. Granger also explained.