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Hypertensive Urgencies and Emergencies
Prevalence and Clinical Presentation
Bruno Zampaglione, Claudio Pascale, Marco Marchisio, Paolo
Cavallo-Perin
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Author Affiliations
From the Ward of Internal Medicine II and Emergency
Department, Martini Hospital, Turin, and Institute of Internal
Medicine, University of Turin (Italy).
Correspondence to Paolo Cavallo-Perin, MD, Istituto di
Medicina Interna, Corso A.M. Dogliotti, 14, 10126 Torino, Italy.
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Abstract
Abstract The prevalence and clinical picture of hypertensive
urgencies and emergencies in an emergency department are
poorly known. The aim of the present study was to evaluate the
prevalence of hypertensive crises (urgencies and emergencies) in
an emergency department during 12 months of observation and
the frequency of end-organ damage with related clinical pictures
during the first 24 hours after presentation. Hypertensive crises
(76% urgencies, 24% emergencies) represented more than one
fourth of all medical urgencies-emergencies. The most frequent
signs of presentation were headache (22%), epistaxis (17%),
faintness, and psychomotor agitation (10%) in hypertensive
urgencies and chest pain (27%), dyspnea (22%), and neurological
deficit (21%) in hypertensive emergencies. Types of end-organ
damage associated with hypertensive emergencies included
cerebral infarction (24%), acute pulmonary edema (23%), and
hypertensive encephalopathy (16%) as well as cerebral
hemorrhage, which accounted for only 4.5%. Age (67±16 versus
60±14 years [mean±SD], P<.001) and diastolic blood pressure
(130±15 versus 126±10 mm Hg, P<.002) were higher in
hypertensive emergencies than urgencies. Hypertension that was
unknown at presentation was present in 8% of hypertensive
emergencies and 28% of hypertensive urgencies. In conclusion
hypertensive urgencies and emergencies are common events in
the emergency department and differ in their clinical patterns of
presentation. Cerebral infarction and acute pulmonary edema are
the most frequent types of end-organ damage in hypertensive

The criteria used to define . to May 31. All patients over 18 years of age who presented to the emergency department with a hypertensive crisis were included in the study. Distinguishing hypertensive urgencies from emergencies is important in formulating a therapeutic plan.emergencies. There are no private emergency departments either in Turin or the whole Piedmont region of Italy. The Italian National Health Service is available to all Italian citizens. Key Words: hypertension. 1993. and Treatment of High Blood Pressure 1 proposed an operational classification of hypertensive crises as either emergencies or urgencies.1 2 3 Epidemiological studies indicate that the prevalence of hypertension in adults is ≈15% to 22% depending on the population considered. whereas in the latter it is to lower blood pressure immediately (not necessarily to normal ranges) to prevent or limit target organ disease. either directly or when sent there by their doctor. Severe elevations in blood pressure were classified as “hypertensive emergencies” in the presence of acute or ongoing end-organ damage or as “hypertensive urgencies” in the absence of target-organ involvement. The aim of the present study was to evaluate the prevalence of hypertensive emergencies and urgencies in an emergency department during 12 months of observation and the frequency of end-organ damage with the related clinical picture during the first 24 hours after presentation of the patient.4 but data on hypertensive urgencies and emergencies are lacking both in the general population and emergency departments. detection and control emergency treatment The 1993 report of the Joint National Committee on Detection. Italy) from June 1. Previous Section Next Section Methods The present study was done at the Emergency Department of the Martini Hospital (Turin. arterial hypertension. 1992. Citizens have access to a public emergency department 24 hours a day. a certain degree of which can pose an immediate threat to the integrity of the cardiovascular system. all patients were white. In the former the goal is to reduce blood pressure within 24 hours. Evaluation.

or furosemide. left ventricular failure. acute myocardial infarction or unstable angina pectoris. ECG. and emergencies is expressed both as a percentage of the total number of patients applying to the Internal Medicine Section of the Emergency Department and as a percentage of all medical urgencies-emergencies. physical examination. roentgenogram. stroke (cerebral infarction or intracerebral or subarachnoid hemorrhage). according to previous reports. and routine blood and urine chemical analyses. computed tomographic scanning in particular was performed in all patients with neurological symptoms.5 6 7 8 Both patients previously recognized to be hypertensive (those with known hypertension) and those who were not previously known to have hypertension (those with unknown hypertension) were considered. Evaluation. The prevalence of hypertensive crises. All these conditions were diagnosed clinically and by diagnostic tests (blood and urine chemistry. clonidine.1 Each patient underwent a complete history. We classified as hypertensive emergencies all cases in which the increase in blood pressure was associated with one or more of the following types of acute or ongoing end-organ damage1 : hypertensive encephalopathy. In the absence of endorgan damage all other hypertensive crises were considered by exclusion to be hypertensive urgencies. sodium nitroprusside. The average of two consecutive readings taken 30 seconds apart was used. congestive heart failure. Blood pressure was measured with the patient in the recumbent position by use of a mercury sphygmomanometer according to a standard technique. captopril. computed tomography. Statistical analysis was . any patient with an illness or injury that by its nature and/or severity is a direct threat to life or places the patient at high risk of life-threatening complications. 5 7 9 10 All subjects gave informed consent to participate in the study.hypertensive crisis were those of the Joint National Committee on Detection. Each patient was monitored at the emergency department for at least 24 hours and treated according to his or her condition with nifedipine.11 All results were expressed as mean±SD. or aortic dissection. that is. We included in medical urgenciesemergencies any critically ill patient. eye fundus examination. progressive renal insufficiency. urgencies. and ultrasound imaging) as appropriate. and Treatment of High Blood Pressure 1 and included diastolic blood pressure ≥120 mm Hg. and eclampsia. acute pulmonary edema.

The circadian and circannual distributions of hypertensive urgencies and emergencies showed two peaks during the day (at 9 AM and 7 to 8 PM) and one peak during the year (January). and there were more women than men in all groups. including 28% of those with a hypertensive urgency and 8% of those with a hypertensive emergency. Hypertension was unknown in 23% of patients presenting with a hypertensive crisis.performed by Student’s t and χ2 tests. The numbers of hypertensive crises. whereas the number of all medical urgenciesemergencies was 1634 (11. The number of hypertensive crises according to Joint National Committee on Detection.5%). • View this table: In this window In a new window Table 1. Evaluation. mean values of age and diastolic blood pressure were significantly higher in hypertensive emergencies than urgencies (P<. Data on Patients Who Applied to the Emergency Department During the 12-Month Study Period The Figure⇓ presents the distribution of hypertensive urgencies and emergencies by age class in men and women: the peaks of urgencies and emergencies were earlier in men than women (51 to 60 versus 61 to 70 years of age and 61 to 70 versus 81 to 90 years of age. respectively. urgencies.002 to P<.001). Previous Section Next Section Results The number of patients who applied to the Internal Medicine Section of the Emergency Department during the year of the study was 14 209. and Treatment of High Blood Pressure criteria and a presenting diastolic blood pressure ≥120 mm Hg was 449. . and emergencies are reported in Table 1⇓. No patient showing features of a hypertensive emergency had a diastolic pressure <120 mm Hg. respectively).

The majority (83%) of the patients with hypertensive emergencies showed only one type of endorgan damage. . and emergencies. respectively) two or three types of end-organ damages were present simultaneously. Table 2⇓ reports the prevalences of hypertensive crises. urgencies.• View larger version: • In a new window Download as PowerPoint Slide Figure 1. Bar graphs show distribution of cases of hypertensive urgencies and emergencies by decades of age in men and women. whereas Table 3⇓ reports the frequency of each type of end-organ damage in the group with hypertensive emergencies. whereas in small groups (14% and 3%.

urgencies. headache.04 to P<.• View this table: In this window In a new window Table 2. Urgencies. but to our knowledge they are not available in the literature and unfortunately cannot be estimated from the present study.001). and Emergencies Previous Section Next Section Discussion The present study provides an estimate of the prevalence of hypertensive crises in an emergency department during 1 year. and neurological deficit were more frequent in emergencies (P<. whereas chest pain. To our knowledge. • View this table: In this window In a new window Table 4. they are by definition characterized by end-organ damage so that the medical staff . respectively). Urgencies. Data on the incidence of hypertensive crises in the general or hypertensive population would be most interesting from the epidemiological viewpoint. and Emergencies During the 12-Month Study Period • View this table: In this window In a new window Table 3.001). Prevalence of Hypertensive Crises. dyspnea.02 to P<. Although hypertensive emergencies represent only one fourth of hypertensive crises. and emergencies. Frequency of Signs and Symptoms in Hypertensive Crises. this last finding has never been reported before and indicates that hypertensive crises represent an important and common event in emergency medicine and require appropriate resources for their diagnosis and treatment. psychomotor agitation. epistaxis. Types of End-Organ Damage Associated With Hypertensive Emergencies Table 4⇓ reports the frequency of signs and symptoms in all hypertensive crises. Using the operational classification of hypertensive crises in urgencies and emergencies proposed by the Joint National Committee1 we found that hypertensive urgencies are more frequent than hypertensive emergencies (76% and 24%. This accounts for only 3% of the total patients but approximately one fourth (27%) of the urgencies-emergencies. and arrhythmia were more frequent in urgencies than emergencies (P<.

indicating that a hypertensive crisis occurs most commonly in patients with known hypertension. Furthermore. Approximately one fourth of the patients presenting with hypertensive crises had unknown hypertension (Table 1⇑). ≈60% were women (Table 1⇑). Other reports on this topic could enable us to compare the data from various areas of the same country or different countries. postmenopausal age seems to increase the susceptibility to end-organ damage. Another interesting result of the present study deals with the frequency of signs and symptoms of hypertensive urgencies and emergencies and the pattern of end-organ damage in hypertensive emergencies. as previously noted. As far as the time of presentation of hypertensive crises is concerned. In addition.12 In our series of patients presenting with a hypertensive crisis. We found headache and epistaxis to be the most frequent signs at presentation in hypertensive urgencies (22% and 17%. and neurological deficit were the most frequent signs in hypertensive emergencies (27%. even though the Framingham Study showed that sudden cardiac death had a circadian variation with a peak at 7 to 9 AM. acute . respectively). Furthermore.13 However. 22%.devotes a lot of time and effort to these patients. On the other hand. dyspnea. the proportion of our patients with unknown hypertension is higher in hypertensive urgencies (28%) than emergencies (8%). whereas chest pain. These data confirm a previous report14 that suggested that often hypertensive patients did not take medication as prescribed or received inadequate therapy. This high percentage of women is also present in hypertensive urgencies and probably reflects the larger number of women than men present in hypertensive populations. owing to the variability of the latency period between the appearance of symptoms and arrival at the Emergency Department either by their own choice or having been sent by their doctor (transport time). the most frequent end-organ damage associated with hypertensive emergencies were cerebral infarction. The peaks during the day do not represent the time at which the crises occurred. and 21%) (Table 4⇑). this excess disappears in hypertensive emergencies (Figure⇑). we found two peaks during the day (at 9 AM and 7 to 8 PM) and one peak during the year (January). which suggests that hypertensive men are more susceptible than hypertensive women to end-organ damage. the circadian and circannual rhythms of hypertensive crises are unknown.

Oparil S. In conclusion. 23%. Previous Section References 1 2 3 4 5 6 7 The Fifth Report of the Joint National Committee on Detection.1209-1217. Gifford R. 1985. Accepted September 11. Revision received June 8.323:1177-1183. Single-dose sublingual nifedipine as the only treatment in hypertensive urgencies and emergencies. In: Civetta JM. ↵ Gonzales VM. ↵ .3(suppl):10-15. Treatment of hypertensive crisis. 1991. Philadelphia. CrossRefMedline ↵ Ault M. respectively). Taylor RW. that a quite differentclinical pattern of presentation is present in hypertensive urgencies versus emergencies. 1995. Ellrodt A. Ibarra C. the present study indicates that hypertensive urgencies and emergencies represent one fourth of all events in emergency medicine. eds. 1993. Jeries C. CrossRefMedline ↵ Dellinger RP. and that cerebral infarction and acute pulmonary edema are the most frequent types of end-organ damage in hypertensive emergencies. 1984. The clinical pattern of presentation of hypertensive crises had never been studied before and is of some interest in clarifying the natural history of the disease in this respect.pulmonary edema. Pa: JB Lippincott Co: 1992.51:421-430. Baltimore. A compendium for the treatment of hypertensive emergencies. 1991.153:154-183. Previous Section Next Section Acknowledgments We are indebted to Claudio Vernetti for his skillful assistance in figure preparation and to Mariangela Mosca for language revision. Angiology. cerebral hemorrhage accounted for only 4. and hypertensive encephalopathy (24%. 1995. Clinical Hypertension. 1995. N Engl J Med. Received April 27. Evaluation and Treatment of High Blood Pressure. Arch Intern Med. Cleve Clin Q. Kirby RR.42:908-913. Critical Care. Am J Emerg Med. Hypertensive emergencies and urgencies. Pathophysiological events leading to endorgan effects of acute hypertension. Md: Williams & Wilkins. Medline ↵ Kaplan NM. ↵ Calhoun DA.5% (Table 3⇑). and 16%. ↵ Vidt D. 1990.329-348.

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