Risk of MACE After Emergency Department Visits for Hypertensive Urgency
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
Chronic hypertension is an established long-term risk factor for major adverse cardiovascular events (MACEs). However, little is known about short-term MACE risk after hypertensive urgency, defined as an episode of acute severe hypertension without evidence of target-organ damage. We sought to evaluate the short-term risk of MACE after an emergency department (ED) visit for hypertensive urgency resulting in discharge to home.
METHODS
We performed a case-crossover study using deidentified administrative claims data. Our case periods were 1-week intervals from 0 to 12 weeks before hospitalization for MACE. We compared ED visits for hypertensive urgency during these case periods versus equivalent control periods 1 year earlier. Hypertensive urgency and MACE components were all ascertained using previously validated International Classification of Diseases, Tenth RevisionClinical Modification codes. We used McNemar test for matched data to calculate risk ratios.
RESULTS
Among 2 225 722 patients with MACE, 1 893 401 (85.1%) had a prior diagnosis of hypertension. There were 4644 (0.2%) patients who had at least 1 ED visit for hypertensive urgency during the 12 weeks preceding their MACE hospitalization. An ED visit for hypertensive urgency was significantly more common in the first week before MACE compared with the same chronological week 1 year earlier (risk ratio, 3.5 [95% CI, 2.9-4.2]). The association between hypertensive urgency and MACE decreased in magnitude with increasing temporal distance from MACE and was no longer significant by 11 weeks before MACE (risk ratio, 1.2 [95% CI, 0.99-1.6]).
CONCLUSIONS
ED visits for hypertensive urgency were associated with a substantially increased short-term risk of subsequent MACE.
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Additional Info
Disclosure statements are available on the authors' profiles:
Risk of Major Adverse Cardiovascular Events After Emergency Department Visits for Hypertensive Urgency
Hypertension 2024 Apr 25;[EPub Ahead of Print], AL Liberman, J Razzak, RI Lappin, BB Navi, SS Bruce, V Liao, JH Kaiser, C Ng, AZ Segal, H KamelFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
In this case–crossover study, the authors identify an association between presenting to the hospital with hypertensive urgency and subsequent rehospitalization in the next 10 weeks for major adverse cardiac events (MACE). Despite very elevated blood pressure (BP) measurements, patients with hypertensive urgency are typically discharged from the emergency department (ED) without admission, as long as evidence for target-organ damage has been excluded. This is in contrast with hypertensive emergency where target-organ damage is demonstrated in the presence of very elevated BP; patients with hypertensive emergency are known to be at high risk and are admitted to the hospital for expedited treatment to control BP.
Because patients with hypertensive urgency are thought to be at lower risk, they are not typically admitted to the hospital.
However, one concern is that, following discharge from the ED, these patients may not get the appropriate drug therapy or prompt follow-up of BP that they need. In this paper, by showing us that patients with hypertensive urgency are at increased short-term risk for readmission for MACE, the authors remind us that these patients need lock-tight and prompt follow-up to ensure they get their BP under control. Perhaps when the clinician feels that this type of follow-up is not possible (eg, homeless or uninsured patients), then these data suggest that we might want to keep them in the ED at least until the BP is reasonably well-controlled. In my experience, this practice often already happens, but maybe it should be uniformly applied to all patients in all systems?
While I have no doubt that hypertensive urgency is a state of high risk that warrants close follow-up and prompt management, there are some caveats to note for this particular paper. First, the exposure of hypertensive urgency was based on an ICD-10 code introduced in 2015. The authors state that prior data have shown this code to be validated and to work well; however, in support of this, they cite an unpublished paper from their own group looking at just 50 ED admissions. I think we need to know more about whether this code is actually capturing patients truly with hypertensive urgency and is not being applied erroneously to some patients with a hypertensive emergency. After all, ruling out a hypertensive emergency requires a thorough and complete evaluation for target-organ damage, and, in my experience, this is not often done properly in routine clinical care. In addition, while the authors found an increased relative risk for MACE in the 10 weeks following presentation with hypertensive urgency, the actual prevalence of hypertensive urgency in cases was exceedingly small (0.2%) — begging the question as to how important this issue is in the face of other very pressing medical problems facing our healthcare systems.