Accuracy of a Symptom-Based Approach to Identify Hypertensive Emergencies in the Emergency Department
Abstract
:1. Introduction
2. Methods
2.1. Inclusion Criteria
2.2. Exclusion Criteria
3. Medical Record Review and Definitions
3.1. Past Medical History
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- Cardiovascular risk factors: smoking habit, history of arterial hypertension, diabetes mellitus, dyslipidemia;
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- Previous cardiovascular events: coronary artery disease, chronic heart failure, atrial fibrillation (paroxysmal, persistent, and permanent), chronic kidney disease (i.e., glomerular filtration rate < 60 mL/min/1.73 m2), previous ischemic or hemorrhagic stroke, previous transient ischemic attack.
3.2. Ongoing Cardiovascular Therapy
3.3. Presenting Symptoms
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- Main symptoms: chest pain (both typical and atypical), dyspnea (as subjective perception), neurological focal signs (motor, sensory, or speech symptoms), headache (regardless of severity), visual impairment (reduced visual acuity or visual fields).
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- Less specific symptoms: vertigo, confusion, epistaxis, syncope or pre-syncope, nausea or vomiting, abdominal pain.
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- Unspecific symptoms: all other reported symptoms.
3.4. Vital Signs on Admission
3.5. Laboratory Analysis
3.6. Hypertensive Emergency and Uncontrolled Hypertension
- Hypertensive emergency: systolic BP > 180 mm/Hg and/or diastolic BP > 110 mm/Hg and associated aHMOD;
- Uncontrolled hypertension: systolic BP > 180 mm/Hg and/or diastolic BP > 110 mm/Hg without aHMOD.
4. Statistical Analysis
Symptoms Accuracy
5. Results
Symptoms-Based Diagnostic Strategy
6. Discussion
7. Symptoms Accuracy and Clinical Implications
8. Limitations
9. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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Hypertensive Emergencies (n = 79) | Uncontrolled Hypertension (n = 639) | p-Value | |
---|---|---|---|
Demographic Characteristics | |||
Age (years) | 73.2 ± 13 | 69.5 ± 14 | 0.03 |
Female sex [n (%)] | 43 (54) | 358 (56) | 0.79 |
Cardiovascular Risk Factors | |||
Current smokers [n (%)] | 18 (23) | 138 (22) | 0.81 |
Arterial hypertension [n (%)] | 61 (77) | 501 (78) | 0.81 |
Diabetes mellitus [n (%)] | 16 (20) | 108 (17) | 0.46 |
Dyslipidemia [n (%)] | 14 (18) | 88 (14) | 0.34 |
No risk factors [n (%)] | 11 (14) | 95 (15) | 0.82 |
Previous Cardiovascular Events | |||
Coronary artery disease [n (%)] | 19 (24) | 70 (11) | <0.01 |
Chronic heart failure [n (%)] | 5 (6) | 15 (2) | 0.04 |
Atrial fibrillation [n (%)] | 11 (14) | 61 (10) | 0.22 |
Chronic kidney disease [n (%)] | 8 (10) | 42 (7) | 0.24 |
Previous stroke [n (%)] | 9 (11) | 40 (6) | 0.09 |
No previous events [n (%)] | 41 (52) | 462 (72) | <0.01 |
Vital Signs in ED (Medical Evaluation) | |||
SBP at admission (mm/Hg) | 193 ± 18 | 188 ± 16 | 0.06 |
DBP at admission (mm/Hg) | 100 ± 16 | 98 ± 13 | 0.33 |
SBP at discharge (mm/Hg) | 155 ± 21 | 151 ± 17 | 0.09 |
DBP at discharge (mm/Hg) | 87 ± 12 | 84 ± 11 | 0.06 |
HR at admission (bpm) | 88 ± 22 | 84 ± 18 | 0.23 |
Oxygen saturation at admission (%) | 95 ± 4 | 96 ± 5 | 0.11 |
Hypertensive Emergencies (n = 79) | Uncontrolled Hypertension (n = 639) | p-Value | |
---|---|---|---|
Ongoing Antihypertensive Treatment | |||
No antihypertensive drugs [n (%)] | 22 (28) | 208 (33) | 0.44 |
1 antihypertensive drug [n (%)] | 14 (18) | 149 (23) | 0.26 |
2 antihypertensive drugs [n (%)] | 18 (23) | 147 (23) | 0.97 |
≥3 antihypertensive drugs [n (%)] | 25 (32) | 135 (21) | 0.03 |
Specific Pharmacological Classes of Antihypertensive Treatment | |||
ACE-I [n (%)] | 19 (24) | 151 (24) | 0.93 |
ARBs [n (%)] | 17 (22) | 146 (23) | 0.79 |
Beta-Blockers [n (%)] | 38 (48) | 201 (32) | <0.01 |
Calcium Channel Blockers [n (%)] | 19 (24) | 132 (21) | 0.49 |
Thiazide diuretics [n (%)] | 6 (8) | 94 (15) | 0.09 |
Loop diuretics [n (%)] | 21 (27) | 75 (12) | <0.01 |
Potassium-sparing diuretics [n (%)] | 4 (5) | 30 (5) | 0.88 |
Alpha-Blockers [n (%)] | 5 (6) | 57 (9) | 0.44 |
Alpha−2 agonists [n (%)] | 1 (1) | 11 (2) | 0.77 |
Ongoing Antiplatelet and Anticoagulant Treatment | |||
Acetylsalicylic acid [n (%)] | 22 (28) | 108 (17) | 0.02 |
Vitamin K antagonist [n (%)] | 8 (10) | 36 (6) | 0.12 |
Direct oral anticoagulants [n (%)] | 9 (11) | 45 (7) | 0.17 |
Hypertensive Emergencies (n = 79) | Uncontrolled Hypertension (n = 639) | p-Value | |
---|---|---|---|
Laboratory Data | |||
Hemoglobin (g/dL) | n = 79 13.4 ± 1.9 | n = 552 13.5 ± 1.9 | 0.86 |
Creatinine (mg/dL) | n = 79 1.16 ± 0.8 | n = 546 1.08 ± 0.9 | 0.47 |
Sodium (mEq/L) | n = 79 139 ± 3.1 | n = 546 139 ± 3.9 | 0.87 |
Potassium (mEq/L) | n = 79 4.1 ± 0.5 | n = 79 4 ± 0.5 | 0.76 |
Troponin T (ng/L) | n = 43 75.3 ± 133 | n = 268 23.1 ± 49 | 0.02 |
NTproBNP (pg/mL) | n = 24 7.573 ± 18.649 | n = 86 3.513 ± 10.415 | 0.16 |
LDH (IU/L) | n = 20 506 ± 43 | n = 112 483 ± 41 | 0.22 |
Univariate Logistic Regression Analysis | ||||
---|---|---|---|---|
Potential Predictors | β Coefficient | 95% CI | Std. Error | p-Value |
Age (years) | 1.023 | 1.01–1.04 | 0.01 | 0.02 |
Coronary artery disease | 2.574 | 1.45–4.56 | 0.29 | <0.01 |
Chronic heart failure | 2.811 | 1.01–7.96 | 0.53 | 0.04 |
≥3 antihypertensive drugs | 1.728 | 1.04–2.88 | 0.26 | 0.04 |
Main symptoms (≥1) | 18.442 | 7.90–43 | 0.43 | <0.01 |
Multivariate Logistic Regression Analysis | ||||
Potential Predictors | β Coefficient | 95% CI | Std. Error | p-Value |
Age (years) | 1.021 | 1.01–1.04 | 0.01 | 0.04 |
Coronary artery disease | 1.917 | 0.99–3.70 | 0.34 | 0.06 |
Chronic heart failure | 1.693 | 0.50–5.72 | 0.62 | 0.40 |
≥3 antihypertensive drugs | 1.150 | 0.64–2.07 | 0.30 | 0.64 |
Main symptoms (≥1) | 18.314 | 7.82–42.9 | 0.43 | <0.01 |
Hypertensive Emergencies (n = 79) | Uncontrolled Hypertension (n = 639) | p-Value | |
---|---|---|---|
Main symptoms | |||
Chest pain [n (%)] | 13 (17) | 75 (12) | 0.23 |
Dyspnea [n (%)] | 25 (32) | 72 (11) | <0.01 |
Neurological focal signs [n (%)] | 30 (38) | 30 (5) | <0.01 |
Headache [n (%)] | 6 (8) | 84 (13) | 0.16 |
Visual impairment [n (%)] | 4 (5) | 16 (3) | 0.19 |
Less specific symptoms | |||
Vertigo/Dizziness [n (%)] | 2 (3) | 61 (10) | 0.04 |
Confusion [n (%)] | 10 (13) | 61 (10) | 0.38 |
Epistaxis [n (%)] | 0 (0) | 22 (3) | 0.09 |
Syncope/pre-syncope [n (%)] | 0 (0) | 25 (4) | 0.07 |
Nausea/vomiting [n (%)] | 4 (5) | 49 (8) | 0.40 |
Palpitations [n (%)] | 3 (4) | 48 (8) | 0.23 |
Abdominal pain [n (%)] | 7 (9) | 69 (11) | 0.60 |
Totally unspecific symptoms | |||
Miscellaneous [n (%)] | 0 (0) | 133 (21) | <0.01 |
No symptoms [n (%)] | 0 (0) | 63 (10) | <0.01 |
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Vallelonga, F.; Carbone, F.; Benedetto, F.; Airale, L.; Totaro, S.; Leone, D.; Astarita, A.; Avenatti, E.; Maule, S.; Veglio, F.; et al. Accuracy of a Symptom-Based Approach to Identify Hypertensive Emergencies in the Emergency Department. J. Clin. Med. 2020, 9, 2201. https://doi.org/10.3390/jcm9072201
Vallelonga F, Carbone F, Benedetto F, Airale L, Totaro S, Leone D, Astarita A, Avenatti E, Maule S, Veglio F, et al. Accuracy of a Symptom-Based Approach to Identify Hypertensive Emergencies in the Emergency Department. Journal of Clinical Medicine. 2020; 9(7):2201. https://doi.org/10.3390/jcm9072201
Chicago/Turabian StyleVallelonga, Fabrizio, Federica Carbone, Francesco Benedetto, Lorenzo Airale, Silvia Totaro, Dario Leone, Anna Astarita, Eleonora Avenatti, Simona Maule, Franco Veglio, and et al. 2020. "Accuracy of a Symptom-Based Approach to Identify Hypertensive Emergencies in the Emergency Department" Journal of Clinical Medicine 9, no. 7: 2201. https://doi.org/10.3390/jcm9072201