|Year : 2020 | Volume
| Issue : 4 | Page : 224-228
Clinical profile of hypertensive patients presenting to the emergency department
Yerra Vinayak1, Madhusudan Mukkara2, A Krishna Simha Reddy1, N Harini Devi3, MR Kiran Kumar1, Rani Jonnakuti1
1 Department of Emergency Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Anaesthesiology and Critical Care, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Biochemistry, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
|Date of Submission||23-Mar-2020|
|Date of Decision||07-May-2020|
|Date of Acceptance||15-May-2020|
|Date of Web Publication||5-Jan-2021|
M R Kiran Kumar
Assistant Professor, Department of Emergency Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: The clinical profile of patients with hypertension presenting to emergency is understudied and unknown in developing countries like India.
Method: We prospectively studied the clinical profile, target organ damage, laboratory parameters and imaging parameters in 532 patients with hypertension (461 [86.7%] previously known hypertensives and 71 [13.3%] newly diagnosed hypertensives) presenting to the emergency department at our tertiary care teaching hospital.
Results: Their mean age was 57 ± 13.2 years; 65.6% were males. Neurological deficits (n = 164; 30.8%) were the commonest presenting symptom followed by chest pain (n = 143; 26.9%) and dyspnoea (n = 109; 20.5%). Hyponatremia (n = 188; 35.3%) and hyperkalemia (n = 59; 11.1%). Cerebrovascular accidents were the commonest target organ damage. Higher blood pressure at presentation and at 8 hours were associated with fatal outcomes.
Conclusion: Target organ damage was higher in known hypertensives with poor drug compliance and higher age groups particularly males. Cerebrovascular accidents were the commonest mode of presentation.
Keywords: Accelerated, emergency, hypertension, target organ damage
|How to cite this article:|
Vinayak Y, Mukkara M, Simha Reddy A K, Devi N H, Kiran Kumar M R, Jonnakuti R. Clinical profile of hypertensive patients presenting to the emergency department. J Clin Sci Res 2020;9:224-8
|How to cite this URL:|
Vinayak Y, Mukkara M, Simha Reddy A K, Devi N H, Kiran Kumar M R, Jonnakuti R. Clinical profile of hypertensive patients presenting to the emergency department. J Clin Sci Res [serial online] 2020 [cited 2021 Mar 7];9:224-8. Available from: https://www.jcsr.co.in/text.asp?2020/9/4/224/306189
| Introduction|| |
Hypertension affects nearly one billion individuals worldwide as per the observations made by the Joint National Committee (JNC) on prevention, detection, evaluation and treatment of high blood pressure (JNC VIII) report in 2018 and approximately 7.1 million deaths per year were attributed to uncontrolled hypertension. Target organ damage resulting from hypertension includes those affecting the brain, heart, kidneys and the eyes and commonly presents as focal neurological deficits, dyspnoea, chest pain, headache, loss of vision. In India, one out of every five has hypertension and 50% of people >50 years have hypertension. Hypertension is directly responsible for 57% of all stroke deaths and 24% of all coronary heart disease deaths in India. Hypertension is present in 25% urban and 10% of rural subjects in India. With this background, we have studied the clinical presentation, biochemical parameters and radiological parameters (whenever indicated) and target organ dysfunction in patients with hypertension (known or newly diagnosed) presented to Emergency Department (ED) of Sri Venkateswara Institute of Medical Sciences, Tirupati, a tertiary care of university teaching hospital in South India.
| Material and Methods|| |
All patients of age 18 years and above with a history of hypertension or newly detected hypertensives? presenting to ED, Sri Venkateswara Institute of Medical Sciences, Tirupati, a tertiary care teaching hospital in South India, between March 2018 and February 2019 were included in the study. Patients aged <18 years and more than 80 years and patient attendants unwilling to participate in the study were excluded from the study. The study was approved by the Institutional Ethics Committee. Written informed consent was obtained from all the participants. In patients who were unconscious, consent was obtained from the next responsible attendants.
All the participants were subjected to a detailed physical examination, consisting of general physical examination, detailed neurological examination, and examination of other systems and those patients with known hypertension or newly detected hypertension were enrolled in the study. After a thorough clinical examination, relevant investigations were sent based on their presenting complaints and associated risk factors. Data pertaining to clinical presentation, physical examination, laboratory and imaging studies were recorded in a pre-designed proforma.
Data were recorded on a pre-designed proforma and managed using Microsoft Excel 2007 (Microsoft Corp, Redmond, WA). Data were double-checked for any transcription errors.
Descriptive data were presented as mean ± standard deviation or median (interquartile range) for continuous variables and as frequencies and percentages for categorical variables. For the purposes of statistical analysis, patients who had 'left against medical advice' were considered to have the worst outcome, i.e., 'death'. To test the association between categorical variables, Chi-square test. The statistical software IBM SPSS Statistics version 20.0 (IBM Corp Somers NY, USA); was used for statistical analysis. A P value <0.05 was considered statistically significant.
| Results|| |
During the study period, 532 patients were studied. Of these, 349 (65.6%) were males. Their mean age was 57 ± 13.2 years. The? most common presenting symptoms were neurological deficits 164 (30.8%), followed by chest pain 143 (26.9%) and dyspnoea 109 (20.5%). Of the 532 patients studied, 461 (86.7%) were previously known hypertensives and newly diagnosed hypertensives were 71 (13.3%). Out of 461 known hypertensives, 341 patients have good drug compliance and 120 patients were poor drug compliant. Of the 532 patients studied dyslipidaemia in 199 patients, 162 were smokers, 150 had diabetes mellitus and 129 consumed alcohol. In the present study 246 (46.2%) patients presented with hypertensive crisis among these 210 (85.4%) were known hypertensives and 36 (14.6%) were newly diagnosed hypertensives. The mean systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean blood pressure (MBP) were 166.2 ± 22.4 mm of Hg, 96.2 ± 15.8 mm of Hg and 121.3 ± 16.4 mm of Hg in known hypertensives and 153.2 ± 20.4 mm of Hg, 92.1 ± 13.9 mm of Hg and 116. 3 ± 14.3 mm of Hg in newly diagnosed hypertensives. The mean SBP, DBP and MBP decreased with treatment from presentation to discharge (P < 0.001) [Table 1].
Fundus examination was done in 489 (92%) of patients, and the results are as given below. The fundoscopic evaluation was normal in 174 (34.4%) of patients, 99 (20%) patients had Grade I change, 134 (27.4%) patients had Grade II changes, 30 (6%) patients had Grade III changes and 52 (10.6%) had evidence of papilloedema. Fundus could not be visualised in 43 (8%) patients.
Electrocardiogram (ECG) changes-ST-T changes were seen in 155 (29.2%) patients, arrhythmias in 8 (1.5%), left ventricular hypertrophy (LVH) voltage criteria in 69 (12.9%) patients. In this study, 222 (41.7%) patients had evidence of cardiac dysfunction, regional wall motion abnormality in 155 (29.2%) patients, was seen in 98 (18.4%), and normal in 310 patients. Neurological involvement is seen in 216 (40.7%) patients in the present study. Neurological deficits were present in 164 (30.8%) patients, convulsions in 20 (3.8%) and blurring of vision in 49 (9.2%). In 216 patients with neurological involvement computed tomography brain scan showed acute intracerebral? haemorrhage in 98 (45.3%), acute cerebral infarct in 72 (33.4%) and subarachnoid h?aemorrhage in 13 (06%).
Renal involvement was seen in 139 (26.1%) of patients. Among all the 532 patients included in the study, mean serum urea was 56.4 ±? 47.2 mg/dL and serum creatinine had a mean value of 3.25 ± 1.4 mg/dL. Urine examination showed albuminuria in 135 (25.4%) patients in the present study. The renal sonogram showed renal parenchymal disease of various grades (Grade II to Grade IV) in 139 (26.1%). The outcome of the study showed in-hospital mortality of 73 (13.7%); among these patients, 65 (89%) were known hypertensives and 8 (11%) were newly diagnosed hypertensives. Mortality was similar in males (50/349 i.e., 14.3%) and females (23/183 i.e., 12.5%). The mean age of those who died (60.4 ± 9.5 years) was higher than that of those who were discharged alive (57.5 ± years) (P = 0.041). Most of them presented with neurological deficits (58.9%). The target organ damage, chronic kidney disease was more prevalent in patients with known hypertension as compared to those with newly diagnosed hypertension (P = 0.002). Likewise, hypertensive encephalopathy showed a trend to be more common in patients with newly diagnosed hypertension, when compared to known hypertensives, with the difference in proportions nearly reaching significance (P = 0.051) [Table 2].
|Table 2: Comparison of target organ damage in known and newly diagnosed hypertensives|
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| Discussion|| |
In the present study males (65.6%) presenting with hypertension were more than the number of females. In a study it was observed that 55% of patients were male among patients with hypertensive emergencies. The proportions of males in hypertensive emergencies were also higher in another study. This is probably due to an increased susceptibility of males compared with females to hypertension-related target organ damage. This possibility was revealed in the Framingham study, which showed an increased incidence of coronary arterial disease in men in an almost linear mode as age increased.
The proportions of males were higher when studying the group of patients <60 years of age. Most of the female patients belonged to the post-menopausal age group, which shows susceptibility of post-menopausal age to end-organ damage. This is also due to the fact that post-menopausal female haemodynamics were almost similar to the male profile with regard to blood pressure., Age-wise distribution of patients showed the largest groups belonging to the sixth and seventh decade at the time of presentation with 47.9% of the total.
Analysing the presenting symptoms, the largest group of patients in the present study, presented with a neurological deficit (30.8%), followed by chest pain (26.9%) and dyspnoea (20.5%). In a study presenting symptoms of neurological deficits, dyspnoea and chest pain were observed in 48%, 25% and 18% of their patients respectively. In a study, had more patients presenting with chest pain (27%) followed by dyspnoea (22%) and neurological deficits (21%). Neurological deficits in the present study varied from hemiparesis (80%), convulsions (12%) and visual deficits (8%). Hemiparesis accounted for the largest group of patients with neurological deficit.
The majority of patients in the present study were previously known patients with hypertension (86.7%). A large number of patients (83%) in a study were previously diagnosed hypertensives.Another study. reported a larger number (92%) of patients known to have hypertension among their patients. This also shows that patients with hypertension are at a higher risk of developing a hypertensive emergency, more so if they do not adhere to antihypertensive therapy. In the present study, among patients known to have hypertension, 26% have poor drug compliance to antihypertensive medications, which increased the risk for acute target organ damage and hypertensive emergency.
Diabetes mellitus, dyslipidaemia, smoking and alcohol were the other risk factors present in the present group of patients. Patients with dyslipidaemia, smoking, diabetes mellitus and alcohol were 37.4%, 30.5%, 28.2% and 24.1%, respectively, in the present study. The number of patients with diabetes mellitus was 26% in another study These risk factors would have added to premature atherosclerosis and coronary artery disease in these patients pre-disposing them to acute target organ damage. Prevalence of arterial hypertension in diabetic patients is greater than that in patients without diabetes mellitus patients (40%–50% and 20%, respectively). Metabolic abnormalities (hyperglycaemia and dyslipidaemias) might have played a role in the pathogenesis and complications of arterial hypertension, as seen in the present study.
At presentation to hospital the highest recorded SBP was 280 mm of Hg with mean SBP of 165 ± 28.3 mm of Hg. The highest DBP recorded was 160 mm of Hg with a mean of 96 ± 15.7 mm of Hg. A study reported a mean SBP of 193 ± 26 mm Hg in their patients and mean DBP of 129 ± 12 mm of Hg. Blood pressure levels at admission were higher in the group of patients who expired compared to those who were discharged from the hospital. The higher levels of blood pressure would have increased the chance of severe target organ damage in these patients, with an adverse outcome. This indicates a worse prognosis with higher levels of blood pressure at presentation.
Evaluation of fundus revealed changes ranging from hypertensive retinopathy to papilledema in 58% of patients., Papilloedema was seen in 10.6% of patients, which is an evidence of ongoing target organ damage in these patients. Grade I (20.4%), Grade II (27.4%), Grade III (6%), Grade IV (10.6%). Renal dysfunction in the form of raised serum urea and creatinine were seen in 139 (26.1%) of patients, respectively. Urine examination showed albuminuria in 135 (25.4%) patients in the present study and a higher risk for hypertension-related renal disease compared to the patients without proteinuria. Renal sonogram showed renal parenchymal disease of various grades (Grade II to Grade IV) in 139 (26.1%)., Hyponatremia was observed in 35.3% of patients. Eighteen percent of the patients had hypokalaemia and 11.1% had hyperkalemia, which may be due to secondary aldosteronism from increased renin secretion induced by intrarenal ischaemia.
Computed tomography of the brain showed intracerebral haemorrhage (n = 98; 45.3%) as the most common cause for the neurological dysfunction followed by cerebral infarct (n = 72; 33.4%) and subarachnoid haemorrhage (n = 13; 6%). Voltage criteria suggestive of LVH on ECG were seen in 69 patients (2.2%) and on echocardiography, 98 patients (18.4%) had LVH.
A study on complications and survival of 315 patients with malignant phase hypertension found low median survival time in patients with proteinuria and high serum urea and serum creatinine levels at presentation and if LVH was detected on ECG. These findings in a patient in a hypertensive emergency situation may help in prognosticating these patients.
Evaluation for target organ damage in patients in the present study showed cerebrovascular accidents in 40.7% was the most common target organ damage, followed by including acute myocardial infarction in 29.2% and acute left ventricular failure 14%. A study shows intracerebral haemorrhage (17%) left ventricular failure (25%), acute ischaemic stroke (39%) and acute myocardial infarction in (8%) their patients. In another study, target organ damage in the form of left ventricular failure (23%), acute ischemic stroke (24%) and intracerebral haemorrhage (4.5%) were seen. Chronic kidney disease was more common in known hypertensives compared to patients with newly diagnosed hypertension, possibly due to a longer duration of hypertension in the former group of patients. On the other hand, hypertensive encephalopathy appeared to be more common in newly diagnosed hypertensives than known hypertensives, possibly because they were already on treatment with medication and lifestyle modification.
Majority of patients presenting in this study belonged to the sixth and seventh decades of age. The most common mode of presentation is with a neurological deficit. Chronic kidney disease was more common in known hypertensives compared to those with newly diagnosed hypertension. Likewise hypertensive encephalopathy appeared to be more common in newly diagnosed hypertensives than in those with known hypertension, though the difference did not reach the threshold of significance (P = 0.051). Hyponatremia and hypokalaemia, were common in patients with Stage II hypertension. Acute intracerebral haemorrhage was the most common form of target organ damage encountered in the present study. The in-hospital mortality among these patients in this study was 13.7%.
Limitations of study
Limitations of present study were, the study is a single centred study and fundus examination cannot be visualised in all patients (as few were not cooperative and few died before evaluation).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Whelton PK, Carey RM, Aronow WS, Casey DE Jr., Collins KJ, Himmelfarb C, et al
. Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. J Am Coll Cardiol 2018;71:127-248.
World Health Organization, Office of World Health Reporting. Reducing Risks, Promoting Healthy Life, the World Health Report 2002. Geneva: World Health Organization; 2002.
Karras DJ, Ufberg JW, Harrigan RA, Wald DA, Botros MS, McNamara RM. Lack of relationship between hypertension-associated symptoms and blood pressure in hypertensive ED patients. Am J Emerg Med 2005;23:106-10.
Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004;18:73-8.
Mohan A, Naik GS, Harikrishna J, Kumar DP, Rao MH, Sarma K, et al
. Cleistanthus collinus
poisoning: Experience at a medical intensive care unit in a tertiary care hospital in south India. Indian J Med Res 2016;143:793-7.
] [Full text]
Martin JFV, Higashiama E, Garcia E, Luizon MR, Cipullo JP. Perfil de crise hipertensiva: Prevalência e apresentação clínica. Arq BrasCardiol 2004;83:125-30.
Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P. Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension 1996;27:144-7.
Vasan RS, Larson MG, Leip EP, Kannel WB, Levy D. Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study: A cohort study. Lancet 2001;358:1682-6.
Messerli FH, Garavaglia GE, Schmieder RE, Sundgaard-Riise K, Nunez BD, Amodeo C. Disparate cardiovascular findings in men and women with essential hypertension. Ann Intern Med 1987;107:158-61.
Owens JF, Stoney CM, Matthews KA. Menopausal status influences ambulatory blood pressure levels and blood pressure changes during mental stress. Circulation 1993;88:2794-802.
Sowers JR, Epstein M. Diabetes mellitus and associated hypertension, vascular disease, and nephropathy. An update. Hypertension 1995;26:869-79.
Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: Their course and prognosis. Am J Med Sci 1974;268:336-45.
Dodson PM, Lip GY, Eames SM, Gibson JM, Beevers DG. Hypertensive retinopathy: A review of existing classification systems and a suggestion for a simplified grading system. J Hum Hypertens 1996;10:93-8.
Singh A, Gupta K, Chander R, Vira M. Sonographic grading of renal cortical echogenicity and raised serum creatinine in patients with chronic kidney disease. J Evolution Med Dent Sci 2016;5:2279-86.
Hricak H, Cruz C, Romanski R, Uniewski MH, Levin NW, Madrazo BL, et al
. Renal parenchymal disease: Sonographic-histologic correlation. Radiology 1982;144:141-7.
Adler GK, Williams GH. Aldosterone: Villain or protector? Hypertension 2007;50:31-2.
Lip GY, Beevers M, Beevers DG. Complications and survival of 315 patients with malignant-phase hypertension. J Hypertens 1995;13:915-24.
[Table 1], [Table 2]