Hypertensive urgencies and pseudo-urgencies in the Emergency Dept: a proposal of new health-care model in chronic diseases

Flora Ilaria Laurino MD, Nertil Kola MD, Raffaele Izzo MD, Maria Assunta Elena Rao MD, Francesco Rozza MD, Nicola De Luca MD, Marco Mirra MD

Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy

Abstract

Blood pressure (BP) values are extremely variable clinical parameters not only in patients with arterial hypertension but also in the general population. Behind the diagnosis of arterial hypertension there are three different clinical conditions: urgency, emergency and pseudohypertension.

The hypertensive urgency is characterized by high values of PA (> 180/120 mmHg), associated or not with the presence of clinical symptoms, in the absence of acute target organ damage. The presence of organ damage, on the other hand, characterizes the hypertensive emergency. Pseudohypertension is defined as confounder elevated recordings of PA due to high vascular stiffness, white coat hypertension, other comorbidities, anxiety and concerning status.

We evaluated, at the Hypertension Center of the University of Naples Federico II, within the “Campania Salute” register, more than 10,000 patients with different cardiovascular risk, of which 984 (9.2%) required an emergency visit for several clinical pictures such as chest pain and / or dyspnoea, palpitations, vertigo and / or lipotymia and headache associated with elevated pressure values >180/110 mmHg. These patients were predominantly female (56%) and with an average age of 64 ± 11 years. The most frequent reasons for requesting a medical examination were hypertension associated with headache (38%), dyspnea / anxiety (34%) and palpitations (24%). Among all symptomatic patients who received headache only in 18% a therapy modification was performed after the visit, while in patients with dyspnoea and / or anxiety the therapy was changed in 36% of cases. Finally, only in 27% of symptomatic patients for palpitations has been found an arrhythmia to the ECG, making necessary therapeutic drug modifications.

From the analysis of this retrospective study it is suggested an implementation of new health-care models for the management of patients with chronic diseases in order to promote compliance with therapy, prevent co-morbidities and mortality, reducing unnecessary hospitalizations.

Keywords

Campania Salute Project, Outpatient Clinic, Arterial hypertension, Pseudohypertension.

Introduction

Arterial hypertension (AH) is an asymptomatic morbid condition defined by persistent values of systolic blood pressure (SBP) at rest ≥140mmHg and / or diastolic blood pressure (DBP) ≥90mmHg [1]. The new 2017 American guidelines (AHA, ACC), which represent the first update after 14 years, reduce the level of normality to values up to 120/80 mmHg [2]. The pressure is ‘high’ for systolic values between 120 and 129 mmHg and diastolic values of less than 80 mmHg. Hypertension is instead classified in stage 1 in the case of systolic 130-139 mmHg or diastolic 80-89 mmhg and as stage 2 hypertension in the case of systolic values ≥140 mmHg or diastolic values ≥90mmHg. This new cut-off of normality values will enlist 14% more of American hypertensive patients who will increase from 32% to 46%, especially in the under 45 and in women.

The AH confers an increased risk of cardiovascular disease even in the absence of other risk factors, but the absolute risk increases significantly when other factors such as diabetes, hypercholesterolemia or other common cardiovascular risk factors are present [3].

An elevated blood pressure (BP) does not always induce the occurrence of specific symptoms, except in the presence of: severe hypertension, rare cases of secondary hypertension and cardiovascular complications. The diagnosis of AH is difficult, because if pressure values clearly within the limits of the normal values identify a normotensive patient, high blood pressure values do not necessarily identify an hypertensive patient.

The reason for a patient’s access to the Emergency Department may be the excessive increase in the patient’s measured values or the onset of non-specific symptoms related to an AH previously unknown. The disorders that are erroneously attributed to hypertension by a patient are: headache, auricular buzzing, vertigo and pseudo-vertigo, epistaxis, conjunctival hemorrhages, typical symptoms of panic attacks or anxiety crises or feeling of anguish and / or fear, sense of heel and / or empty head, palpitation.

The hypertensive urgencies are defined by a comparison of high blood pressure values (generally> 180/120 mmHg) in the absence of acute organ damage, unlike the hypertensive emergency which includes organ damage that sometimes subjects the patient to danger of life. Such urgencies can be effectively resolved in 24-48h using oral drugs, such as ACE inhibitors, calcium antagonists, beta-blockers, alpha-lytics or the combination of this drugs. The patient who arrives at the Emergency Department with this diagnosis can be discharged after a brief period of observation and followed in time, making the necessary therapeutic changes if necessary [4].

High and persistent pressure values can cause the onset of symptoms such as headache (by increase in intra-cranial pressure with DBP values> 120mmHg and / or with BP values that exceed the upper limit of cerebral selfregulation or in the presence of phaeochromocytoma ), vertigo (expression of vascular lesions of the encephalic trunk and as such are accompanied by other neurological signs).

Another condition to consider among E.D. accesses, especially among elderly patients, is pseudohypertension, that is an indirectly measured, erroneously high BP measurement in subjects who have instead a normal intra-arterial pressure. This phenomenon occurs due to the extreme stiffness and calcification of the brachial artery that would remain open even after the increase in the pressure of the sleeve with respect to the systolic pressure, with persistence to the auscultation of the Korotkoff tones [5].

The goal of AH management is to prevent cardiovascular events and its associated mortality. Adherence to antihypertensive therapy reduces cardiovascular risk. It is important to motivate the patient to maintain lifestyle changes over time and to constantly take the prescribed medications. Patients participating in the treatment have a significantly reduced risk of both coronary and cerebrovascular events. AH control is a public health goal that requires a long-term commitment from the patient and the physician. The instructions given to the patient and his family represent the central point of improving compliance. From the economic point of view, the lack of adherence to therapy leads to unnecessary hospitalizations, strokes and potentially fatal myocardial infarctions, which could be prevented [6,7].

Behind the Advanced Biomedical Sciences Department of the Federico II University of Naples, in the ’80s was started the first regional referal Center to the diagnosis and treatment of arterial hypertension in the southern Italy and also at the end of the years 90, thanks to the Campania Salute project, an integrated system was set up for internet telematic connection between cardiologists and general practitioners, with the creation of a telematic medical record for the follow-up of the patient with high cardiovascular risk [ 8]. This project represents a new health-Care model for the management of the follow-up of chronic diseases by using Innovation Technology that allows the visualization and archiving of clinical data in real time, the integration between primary and secondary care physicians or between doctor and patient, with considerable savings in costs and subjective inconveniences, and the real-time exchange of information, including multimedia (texts, data, signals, images and video) between the various diagnostic environments and between specialized and clinical diagnostic environments.

Methods

Since the end of the 1990s, around 11,000 patients with different criticalities and cardiovascular risk have been enrolled at the Hypertension Center of the Federico II University (Department of Advanced Biomedical Sciences) (Table 1). The Campania Salute Network is a register that collects information from general practitioners and medical specialists in hospitals in the 5 districts of the Campania Region. About 11,000 patients are currently enrolled in the registry, sent by their primary care physician to a peripheral center or to the “Hypertension Center” of the Federico II University, coordinator of the project, for an assessment of the pressure homeostasis. In order to provide management of clinical critical issues in the emergency-urgency and as much as possible assistance focused on the needs of the individual patient, as part of the Campania Salute project, a dedicated platform was set up for monitoring different anthropometric and clinical parameters, such as weight, glycaemia or blood pressure values, by sending an SMS, which is stored in the patient’s telematic medical record and evaluated by the referring specialist, in order to make therapeutic changes in real time, where necessary. Finally, for all the patients followed in the Campania Salute project, we evaluated the direct access to health facilities, as part of a medical visit in an emergency / emergency condition, outside the scheduled control, in case of blood pressure values> 180/110 mmHg, chest pain and / or dyspnoea, recent onset arrhythmia, dizziness and / or lipotymia and headache.

Table 1. Campania Salute Registry study population

Results

Among the 11719 followed patients, 984 (9.2%) required an emergency / emergency visit; these patients were predominantly female (56%) and with an average age of 64 ± 11 years. The most frequent reasons for requesting an urgency and/or emergency medical examination were high blood pressure values associated with headache (38%), dyspnea / anxiety (34%) and palpitation (24%) (Fig. 1). The evaluation of a patient who requested a visit to the Emergency Department for high blood pressure was comprehensive of: an accurate anamnesis, in particular research of possible episodes in the past of high BP values, knowledge of home BP values, medications taken, symptoms, risk factors, familiarity and comorbidity. Moreover, we evaluated for each patient the numerous “confounding factors” that cause “hypertension factitia” like licorice, alcohol, caffeine, cigarette smoke, corticosteroids, cyclosporine, erythropoietin, drugs (amphetamines, cocaine …), NSAIDs, oral contraceptives , psychotropic drugs (IMAO), antineoplastic (especially if associated with steroids). Of all the patients who came to our observation with headache only in 18% of cases a modification of the therapy was made for the real elevated BP assessment, while in patients with dyspnoea and / or anxiety the therapy was modified in 36 % of cases. Finally, only in 27% of patients who reported palpitations was an ECG arrhythmia, requiring therapeutic changes (Fig.1). Moreover, the optimal treatment of AH was performed in the presence of a peculiar clinical presentation, in particular with evidence of organ complications and not on the finding of an absolute value of arterial pressure.

Fig.1. Campania Salute Network – Follow-up Pseudo-Emergencies

Discussion

Usually the patient’s perception of an increased BP is a clinical manifestation of a mood disorder. Furthermore, the increase in BP values is often secondary to the presence of a symptomatology that represents the true “pathological condition” and not the other way round. On this occasion the symptom is the cause of the pressure rise and not the increase in blood pressure due to the symptom that is accessed in the Emergency Department.

The blood pressure values lability and the numerous factors that can influence the result require that the evaluation of the hypertensive patient is carried out by qualified personnel in specialized centers. For this reason, centers for the diagnosis and treatment of arterial hypertension have been worldwide established. The current ESC / ESH 2013 guidelines and the new AHA, ACC 2017 guidelines provide, for the diagnosis, the determination of at least two high BP values in the visit and at least two visits; It is also necessary to evaluate the BP outside the clinic or home to exclude the presence of “borderline” hypertension, from “white coat” or “variable” [2,9]. The environment must be peaceful and promote relaxation; a rest of at least five minutes is required (in the opposite case an increase of about 12/6 mmHg) and the patient must not have been active for at least thirty minutes, must not have smoked, taken over-the-counter and caffeine. The patient is usually silent, lying or sitting, with the legs not crossed and with the arm on which the cap is supported by a table. The cuff should be of adequate size to the circumference of the arm and positioned above and medially, under the medial bicipital groove with the center of the length of the brachial artery airway. The sleeve must be inflated rapidly and deflated at a rate of 2 mmHg / s. Multiple surveys (usually three) are required and, on the first visit, both arms. A correct measurement involves a time not less than eight to eleven minutes.

In the Emergency Department it is important to define new organizational models for patient management. There is no direct relationship between clinical risk and occasional pressure values, as the latter may be affected by numerous “confounding factors” and cause “hypertension factitia”. These factors are: licorice, alcohol, caffeine, cigarette smoke, corticosteroids , ciclosporin, erythropoietin, drugs (amphetamines, cocaine …), NSAIDs, oral contraceptives, psychotropic drugs (IMAO), antineoplastic drugs (especially if associated with steroids). In the United States of America, approximately 5-10% of patients entering the Emergency Department with high blood pressure report cocaine intake [10].

Pharmacological therapy in patients with high blood pressure, provided for by the new American guidelines, should be prescribed only: in patients who have already had a cardiovascular event (eg a stroke or a heart attack), in those at high risk of stroke or heart attack age, in the presence of diabetes mellitus, chronic renal failure or at high risk of atherosclerosis. A recent study showed that out of 549 patients accessing in Emergency Department for “hypertensive crisis” 30% shows a spontaneous reduction in values after 30 minutes of rest [11].

It is also important, in the elderly patients, to identify arterial pseudopiertension, that is, an indirectly measured, erroneously high blood pressure measurement in subjects who have instead a normal intra-arterial pressure due to the brachial artery stiffness. This characteristic is evident through the Osler maneuver or sign, that is, the palpation of the brachial or radial artery underneath the inflated sphygmomanometer sleeve above the systolic pressure values. Its diagnostic value has decreased in value with time and it is currently thought that a positive Osler maneuver can commonly be found in the elderly, whether they are hypertensive or normotensive (11% of people over 75 and 44% of those with more than 85 years have a positive Osler maneuver) [12]. It is implicit in the definition that the diagnosis of pseudohypertension requires the gory measurement of arterial pressure. An accurate, accurate and reliable BP measurement and instructing the patient for home-based measurements are essential before formulating the correct diagnosis and initiating drug therapy.
The clinical evaluation in hypertensive urgency begins with the treatment of anxiety and underlying pain, reassuring the patient and possibly administering in anxiolytic or an analgesic, but looking for any symptoms or signs of alarm such as severe headaches, changes in the state of consciousness, convulsions, signs focal neurological disorders, changes in the visus, chest or abdominal pain, dyspnoea, pulmonary / peripheral edema, oliguria.

Immediate normalization of BP values in the absence of target organ lesions is not always necessary. A sudden and rapid pressure reduction is potentially harmful and may not be beneficial. It is important to adapt the antihypertensive treatment according to the specific situations: elderly subjects, comorbidities, or anxiety. In the trend of the last 15 years there has been a reduction in requests for emergency medical examinations due to episodes of epistaxis or of ringing buzzing, registering an increase in requests for states of distress.

Conclusions

It is important to implement a new organizational model for an optimal collaboration between the local doctor and the specialist reference center to instruct patients with chronic degenerative diseases to increase compliance with the therapy and manage any critical issues that do not often require access to the Emergency Department.
The severity of AH is not related to the BP measured values, but rather depends on the possible involvement of one or more target organs. It is important to distinguish the urgent causes that endanger the patient life due to the involvement of the target organ and that require an immediate clinical evaluation and the non-urgent causes, without injuries of the target organs, which can be evaluated and treated in the course of the hours following the hypertensive crisis.
It is always necessary to look for factors that affect pressure values to obtain the most standardized, accurate, accurate and reliable BP estimation and to instruct the patient for home measurements. The objective of the management of hypertension through an organized path in the Reference Center is to reduce comorbidity and mortality but also the number of patients who for this reason go to the always overcrowded emergency room.

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