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Articles

Hypertensive Urgencies and EmergenciesPrevalence and Clinical Presentation

Bruno Zampaglione, Claudio Pascale, Marco Marchisio, Paolo

Cavallo-Perin+

Author Afliations From the Ward o !nternal Medicine !! and "mergenc#

$epartment, Martini %ospital, &urin, and !nstitute o !nternalMedicine, 'niversit# o &urin (!tal#)*

Correspondence to Paolo Cavallo-Perin, M$, !stituto diMedicina !nterna, Corso A*M* $ogliotti, , ./ &orino, !tal#* 0e1t 2ection

 AbstractA3stract &he prevalence and clinical picture o h#pertensiveurgencies and emergencies in an emergenc# department arepoorl# 4no5n* &he aim o the present stud# 5as to evaluate theprevalence o h#pertensive crises (urgencies and emergencies) inan emergenc# department during . months o o3servation andthe re6uenc# o end-organ damage 5ith related clinical picturesduring the 7rst . hours ater presentation* %#pertensive crises(8/9 urgencies, .9 emergencies) represented more than oneourth o all medical urgencies-emergencies* &he most re6uent

signs o presentation 5ere headache (..9), epista1is (89),aintness, and ps#chomotor agitation (9) in h#pertensiveurgencies and chest pain (.89), d#spnea (..9), and neurologicalde7cit (.9) in h#pertensive emergencies* &#pes o end-organdamage associated 5ith h#pertensive emergencies includedcere3ral inarction (.9), acute pulmonar# edema (.:9), andh#pertensive encephalopath# (/9) as 5ell as cere3ralhemorrhage, 5hich accounted or onl# *;9* Age (/8</ versus/< #ears =mean<2$>, P?*) and diastolic 3lood pressure(:<; versus ./< mm %g, P?*.) 5ere higher in

h#pertensive emergencies than urgencies* %#pertension that 5asun4no5n at presentation 5as present in @9 o h#pertensiveemergencies and .@9 o h#pertensive urgencies* !n conclusionh#pertensive urgencies and emergencies are common events inthe emergenc# department and dier in their clinical patterns o presentation* Cere3ral inarction and acute pulmonar# edema arethe most re6uent t#pes o end-organ damage in h#pertensive

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emergencies*e# Words

h#pertension, arterial h#pertension, detection and control emergenc# treatment

 &he DD: report o the Eoint 0ational Committee on $etection,"valuation, and &reatment o %igh Blood Pressure proposed anoperational classi7cation o h#pertensive crises as eitheremergencies or urgencies* 2evere elevations in 3lood pressure5ere classi7ed as h#pertensive emergenciesG in the presence o acute or ongoing end-organ damage or as h#pertensiveurgenciesG in the a3sence o target-organ involvement, a certaindegree o 5hich can pose an immediate threat to the integrit# o the cardiovascular s#stem* $istinguishing h#pertensive urgenciesrom emergencies is important in ormulating a therapeutic plan*

!n the ormer the goal is to reduce 3lood pressure 5ithin .hours, 5hereas in the latter it is to lo5er 3lood pressureimmediatel# (not necessaril# to normal ranges) to prevent or limittarget organ disease* . :

"pidemiological studies indicate that the prevalence o h#pertension in adults is H;9 to ..9 depending on thepopulation considered, 3ut data on h#pertensive urgencies andemergencies are lac4ing 3oth in the general population andemergenc# departments*

 &he aim o the present stud# 5as to evaluate the prevalence o 

h#pertensive emergencies and urgencies in an emergenc#department during . months o o3servation and the re6uenc#o end-organ damage 5ith the related clinical picture during the7rst . hours ater presentation o the patient*Previous 2ection0e1t 2ection

Methods &he present stud# 5as done at the "mergenc# $epartment o theMartini %ospital (&urin, !tal#) rom Eune , DD., to Ma# :, DD:*

 &he !talian 0ational %ealth 2ervice is availa3le to all !talian

citiIens* CitiIens have access to a pu3lic emergenc# department. hours a da#, either directl# or 5hen sent there 3# their doctor*

 &here are no private emergenc# departments either in &urin orthe 5hole Piedmont region o !tal#*All patients over @ #ears o age 5ho presented to theemergenc# department 5ith a h#pertensive crisis 5ere includedin the stud#J all patients 5ere 5hite* &he criteria used to de7ne

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h#pertensive crisis 5ere those o the Eoint 0ational Committee on$etection, "valuation, and &reatment o %igh Blood Pressure andincluded diastolic 3lood pressure K. mm %g, according toprevious reports*;  /  8  @ Both patients previousl# recogniIed to 3eh#pertensive (those 5ith 4no5n h#pertension) and those 5ho

5ere not previousl# 4no5n to have h#pertension (those 5ithun4no5n h#pertension) 5ere considered* We classi7ed ash#pertensive emergencies all cases in 5hich the increase in 3loodpressure 5as associated 5ith one or more o the ollo5ing t#peso acute or ongoing end-organ damage  h#pertensiveencephalopath#J stro4e (cere3ral inarction or intracere3ral orsu3arachnoid hemorrhage)J acute pulmonar# edema, congestiveheart ailure, let ventricular ailure, or aortic dissectionJ acutem#ocardial inarction or unsta3le angina pectorisJ progressiverenal insufcienc#J and eclampsia* All these conditions 5ere

diagnosed clinicall# and 3# diagnostic tests (3lood and urinechemistr#, e#e undus e1amination, "CL, roentgenogram,computed tomograph#, and ultrasound imaging) as appropriateJcomputed tomographic scanning in particular 5as perormed inall patients 5ith neurological s#mptoms* !n the a3sence o end-organ damage all other h#pertensive crises 5ere considered 3#e1clusion to 3e h#pertensive urgencies*

"ach patient under5ent a complete histor#, ph#sicale1amination, and routine 3lood and urine chemical anal#ses*Blood pressure 5as measured 5ith the patient in the recum3ent

position 3# use o a mercur# sph#gmomanometer according to astandard techni6ue* &he average o t5o consecutive readingsta4en : seconds apart 5as used* "ach patient 5as monitored atthe emergenc# department or at least . hours and treatedaccording to his or her condition 5ith niedipine, captopril,clonidine, sodium nitroprusside, or urosemide*;  8  D   All su3ectsgave inormed consent to participate in the stud#*

 &he prevalence o h#pertensive crises, urgencies, andemergencies is e1pressed 3oth as a percentage o the totalnum3er o patients appl#ing to the !nternal Medicine 2ection o 

the "mergenc# $epartment and as a percentage o all medicalurgencies-emergencies* We included in medical urgencies-emergencies an# criticall# ill patientJ that is, an# patient 5ith anillness or inur# that 3# its nature andNor severit# is a direct threatto lie or places the patient at high ris4 o lie-threateningcomplications*

All results 5ere e1pressed as mean<2$* 2tatistical anal#sis 5as

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perormed 3# 2tudentOs t and . tests*Previous 2ection0e1t 2ection

Results &he num3er o patients 5ho applied to the !nternal Medicine2ection o the "mergenc# $epartment during the #ear o thestud# 5as .D, 5hereas the num3er o all medical urgencies-emergencies 5as /: (*;9)* &he num3er o h#pertensivecrises according to Eoint 0ational Committee on $etection,"valuation, and &reatment o %igh Blood Pressure criteria and apresenting diastolic 3lood pressure K. mm %g 5as D* 0opatient sho5ing eatures o a h#pertensive emergenc# had adiastolic pressure ?. mm %g* &he num3ers o h#pertensivecrises, urgencies, and emergencies are reported in &a3le QJmean values o age and diastolic 3lood pressure 5ere

signi7cantl# higher in h#pertensive emergencies than urgencies(P?*. to P?*), and there 5ere more 5omen than men in allgroups* %#pertension 5as un4no5n in .:9 o patients presenting5ith a h#pertensive crisis, including .@9 o those 5ith ah#pertensive urgenc# and @9 o those 5ith a h#pertensiveemergenc#*

Rie5 this ta3leS !n this 5indo5 !n a ne5 5indo5

 &a3le *$ata on Patients Who Applied to the "mergenc# $epartment

$uring the .-Month 2tud# Period &he FigureQ presents the distri3ution o h#pertensive urgenciesand emergencies 3# age class in men and 5omen the pea4s o urgencies and emergencies 5ere earlier in men than 5omen (;to / versus / to 8 #ears o age and / to 8 versus @ to D#ears o age, respectivel#)* &he circadian and circannualdistri3utions o h#pertensive urgencies and emergencies sho5edt5o pea4s during the da# (at D AM and 8 to @ PM) and one pea4during the #ear (Eanuar#), respectivel#*

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Rie5 larger versionS !n a ne5 5indo5

S $o5nload as Po5erPoint 2lide

Figure *Bar graphs sho5 distri3ution o cases o h#pertensive urgenciesand emergencies 3# decades o age in men and 5omen*

 &a3le .Q  reports the prevalences o h#pertensive crises,urgencies, and emergencies, 5hereas &a3le :Q  reports there6uenc# o each t#pe o end-organ damage in the group 5ithh#pertensive emergencies* &he maorit# (@:9) o the patients5ith h#pertensive emergencies sho5ed onl# one t#pe o end-organ damage, 5hereas in small groups (9 and :9,respectivel#) t5o or three t#pes o end-organ damages 5erepresent simultaneousl#*

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Rie5 this ta3leS !n this 5indo5 !n a ne5 5indo5

 &a3le .*Prevalence o %#pertensive Crises, 'rgencies, and "mergencies$uring the .-Month 2tud# Period

Rie5 this ta3leS !n this 5indo5 !n a ne5 5indo5

 &a3le :* &#pes o "nd-Trgan $amage Associated With %#pertensive"mergencies

 &a3le Q  reports the re6uenc# o signs and s#mptoms in allh#pertensive crises, urgencies, and emergenciesJ headache,epista1is, ps#chomotor agitation, and arrh#thmia 5ere morere6uent in urgencies than emergencies (P?* to P?*),5hereas chest pain, d#spnea, and neurological de7cit 5ere more

re6uent in emergencies (P?*. to P?*)*Rie5 this ta3leS !n this 5indo5 !n a ne5 5indo5

 &a3le *Fre6uenc# o 2igns and 2#mptoms in %#pertensive Crises,'rgencies, and "mergencies

Previous 2ection0e1t 2ection

Discussion &he present stud# provides an estimate o the prevalence o h#pertensive crises in an emergenc# department during #ear*

 &his accounts or onl# :9 o the total patients 3ut appro1imatel#one ourth (.89) o the urgencies-emergencies* &o our4no5ledge, this last 7nding has never 3een reported 3eore andindicates that h#pertensive crises represent an important andcommon event in emergenc# medicine and re6uire appropriateresources or their diagnosis and treatment* $ata on theincidence o h#pertensive crises in the general or h#pertensivepopulation 5ould 3e most interesting rom the epidemiologicalvie5point, 3ut to our 4no5ledge the# are not availa3le in theliterature and unortunatel# cannot 3e estimated rom thepresent stud#* 'sing the operational classi7cation o h#pertensivecrises in urgencies and emergencies proposed 3# the Eoint0ational Committee 5e ound that h#pertensive urgencies aremore re6uent than h#pertensive emergencies (8/9 and .9,respectivel#)* Although h#pertensive emergencies represent onl#one ourth o h#pertensive crises, the# are 3# de7nitioncharacteriIed 3# end-organ damage so that the medical sta 

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devotes a lot o time and eort to these patients* Tther reportson this topic could ena3le us to compare the data rom variousareas o the same countr# or dierent countries*As ar as the time o presentation o h#pertensive crises isconcerned, as previousl# noted, 5e ound t5o pea4s during the

da# (at D AM  and 8 to @ PM) and one pea4 during the #ear(Eanuar#)* &he pea4s during the da# do not represent the time at5hich the crises occurred, o5ing to the varia3ilit# o the latenc#period 3et5een the appearance o s#mptoms and arrival at the"mergenc# $epartment either 3# their o5n choice or having3een sent 3# their doctor (transport time)* Tn the other hand, thecircadian and circannual rh#thms o h#pertensive crises areun4no5n, even though the Framingham 2tud# sho5ed thatsudden cardiac death had a circadian variation 5ith a pea4 at 8to D AM*.

!n our series o patients presenting 5ith a h#pertensive crisis,H/9 5ere 5omen (&a3le U)* &his high percentage o 5omen isalso present in h#pertensive urgencies and pro3a3l# reVects thelarger num3er o 5omen than men present in h#pertensivepopulations*:  %o5ever, this e1cess disappears in h#pertensiveemergencies (FigureU), 5hich suggests that h#pertensive menare more suscepti3le than h#pertensive 5omen to end-organdamage* !n addition, postmenopausal age seems to increase thesuscepti3ilit# to end-organ damage*Appro1imatel# one ourth o the patients presenting 5ith

h#pertensive crises had un4no5n h#pertension (&a3le U),indicating that a h#pertensive crisis occurs most commonl# inpatients 5ith 4no5n h#pertension* &hese data con7rm a previousreport that suggested that oten h#pertensive patients did notta4e medication as prescri3ed or received inade6uate therap#*Furthermore, the proportion o our patients 5ith un4no5nh#pertension is higher in h#pertensive urgencies (.@9) thanemergencies (@9)* Another interesting result o the present stud#deals 5ith the re6uenc# o signs and s#mptoms o h#pertensiveurgencies and emergencies and the pattern o end-organ damage

in h#pertensive emergencies* We ound headache and epista1isto 3e the most re6uent signs at presentation in h#pertensiveurgencies (..9 and 89, respectivel#), 5hereas chest pain,d#spnea, and neurological de7cit 5ere the most re6uent signs inh#pertensive emergencies (.89, ..9, and .9) (&a3le U)*Furthermore, the most re6uent end-organ damage associated5ith h#pertensive emergencies 5ere cere3ral inarction, acute

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pulmonar# edema, and h#pertensive encephalopath# (.9, .:9,and /9, respectivel#)J cere3ral hemorrhage accounted or onl#*;9 (&a3le :U)* &he clinical pattern o presentation o h#pertensive crises had never 3een studied 3eore and is o someinterest in clari#ing the natural histor# o the disease in this

respect*!n conclusion, the present stud# indicates that h#pertensiveurgencies and emergencies represent one ourth o all events inemergenc# medicine, that a 6uite dierentclinical pattern o presentation is present in h#pertensive urgencies versusemergencies, and that cere3ral inarction and acute pulmonar#edema are the most re6uent t#pes o end-organ damage inh#pertensive emergencies*Previous 2ection0e1t 2ection

 AcknowledgmentsWe are inde3ted to Claudio Rernetti or his s4illul assistance in7gure preparation and to Mariangela Mosca or language revision*

eceived April .8, DD;* evision received Eune @, DD;* Accepted 2eptem3er , DD;*

Previous 2ection 

References X  &he Fith eport o the Eoint 0ational Committee on $etection,

"valuation and &reatment o %igh Blood Pressure* Arch !nternMed* DD:J;:;-@:* CrosseMedline

. X Ault M, "llrodt A* Pathoph#siological events leading to end-organ eects o acute h#pertension* Am E "merg Med*D@;J:(suppl)-;*

: X Ridt $, Liord * A compendium or the treatment o h#per-tensive emergencies* Cleve Clin Y* D@J;.-:* Medline

X aplan 0M* Clinical %#pertension* Baltimore, Md Williams Wil4insJ DDJ:.D-:@*

; X Calhoun $A, Tparil 2* &reatment o h#pertensive crisis* 0 "ngl E

Med* DDJ:.:88-@:* CrosseMedline

/ X $ellinger P* %#pertensive emergencies and urgencies* !nCivetta EM, &a#lor W, ir3# , eds* Critical Care* Philadelphia,Pa EB [ippincott Co DD.J.D-.8*

8 X LonIales RM, !3arra C, Eeries C* 2ingle-dose su3lingualniedipine as the onl# treatment in h#pertensive urgencies andemergencies* Angiolog#* DDJ.D@-D:*

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@ X %ouston MC* %#pertensive emergencies and urgenciespathoph#siolog# and clinical aspects* Am %eart E* D@/J.;-.*

D X Pascale C, Zampaglione B, Marchisio M* Management o h#per-tensive crisis niedipine in comparison 5ith captopril, clonidine,

and urosemide* Curr &her es* DD.J;D-@* X 2chillinger $* 0iedipine in h#pertensive emergencies a

prospective stud#* E "merg Med* D@8J;/:-8:* CrosseMedline

X %udson [$* "ssentials o critical care medicine approach to thecriticall# ill patient* !n elle# W0, ed* &e1t3oo4 o !nternalMedicine* Philadelphia, Pa EB [ippincott CoJ DD.J@.-@*

. X Willic4 20* Circadian variation in the incidence o suddencardiac death in the Framingham %eart 2tud# Population* Am ECardiol* D@8J/@-@/* CrosseMedline

: X  Eulius 2* Borderline h#pertension an overvie5* Med Clin 0orth

Am* D88J/D;-;* Medline X incaid-2mith P* Malignant h#pertension* Cardiovasc ev ep*

D@J.-;*