Clinical presentation and management of patients with uncontrolled, severe hypertension: Results from a public teaching hospital

Context: There is relatively little data available on the management of patients with severe, uncomplicated hypertension and severe hypertension with stable hypertensive complications. Objective: To determine the incidence, clinical features, acute management, and clinical course of severe, uncomplicated hypertension and severe hypertension with stable hypertensive complications presenting for emergency department care in a large public teaching hospital. Design: Chart survey of consecutive emergency department visits. Patients: Ninety-one of 2898 consecutive visits to a public teaching hospital emergency department were specifically for severe, uncomplicated hypertension. Results: Of 2898 consecutive medical emergency department visits, there were 142 (4.9%) patient visits specifically for systolic blood pressure (SBP) ≥ 220 mmHg or diastolic blood pressure (DBP) ≥ 120 mmHg. Ninety-one of the 142 patient visits were for severe hypertension in the absence of acute target organ impact or neuroretinopathy received acute drug therapy. Twenty-nine received two drugs, and 15 received three drugs. Sixty-eight patients (75%) received clonidine, and 15 (16.5%) received short-acting nifedipine despite widely published concerns about the safety of this practice. We found a wide variability of blood pressure response to treatment. The average decline in SBP was 50 ± 31 mmHg and the average decline of DBP was 34 ± 20 mmHg over 4.2 ± 2.9 h. Forty-two patients (46%) had the SBP reduced to less than 160 mmHg, and 46 patients (50%) the DBP to less than 100 mmHg. Long-term management and follow-up were suboptimal. Of 74 patients discharged from the emergency room, 22 patients (30%) returned because of uncontrolled hypertension within an average of 33 ± 28 days, 10 patients with hypertensive complications. Conclusions: Severe hypertension continues to present an important and common problem. Physicians appear to place a strong emphasis on acute lowering of the blood pressure to near-normal levels. Patients are frequently lost to follow-up and have a very high rate of recurrent emergency department visits and hypertensive complications. This study points to a need for detailed, specific practice guidelines and comprehensive disease management protocols for severe, uncomplicated hypertension.