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
- -
- 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
APA StyleVallelonga, F., Carbone, F., Benedetto, F., Airale, L., Totaro, S., Leone, D., Astarita, A., Avenatti, E., Maule, S., Veglio, F., Lupia, E., & Milan, A. (2020). Accuracy of a Symptom-Based Approach to Identify Hypertensive Emergencies in the Emergency Department. Journal of Clinical Medicine, 9(7), 2201. https://doi.org/10.3390/jcm9072201