Sponsored by a grant from The Medicines Company to the Center for Outcomes Research, University of...

Sponsored by a grant from The Medicines Company to the Center for Outcomes Research, University of Massachusetts Medical School

Acute Severe Hypertension has Acute Severe Hypertension has High Morbidity, Mortality, High Morbidity, Mortality, and Readmission Rates: and Readmission Rates:

Results from the STAT Registry Results from the STAT Registry

CB Granger, J Gore, J Katz, K Kleinschmidt, A Wyman, F Peacock, F Anderson, on behalf of the STAT Investigators. Presented at the European Society of Cardiology Annual Meeting, September 2, 2008.

2www.outcomes.org/stat

STAT Steering CommitteeSTAT Steering Committee

Albert Einstein College of MedicineAlbert Einstein College of MedicineAlan S MultzAlan S Multz

Cleveland ClinicCleveland ClinicW Frank PeacockW Frank Peacock

Columbia UniversityColumbia UniversityStephan A MayerStephan A Mayer

Duke University Duke University Christopher Granger*Christopher Granger*Eric PetersonEric Peterson

Ohio State UniversityOhio State UniversityJoseph F DastaJoseph F Dasta

Uniformed Services UniversityUniformed Services UniversityAndrew F ShorrAndrew F Shorr

University of California University of California Alpesh Amin Alpesh Amin

University of MassachusettsUniversity of MassachusettsFred AndersonFred AndersonJoel GoreJoel Gore

University of PennsylvaniaUniversity of PennsylvaniaCharles PollackCharles Pollack

University of Southern CaliforniaUniversity of Southern CaliforniaGene Yong SungGene Yong Sung

University of Texas at HoustonUniversity of Texas at HoustonJames FergusonJames FergusonJoseph VaronJoseph Varon

University of Texas SouthwesternUniversity of Texas SouthwesternKurt KleinschmidtKurt Kleinschmidt

Project and data coordinated by and Project and data coordinated by and analyzed by Center for Outcomes analyzed by Center for Outcomes Research, University of Massachusetts, Research, University of Massachusetts, Worcester, MAWorcester, MA

*Chair


Participating Investigators in STAT Participating Investigators in STAT (25 US Centers)(25 US Centers)

Cleveland, OH

Worcester MA

Dallas, TX

New York, NYPhiladelphia, PA

Houston, TX

Durham, NC

Sacramento, CA

Columbus, OH

Miami, FL

Boston, MA

Detroit, MI (3)Detroit, MI (3)

New Orleans, LA

Chandler, AZ

Royal Oak, MIRoyal Oak, MI Stony Brook, NY

Charleston, SC

Winston-Salem, NC

Ann Arbor, MIAnn Arbor, MI

Joseph VaronPhil LevyRichard NowakJohn DevlinJim FroehlichBrian O'NeilMarc LapointKurt KleinschmidtW Frank PeacockJoel M GoreCharles PollackJon Schrock

Lala DunbarJohn CienkiStephan S MayerAnthony GerlachDeborah DiercksAdam SingerGene Yong SungJason KatzNamarata PatilDavid ClineIcima FergusBrian Tiffany


BackgroundBackground

Acute severe hypertension is common – Acute severe hypertension is common – occurring in 1-2% of the 72 million US patients occurring in 1-2% of the 72 million US patients with hypertension, and comprising up to 25% of with hypertension, and comprising up to 25% of visits in busy urban emergency departmentsvisits in busy urban emergency departments

Contemporary patient features, management Contemporary patient features, management and outcomes are not well knownand outcomes are not well known

Traditional definitions of who needs intensive Traditional definitions of who needs intensive therapy have been based on target organ therapy have been based on target organ dysfunctiondysfunction


GoalGoal

Improve understanding of clinical Improve understanding of clinical

conditions of acute severe hypertension conditions of acute severe hypertension

managed in a critical care setting and managed in a critical care setting and

treated with IV antihypertensive drugstreated with IV antihypertensive drugs


Inclusion CriteriaInclusion Criteria

>18 years of age>18 years of age Presenting to the hospital with acute Presenting to the hospital with acute

severe HTNsevere HTN Treated in a critical care settingTreated in a critical care setting Acute severe HTN treated with an IV agentAcute severe HTN treated with an IV agent Severe hypertensionSevere hypertension

– At least one SBP >180 mmHg and/orAt least one SBP >180 mmHg and/or– At least one DBP >110 mmHgAt least one DBP >110 mmHg

SAH patients with SBP >140 and/or DBP >90SAH patients with SBP >140 and/or DBP >90


Study PopulationStudy Population

PatientsPatients 1,588 1,588

Age - median (IQR) Age - median (IQR) 58 (49, 70)58 (49, 70)

Female sexFemale sex 49% 49%

Black raceBlack race 56% 56%

White raceWhite race 34% 34%

Qualifying BP (mmHg)Qualifying BP (mmHg)

SystolicSystolic 200 (186, 220)200 (186, 220)

DiastolicDiastolic 110 (93, 123)110 (93, 123)

LOS - median (IQR) LOS - median (IQR) 5 days (2, 9)5 days (2, 9)


Patient DemographicsPatient Demographics

Medical historyMedical history %%

HypertensionHypertension 8989

Tobacco or alcohol useTobacco or alcohol use 3838

DiabetesDiabetes 3535

Chronic kidney diseaseChronic kidney disease 3131

End stage renal diseaseEnd stage renal disease 1111

Previous hospitalization for HTNPrevious hospitalization for HTN 2727

Neurological eventNeurological event 2323

Drug abuseDrug abuse 1515


Predisposing Factors Contributing to Predisposing Factors Contributing to Hypertensive Event (35%)Hypertensive Event (35%)

FactorsFactors %%

Medication non-adherenceMedication non-adherence 2525

ChronicChronic 1616

CurrentCurrent 1010

Missed or incomplete dialysisMissed or incomplete dialysis 33

Anxiety/psychosocial reactionAnxiety/psychosocial reaction 22

Drug abuseDrug abuse 1111


Primary Admitting DiagnosisPrimary Admitting Diagnosis

2%

2%

3%

4%

7%

8%

10%

11%

27%

0% 10% 20% 30%

Aortic dissection

Subdural hematoma

Renal failure

Ischemic stroke

Hemorrhagic stroke

Acute heart failure/PE

MI/ACS

Subarachnoid hemorrhage

Hypertension


Resource UseResource Use

Procedure/care Procedure/care % %

Brain imaging (CT, MRI) Brain imaging (CT, MRI) 48 48

Admitted to ICUAdmitted to ICU 4848

Echocardiography Echocardiography 4545

Arterial lineArterial line 2525

Mechanical ventilation Mechanical ventilation 1818

Funduscopic examFunduscopic exam 1313


Time from Qualifying BP to Initiation Time from Qualifying BP to Initiation of IV Therapyof IV Therapy

46.6%

74.2%

88.5%

97.0%100.0%

0%

20%

40%

60%

80%

100%

Within 1 hr Within 3 hrs Within 6 hrs Within 12 hrs Within 24 hrs


First IV AntihypertensiveFirst IV Antihypertensive

8%

5%

8%

15%

15%

17%

32%

0% 10% 20% 30% 40%

Other

Sodium nitroprusside

Nicardapine

Hydralazine

Nitroglycerin

Metoprolol

Labetolol


Number of Different IV Antihypertensives Number of Different IV Antihypertensives During Hospitalization by First ReceivedDuring Hospitalization by First Received

22%

51%

41%

41%

40%

32%

32%

28%

45%

27%

37%

42%

46%

21%

14%

32%

23%

25%

Sodium nitroprusside (n=82)

Nicardapine (n=121)

Hydralazine (n=235)

Nitroglycerin (n=241)

Metoprolol (n=277)

Labetolol (n=501)

Fir

st

IV A

nti

hy

pe

rte

ns

ive

Percent of Patients

One Two Three or more


Median Systolic BP Over 24 h by First Median Systolic BP Over 24 h by First IV AntihypertensiveIV Antihypertensive

-40

-30

-20

-10

0

0 2 4 6 8 10 12 14 16 18 20 22 24

Time since IV initiation (h)

Ch

ang

e fr

om

qu

alif

yin

g (

%)

Enalaprilat* Hydralazine*Labetolol* Metoprolol*Nicardipine* Sodium Nitroprusside*Nitroglycerin*


STAT ResultsSTAT Results

Median time to SBP of <160 mmHg: 4 hrsMedian time to SBP of <160 mmHg: 4 hrs 60% increased to >180 after initial control60% increased to >180 after initial control 4% had iatrogenic hypotension4% had iatrogenic hypotension 29% had recurrent, severe HTN 29% had recurrent, severe HTN

necessitating reinstitution of parenteral necessitating reinstitution of parenteral therapytherapy

65% had no documentation of follow-up 65% had no documentation of follow-up appointment being either scheduled or appointment being either scheduled or attendedattended


Patient OutcomesPatient Outcomes

6.9%

11.0%

37.0%

9.3%

0%

10%

20%

30%

40%

50%

In-hospitaldeath*

Admit to 90-daydeath*

90-dayreadmission†

90-dayreadmission due

to HTN†

*n=1588 (all patients); †n=1415 (all patients alive at discharge and with 90-day follow-up)


Short-Term (2 to 6 month) OutcomesShort-Term (2 to 6 month) Outcomes

Acute ConditionAcute Condition DeathDeath RehospitalizationRehospitalization

ACSACS1,2,31,2,3 5-7%5-7% 30%30%

CHFCHF44 8.5%8.5% 26%26%

Severe HypertensionSevere Hypertension55 11%11% 37%37%

1. OASIS-5 NEJM 20062. GUSTO IIb NEJM 19963. GRACE JAMA 20074. IMPACT-HF J Cardiac Failure 20045. STAT Registry results


SummarySummary

Acute severe hypertensionAcute severe hypertension– Recurrent conditionRecurrent condition

– Associated with poor medical adherenceAssociated with poor medical adherence

– Heterogeneous management: ICU admission, Heterogeneous management: ICU admission, drugs used, BP targetsdrugs used, BP targets

– Alarmingly low rates of follow-upAlarmingly low rates of follow-up

– High mortality and morbidity, especially with High mortality and morbidity, especially with new or worsening end-organ damagenew or worsening end-organ damage

Major need to improve prevention and Major need to improve prevention and treatment of this understudied conditiontreatment of this understudied condition

Sponsored by a grant from The Medicines Company to the Center for Outcomes Research, University of...

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