Back in the day, before safe and effective oral antihypertensives were widely available, severe hypertension could have a prognosis as poor as many cancers, leading to the term "malignant hypertension."
In recent years, as treatment options have improved, this term has fallen out of favor, replaced by this nomenclature:
- Hypertensive emergency = markedly elevated blood pressure and signs or symptoms of acute, ongoing target-organ damage
- Hypertensive urgency = asymptomatic blood pressure elevation with SBP ≥ 180 or DBP ≥ 120
Unfortunately, the new terminology is confusing, and according to a in JAMA Internal Medicine may be leading to and overtreatment of hypertensive patients.
In the new study, the authors analyzed almost 60,000 ambulatory visits among patients at the Cleveland Clinic, a whopping 4.6% of whom met the definition of hypertensive urgency (this is not an uncommon problem!). Of the patients with hypertensive urgency, most were managed as outpatients but several hundred (~75/year) were referred to the emergency department (ED).
The authors then compared the outcomes among the patients referred to the ED versus matched control patients managed in the ambulatory setting.
They found that ED visits, hospitalizations, and major adverse cardiovascular events were similar among those referred to the ED versus those cared for in the ambulatory setting, and that cardiovascular events within 6 months were low (0.9%) in both groups. After 6 months, two-thirds of patients in both groups continued to have uncontrolled hypertension.
Because this was an observational study and patients referred to the ED likely differed in important ways relative to those managed in the ambulatory setting, the inferences we can make from these findings are limited. Nonetheless, this study raises a number of important points for us as Slow Medicine practitioners.
First, hypertensive urgency is common and rates of major adverse cardiovascular events within a 6-month period are low. We should not over-react to this common diagnosis, despite the somewhat alarming terminology. Perhaps it is time for another change in nomenclature, e.g., simply: "stage II hypertension."
Second, blood pressure can be quite difficult to control, particularly for those with stage II hypertension. At the population level, , suggesting the need for more standardized population-based approaches – think pharmacist-run blood pressure clinics in the community.
Finally, in the face of limited evidence, it is not clear which patients with hypertensive urgency – if any – benefit from emergency room referral. Those in this study referred to the emergency room had similar outcomes to matched controls in the ambulatory setting, though again since this wasn't a randomized trial, it is not possible to draw firm conclusions.
Still, without compelling data that emergency room referral improves outcomes, we should be judicious in making such referrals since patients may experience numerous attendant harms, such as unnecessary testing, radiation, and overly aggressive treatment.
The good news is that many of the immediate "malignant" complications of hypertension can be greatly reduced with modern antihypertensive therapy. The bad news is we have much work to do to prevent the insidious longer term complications, even with our ever-growing pharmaceutical armamentarium.
"Updates in Slow Medicine" applies the latest medical research to support a thoughtful approach to clinical care. It is produced by , of Harvard Medical School, and , of AltaMed Health System in Los Angeles. , is a palliative care fellow at the Mount Sinai Hospital in New York. To learn more, visit their Facebook page.