Journal of the American Society of Hypertension 6(4) (2012) 291–295

Research Article
Relationship between blood pressure and persistent epistaxis
at the emergency department: a retrospective study
Moriyuki Terakura, MD*, Ryuichi Fujisaki, MD, Takaoki Suda, MD, Toshio Sagawa, MD,
and Tetsuya Sakamoto, MD
Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
Manuscript received March 1, 2012 and accepted May 8, 2012

Abstract

Background: Persistent nosebleed episodes have occurred in patients with idiopathic epistaxis from Kiesselbach’s area
despite confirmed location of the bleeding site, but the cause remains unclear. We tried to determine whether persistent
epistaxis was associated with blood pressure.
Methods and Results: Between May 2009 and May 2010, the records for 133 adult patients with idiopathic epistaxis from
Kiesselbach’s area were obtained from the emergency department of our hospital. The bleeding site was pressed with a cotton
strip for about 30 minutes, followed by checking for nosebleed. Comparison of background factors by the presence or
absence of persistent epistaxis revealed a significantly higher systolic blood pressure in patients with persistent nosebleed
than in those without (181.3
26.9 vs. 156.6
26.1 mm Hg; P < .0001). Persistent epistaxis was significantly more frequent
in patients with hypertension than in those without (26% vs. 8%; P ¼ .002). Multivariate logistic analysis revealed systolic
blood pressure to be an independent factor associated with epistaxis persistence (odds ratio, 1.03; 95% confidence interval,
1.01–1.06; P ¼ .002).
Conclusion: Proper blood pressure management is necessary for the prevention of persistent epistaxis from Kiesselbach’s area
in the clinical setting of emergency care practice. J Am Soc Hypertens 2012;6(4):291–295. Ó 2012 American Society of
Hypertension. All rights reserved.
Keywords: Persistent epistaxis; Kiesselbach’s area; systolic blood pressure.

Introduction emergency care activity increase is anticipated for this ED,

In May 2009, an all-around medical aid emergency
department (ED) was established at Teikyo University
Hospital to provide primary and secondary emergency
care, mainly accepting patients requiring ambulance service
in the ED during general outpatient service hours and both
patients brought to the ED and ambulatory patients seen
outside of regular service hours. In total, there were 313
patients who were initially examined/treated for idiopathic
epistaxis by emergency physicians at our ED during the
1-year period between May 2009 and May 2010, and a future
There has been no significant support for this work that could
have influenced the outcome. None of the authors have declared
any financial conflicts of interest regarding this study.
*Corresponding author: Moriyuki Terakura, MD, 2-11-1 Kaga,
Itabashi, Tokyo, Japan 173-8606.
E-mail: m-teraku@mb3.suisui.ne.jp
1933-1711/$ - see front matter Ó 2012 American Society of Hypertension. All rights reserved.
doi:10.1016/j.jash.2012.05.001
which serves as a core facility for epistaxis treatment in
northwestern Tokyo.
As for causes of nosebleed, there have been reports from
settings of emergency care practice suggesting associations
with hypertension,1,2 yet the etiology remains largely
unknown.3,4 In particular, persistent nosebleed episodes
have occurred among cases of idiopathic epistaxis from
Kiesselbach’s area despite confirmed location of the
bleeding site, but the cause remains unclear in many
respects. Furthermore, reported studies on patients with
idiopathic epistaxis initially examined/treated by emer-
gency physicians are as yet few, and nearly all such reports
were by otorhinolaryngologists.5,6
This study aimed to determine associations of back-
ground characteristics with the presence or absence of
persistent nosebleed episodes in adult patients with idio-
pathic epistaxis from Kiesselbach’s area (except for sponta-
neous hemostasis).
292 M. Terakura et al. / Journal of the American Society of Hypertension 6(4) (2012) 291–295
Methods
The study population comprised 133 consecutive adult
patients with idiopathic epistaxis from Kiesselbach’s area
(excluding cases in which bleeding stopped spontaneously)
for whom documented blood pressure (BP) data between
May 2009 and May 2010 were available at the ED of out
hospital.
Patients with any of the following criteria were excluded: 1)
bleeding other than idiopathic epistaxis (ie, traumatic epistaxis,
hemorrhage from tumor), 2) age younger than 20 years, 3)
bleeding site other than Kiesselbach’s area or unknown, 4)
initially examined by an otorhinolaryngologist, 5) BP data
undetermined, 6) bleeding that subsided spontaneously, and
7) use of a drug or drugs that stimulate epinephrine release.
For the control of nasal bleeding, an emergency physician
first located the site of bleeding through a rhinoscope, the
bleeding site was then pressed with a cotton strip moistened
with a 1:10,000 dilution of epinephrine (Bosmin) plus 4%
lidocaine hydrochloride (Xylocaine) for about 30 minutes,
followed by checking for persistent nosebleed episodes.
The purpose of this study was to determine associations
of background characteristics with the presence or absence
of persistent episodes of nosebleed from Kiesselbach’s area
in adult patients and thereby to contribute to prevention of
persistent epistaxis.
The study protocol was in accordance with the tenets of
the Declaration of Helsinki. This study was approved by the
Ethics Committee of Teikyo University Hospital (Teikyo
Ethics Committee Approval No. 11-031).
Statistical Analysis
Continuous variables were expressed as mean
standard
deviation. Two groups were compared using the t-test or
Mann-Whitney test. Intergroup comparisons were carried
out using Fisher’s exact test or the chi-squared (c2) test. The
correlation coefficient was Spearman’s rank correlation coef-
ficient. Relationships of persistent epistaxis with individual
background factors (gender [female, male], age, any history
of nosebleed episodes, systolic and diastolic BPs, whether
currently on anticoagulants, whether hypertensive, whether
under treatment for hypertension, whether on dialysis therapy,
any history of cerebral infarction, any cardiac disorder, dia-
betes mellitus, malignant tumor(s), any hepatic disorder,
bronchial asthma, any thyroid disorder or hyperlipidemia,
and whether a bleeding point was confirmed) were evaluated
using univariate logistic analysis. Subsequently, background
factors found to show P < .2 and the presence or absence of
persistent nosebleed episodes were subjected to multivariate
logistic analysis, and results of the analysis were expressed in
terms of odds ratios (OR) with 95% confidence intervals (CI).
Furthermore, for each significant independent variable
derived from the multivariate logistic analysis, a receiver
operating characteristic (ROC) curve was constructed and
the area under the curve (AUC) and optimal cutoff value
were calculated. In all interpretations for statistical signifi-
cance, differences were considered significant at P < .05.
The SPSS statistical package for windows, version 11.0.1J
(SPSS Inc., Chicago, Illinois) was used in all of the previ-
ously described statistical analyses.
Results
Table 1 shows comparisons of background factors by
whether or not persistent epistaxis occurred. Systolic BP
was significantly higher in patients who had persistent nose-
bleed episodes than in those without persistent bleeding
(181.3
26.9 vs 156.6
26.1 mm Hg; P < .0001). Persistent
epistaxis incidence was significantly higher in patients with
than in those without hypertension (26% vs. 8%; P ¼ .002).
As shown in Table 2, pertinent data were subjected first to
univariate logistic analysis taking whether or not persistent
epistaxis occurred as a dependent variable and also taking
the following parameters as independent variables: gender
(female, male), age, the presence or absence of a past history
of epistaxis, systolic BP, diastolic BP, whether or not the
patient was on anticoagulant medication, was a known
hypertensive, was under treatment for hypertension, was
receiving dialysis, had any history of cerebral infarction,
any cardiac disorder, diabetes mellitus, any malignant tumor,
any hepatic disorder, bronchial asthma, thyroid disorder, or
hyperlipidemia, and whether a bleeding point was locatable
or not. Subsequently, independent factors found to show P <
.2 and the presence or absence of persistent epistaxis (depen-
dent variable) was subjected to multivariate logistic analysis,
and the results are presented herein.
The univariate logistic analysis revealed systolic BP and
whether the patient had hypertension to be significant vari-
ables. The independent factors showing P < .2 included:
systolic BP, diastolic BP, whether the patient had hyperten-
sion, was being treated for hypertension, had any malignant
tumor or had bronchial asthma. Two variables, whether the
patient was receiving anticoagulant medication and whether
the patient had heart disease, showed multicollinearity (R ¼
0.917, P ¼ .0001) and therefore were excluded from the
independent variables for multivariate logistic analysis.
In the multivariate logistic analysis, the c2 test showed
P < .0001, the Hosmer-Lemeshow test was as good as
0.774, and the discriminatory predictive value was 77.8%,
indicating that systolic BP constituted an independent
factor associated with whether or not persistent epistaxis
occurred (P ¼ .002; OR, 1.03 [95%CI, 1.01–1.06]).
For evaluation of the predictability and diagnosability of
nasal persistent bleeding based on systolic BP, found to be
a significant independent associative variable by multivariate
logistic analysis, and for calculation of the optimal cutoff
value, we constructed a ROC curve (Fig. 1). The AUC of
ROC for evaluating predictability and diagnosability from
the ROC curve was calculated to be 0.746 (95%CI,
 M. Terakura et al. / Journal of the American Society of Hypertension 6(4) (2012) 291–295 293

Table 1
Comparison of background factors by the presence or absence of persistent epistaxis
Number Persistent Epistaxis (þ) Persistent Epistaxis (-) P
Total 133 34 99 —
Gender (female:male) 47:86 11:23 36:63 NS
Age (mean
SD) 63.9
12.8 64.2
11.5 63.8
13.2 NS
History of epistaxis (absence:presence) 117:16 30:4 87:12 NS
Systolic blood pressure (mm Hg) 162.9
28.3 181.3
26.9 156.6
26.1 <.0001
Diastolic blood pressure (mm Hg) 91.0
16.4 95.6
15.1 89.4
16.6 NS
Anticoagulant medication (absence:presence) 101:32 24:10 77:22 NS
History of hypertension (absence:presence) 61:72 8:26 53:46 .002
Current hypertensive treatment (absence:presence) 84:49 17:17 67:32 NS
Receiving dialysis (absence:presence) 130:3 33:1 97:2 NS
History of
Cerebral infarction (absence:presence) 123:10 32:2 91:8 NS
Cardiac disorder (absence:presence) 105:28 24:10 81:18 NS
Diabetes mellitus (absence:presence) 121:12 30:4 91:8 NS
Malignant tumor (absence:presence) 122:11 33:1 89:10 NS
Hepatic disorder (absence:presence) 130:3 33:1 97:2 NS
Bronchial asthma (absence:presence) 129:4 32:2 97:2 NS
Thyroid disorder (absence:presence) 131:2 34:0 97:2 NS
Hyperlipidemia (absence:presence) 122:11 31:3 91:8 NS
Bleeding point (not locatable:locatable) 2:131 1:33 1:98 NS

0.653–0.840). The optimal cutoff value calculated in terms
of the Youden index (maximum of [sensitivity þ speci-
ficity-1])7 was a systolic BP of 160.5 mm Hg.
Discussion
The present study showed systolic BP to be an indepen-
dent factor associated with persistent epistaxis in adult
patients with idiopathic epistaxis from Kiesselbach’s area.
Furthermore, systolic BP was significantly higher in patients
with than in those without persistent epistaxis.
It is recognized that about 60% of individuals experience
epistaxis at least once in their lives, 6% of whom require
some form of treatment.8 Although there are sporadic reports
suggesting a causative association with hypertension,1,2 the
etiology of epistaxis still remains a controversial.3,4 The

Table 2
Results of logistic analysis
Univariate Logistic Analysis P Multivariate Logistic Analysis P
Odds Ratio (95% CI) Odds Ratio (95% CI)
Gender (female:male) 1.20 (0.52–2.73) .909
Age (mean
SD) 1.00 (0.97–1.03) .713
History of epistaxis (absence:presence) 0.97 (0.29–3.23) .922
Systolic blood pressure (mm Hg) 1.04 (1.02–1.05) .0001 1.03 (1.01–1.06) .002
Diastolic blood pressure (mm Hg) 1.22 (0.10–1.05) .071 1.0 (0.97–1.03) .799
Anticoagulant medication (absence:presence) 1.49 (0.61–3.51) .162
History of hypertension (absence:presence) 3.75 (1.54–9.10) .003 1.55 (0.04–6.00) .522
Current hypertensive treatment (absence:presence) 2.10 (0.95–4.63) .068 1.63 (0.48–5.54) .436
Receiving dialysis (absence:presence) 1.47 (0.13–16.7) .426
History of
Cerebral infarction (absence:presence) 0.77 (0.14–3.53) .378
Cardiac disorder (absence:presence) 1.88 (0.764–4.60) .064
Diabetes mellitus (absence:presence) 1.52 (0.43–5.40) .277
Malignant tumor (absence:presence) 0.27 (0.03–2.19) .187 0.34 (0.038–3.00) .327
Hepatic disorder (absence:presence) 1.47 (0.13–16.7) .426
Bronchial asthma (absence:presence) 3.03 (0.41–22.4) .099 8.39 (0.64–110.4) .106
Thyroid disorder (absence:presence) 0.006 (0.00–1.44) .402
Hyperlipidemia (absence:presence) 1.01 (0.28–4.41) .741
Bleeding point (not locatable:locatable) 2.30 (0.18–48.8) .426
294 M. Terakura et al. / Journal of the American Society of Hypertension 6(4) (2012) 291–295
Figure 1. Receiver operating characteristic (ROC) curve for
evaluation of predictability and diagnosability of persistent
epistaxis based on systolic blood pressure and for calculation
of optimal cutoff value. The area under the ROC curve was
calculated to be 0.746 (95% confidence interval [CI], 0.653–
0.840), indicating moderately accurate predictability and diag-
nosability. The optimal cutoff value calculated in terms of the
Youden index (maximum of [sensitivity þ specificity-1]) was
a systolic blood pressure of 160.5 mm Hg.
nose is endowed with moisturizing functions to prevent
foreign body intrusion from the outside, for which purpose
the nasal mucosa has a structure allowing plasma constitu-
ents to permeate capillary walls below the mucosal epithe-
lium of the nose so that they can readily reach the
epithelial surface of the nasal mucosa. These plasma constit-
uents are liable to be effused not only onto the epithelial
surface of the nasal mucosa but into the intercellular matrix
of the nasal mucosal epithelium as well, thereby increasing
inflammatory substances with a consequent state that may
give rise to inflammation of the nasal mucosa.9 In the nasal
mucosa, moreover, there is an abundance of porous arterioles
that are structurally fragile as regards hemodynamic changes
because the nasal mucosa is devoid of elastica interna.10
These anatomical structural features peculiar to the nose
seem to etiologically account for the bleeding liability.
Systolic BP was noted to be an independent factor associ-
ated with persistent epistaxis in the present series. It is
generally recognized that systolic BP increases progres-
sively with advancing age whereas diastolic BP rises
progressively up to an age of about 50 years and remains
practically unchanged thereafter. A majority of subjects
with hypertension who were older than 60 years of age are
hypertensive in terms of systolic BP alone.11 There is a report
demonstrating that sheer stress on blood vessels is increased
by elevated pulse pressure resulting from systolic hyperten-
sion,12 whereas another report describes the spread of
unstable blood microcirculation within the vascular system
as leading to a risk of stroke.11 It might be reasonable to
assume that the same pathophysiological events take place
in the nasal cavity, thereby giving rise to epistaxis.
To evaluate the predictability and diagnosability of persis-
tent epistaxis based on systolic BP, which was noted to be
a significant independent variable by multivariate logistic
analysis as well as to calculate an optimal cutoff value, we
constructed a ROC curve (Fig. 1). An AUC of 0.746 thus
determined was moderately accurate for predictability and
diagnosability. The optimal cutoff value of systolic BP for
predicting persistent epistaxis was 160.5 mm Hg. Inasmuch
as the systolic BP for the group of patients with nasal persis-
tent bleeding was 181.3
26.9 mm Hg (Table 1), it would be
of value to undertake treatment of epistaxis by keeping in
mind that patients showing a systolic BP higher than
155 mm Hg have a risk of persistent epistaxis.
A report on persistent epistaxis from Kiesselbach’s area
by Mladina13 dealt with associations of this syndrome
with (a) deformity/deviation of the nasal septum, (b) vaso-
dilatation in Kiesselbach’s plexus, (c) infection of the nasal
mucosa, and (d) inheritance. Endoscopic examination of
the nose is reportedly required with respect to (a) and (b);
however, no endoscopic examination was performed in
the present series because details about such examination
are lacking. Future assessments including nasal endoscopy
are thus needed.
The frequency with which epistaxis recurred was 12%
to 18.5% for patients treated by otorhinolaryngological
specialists as reported in Japan,5,6 and was 25.6% for the
present series (treated by emergency physicians). Hence,
the latter appears to be somewhat higher. Although this
difference might be attributable at least in part to relatively
insufficient technical skill in this specialty on the part of
emergency physicians, improved future prevention of
persistent epistaxis would be expected from appropriate
BP management based partly on the present study results.
Limitations
As for limitations of this investigation, inter-individual
differences in the treatment ability of surgeons/physicians
were not reflected and adequate assessments for inflamma-
tion of the nasal mucosa and vasculature by nasal endos-
copy were not performed. It is considered preferable that
endoscopic examination of the nose be conducted wherever
feasible.
Causes of nosebleed are currently in dispute, as noted
previously. The BP measurements in this investigation
represent pretreatment data obtained just after arrival at
our hospital. As such, these BP data do not include changes
that might have occurred during the treatment process.
However, anxiety arising in connection with sudden
bleeding from the nose can undeniably influence BP. Reas-
sessments employing a prospective study design encom-
passing objective indices that reflect aspects of anxiety
are needed in the future.
 M. Terakura et al. / Journal of the American Society of Hypertension 6(4) (2012) 291–295
Conclusion
The present data demonstrate systolic BP to be an inde-
pendent factor associated with persistent epistaxis in adult
patients with idiopathic epistaxis from Kiesselbach’s area.
Furthermore, systolic BP was significantly higher in
patients with than in those without persistent epistaxis.
The present study suggests that proper management of
BP is necessary for the prevention of persistent epistaxis
from Kiesselbach’s area in the clinical setting of emergency
care practice.
Acknowledgments
The authors are heartily thankful to the otolaryngologist
in Teikyo University School of Medicine for helping with
the hemostatic treatment.
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