How quickly do I have to lower blood pressure in “hypertensive urgency”?
The term hypertensive urgency was established in 1974 as SBP >180, DBP >110 without evidence of end organ damage, and recommended to “lower MAP by 20 over 24-48 hours."[1] However, there has never been data to quantify the short term cardiovascular risk of hypertensive urgency, let alone the benefit of BP reduction in the short term.
Until now:
Characteristics and Outcomes of Patients Presenting with Hypertensive Urgency in the Office Setting. Patel et al. JAMA IM. 2016;176(7) [2]
Bottom line:
There was no significant difference in stroke or MI (Major Adverse Cardiac Events, MACE) between those admitted to the hospital for urgent management and observation vs. those sent home with uptitrated oral meds for patients with SBP >200.
Design: Retrospective cohort study
Setting: One healthcare system from January 2008 – December 2013
Patients: 58,836 adults with hypertensive urgency (SBP >180 or DBP >110, no symptoms)
Results: No significant difference between those being treated in the hospital over the course of hours vs. sent home on oral agents. Overall 7 day maximum risk of major adverse cardiac risk for all patients, even those with SBP >220, was 0.5%.
Conclusion:
When a patient is truly asymptomatic, this large observational study showed the risk of a serious cardiovascular event in non-urgent therapy in the next week to be less than 0.5%. There is no evidence for a benefit in reducing blood pressure over the course of hours.
Limitations:
This is an observational study which is open to unseen confounders, such as whether or not patients who were referred to the ED may have been sicker than those sent home (although baseline characteristics were were well matched).
The reason why this relatively weak study is impactful is that it is the best we have. The orthodoxy of hypertensive urgency is based on expert opinion alone.
This is an observational study which is open to unseen confounders, such as whether or not patients who were referred to the ED may have been sicker than those sent home (although baseline characteristics were were well matched).
The reason why this relatively weak study is impactful is that it is the best we have. The orthodoxy of hypertensive urgency is based on expert opinion alone.
Important caveat:
This is weak evidence, which means that decision making should be highly dependent on the clinical situation. Patients should be assessed for evidence of encephalopathy, aortic dissection, pulmonary edema, eclampsia, etc.
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