Clinical presentation and management of patients with uncontrolled, severehypertension: results from a public teaching hospital

Context: There is relatively little data available on the management of pat ients with severe, uncomplicated hypertension and severe hypertension with stable hypertensive complications. Objective: To determine the incidence, clinical features, acute management, and clinical course of severe, uncomplicated hypertension and severe hyper tension with stable hypertensive complications presenting for emergency dep artment care in a large public teaching hospital. Design: Chart survey of consecutive emergency department visits. Patients: Ninety-one of 2898 consecutive visits to a public teaching hospit al emergency department were specifically for severe, uncomplicated hyperte nsion. Results: Of 2898 consecutive medical emergency department visits, there wer e 142 (4.9%) patient visits specifically for systolic blood pressure (SBP) greater than or equal to 220 mm Hg or diastolic blood pressure (DBP) greate r than or equal to 120 mm Hg. Ninety-one of the 142 patient visits were for severe hypertension in the absence of acute target organ impact or neurore tinopathy. Eighty-nine patients received acute drug therapy. Twenty-nine pa tients received two drugs, and 15 received three drugs. Sixty-eight patient s (75%) received clonidine, and 15 (16.5%) received short-acting nifedipine despite widely published concerns about the safety of this practice. We fo und a wide variability of blood pressure response to treatment. The average decline in SEP was 50+/-31 mm Hg and the average decline of DBP was 34+/-2 0 mm Hg over 4.2+/-2.9 h. Forty-two patients (46%) had the SEP reduced to l ess than 160 mm Hg, and 46 patients (50%) the DBP to less than 100 mm Hg. L ong-term management and follow-up were suboptimal. Of 74 patients discharge d from the emergency room, 22 patients (30%) returned because of uncontroll ed hypertension within an average of 33+/-28 days, 10 patients with hyperte nsive complications. Conclusions: Severe hypertension continues to present an important and comm on problem. Physicians appear to place a strong emphasis on acute lowering of the blood pressure to near-normal levels. Patients are frequently lost t o follow-up and have a very high rate of recurrent emergency department vis its and hypertensive complications. This study points to a need for detaile d, specific practice guidelines and comprehensive disease management protoc ols for severe, uncomplicated hypertension.