Abstract
Despite major public health initiatives are working in the control of hypertension, hypertensive crisis remains an important clinical problem. This study aimed at examining the characteristics, treatment and outcome of patients with hypertensive crisis admitted to the University of Gondar Specialized Hospital, Ethiopia. A cross‐sectional study was conducted on patient medical records (n = 304) between January 01, 2013 and December 31, 2017. Data were analyzed using Statistical Package for Social Sciences version21. A total of 252 patient medical records were included in the analysis. The mean age of the entire patients was 54 ± 17 years. Two hundred and nineteen (86.9%) patients have a documented history of hypertension and on antihypertensive drugs (n = 166, 65.9%). The majority of cases (n = 166, 65.9%) were hypertensive urgencies. In more than one‐third of the patients (n = 98, 38.9%), the cause of the illness was attributed to non‐compliance to therapy. The most common presenting signs and symptoms at admission were headache (n = 170, 67.5%), dyspnea (n = 36, 14.3%), and vomiting (n = 33, 13.1%). Of 852 tests ordered, the results of one‐third (n = 298,34.9%) were abnormal. Nearly two‐thirds (n = 336, 59.2%) of prescriptions documented were for hypertensive urgency. Captopril (n = 136, 23.9%) and hydralazine (n = 43, 7.6%) were the most commonly prescribed oral and intravenous drugs respectively. Ten patients died during 55 hours of hospital stay. All hospital mortalities were documented for a hypertensive emergency. The median decrement of diastolic blood pressure among patients with no history of previous admission and hypertensive urgency was significantly higher than those patients with a previous history of admission (P = .005) and hypertensive emergency (P = .010). These findings justify better treatment and follow‐up for these patients. Most importantly, to improve compliance with treatment health professionals should provide education to the patients.
Keywords: Gondar, hypertension, hypertensive crisis, outcome, treatment
Abbreviations
- BP
Blood Pressure
- DBP
Diastolic Blood Pressure
- mmHg
Millimeter of Mercury
- SBP
Systolic Blood Pressure
- UOGSH
University of Gondar Specialized Hospital
1. BACKGROUND
Hypertension (systolic blood pressure ≥ 130 mm Hg or diastolic blood pressure ≥ 80 mm Hg) is one of the most important common chronic diseases, affecting approximately 1 billion people worldwide. 1 , 2 Hypertensive crisis is defined as a systolic blood pressure >180 mm Hg or diastolic blood pressure >120 mm Hg. 3 , 4 , 5 Hypertensive crisis can be further classified as a hypertensive urgency or hypertensive emergency depending on end‐organ involvement including cardiac, renal, and neurologic injury. Hypertensive urgency refers to severe hypertension without evidence of new or worsening end‐organ injury while hypertensive emergency refers to severe hypertension that is associated with new or progressive end‐organ damage. 6
In cases with hypertensive urgency, blood pressure (BP) control should be managed with the use of low doses of oral antihypertensive medications, where a gradual decrease of BP over hours to days is expected. Medications that can be used to treat hypertensive urgencies are oral labetalol (3:1 ratio of antagonism of non‐selective β‐adrenergic and a1 receptor), captopril (angiotensin‐converting enzyme inhibitor), and clonidine (central a‐2 agonist). On the other hand, hypertensive emergencies require rapid BP control with a parenteral antihypertensive medication, and in these instances, the patient should be admitted to the intensive care unit. The BP should be reduced within minutes to an hour to about 20%‐25% in the first hour and then to 160/100 or 160/110 millimeter of mercury (mm Hg) within the next 2‐6 hours, then to normal over the next 24‐48 hours. 2 However, BP should not be returned to normal values. 2 , 5 Various medications are available for the treatment of hypertensive emergencies. Nicardipine and sodium nitroprusside are first choices for the majority of hypertensive emergencies, other agents that can be used in hypertensive emergencies include hydralazine, clevidipine (dihydropyridine calcium channel blocker), Enalaprilat, 2 , 7 , 8 and Fenoldopam. 9
According to the 2014 World Health Organization data, the prevalence of raised blood pressure among adults aged ≥18 years in the African region and particularly in Ethiopia was about 29% and 30%, respectively, for both sexes. 10 Whereas in Gondar, a study report conducted in 2017 showed that the overall prevalence of hypertension was 27. 4%. 11 It has been estimated that approximately 1% of patients with hypertension will develop a hypertensive crisis at some point during their lives. Before the advent of antihypertensive therapy, this complication occurred in up to 7% of the hypertensive population. 12
Despite major public health initiatives in the control of hypertension, 13 hypertensive crisis remains an important clinical problem. Most patients who present with a hypertensive crisis have previously been diagnosed as hypertensive and many have been prescribed antihypertensive therapy with inadequate blood pressure control. 5 , 14 , 15 Although the exact causes of sudden severe hypertension are largely unknown, 16 there are risk factors associated with hypertensive crisis include female sex, obesity, coronary artery disease, somatoform disorder, a high number of antihypertensive medications, and non‐compliance to medication prescription. 17 Other risk factors include a sedentary lifestyle, increased age, and caucasian race. 18
Understanding the scale of the problem is essential when designing interventions to improve the treatment approach and outcome. In this regard, data on clinical features, treatment, and outcome of patients referred to the emergency and internal medicine departments for hypertensive crisis are limited, despite their relevance from a public health perspective. Moreover, compliance of patients with antihypertensive treatment is likely to affect the risk of hypertensive emergencies, but evidence on this issue is lacking. Having evidence in this area will help in clarifying the pathogenesis of the disease, to discuss and plan measures aimed at mitigating the chaos that was identified in the healthcare sector, especially regarding the treatment of hypertensive crisis patients. Therefore, the purpose of this study was to address this research gap by examining the characteristics, treatment practice, and outcome of patients with hypertensive crisis admitted to the University of Gondar Specialized Hospital, Ethiopia. Thus, this study was expected to provide essential up‐to‐date information or figures on burden and characteristics, treatment practice, and outcomes of hypertensive crisis. Implementation of recommendations forwarded from the study will enable to reduce frequent high blood pressure associated admissions and deaths. Moreover, it minimizes costs incurred by admissions and complications.
2. METHODS
2.1. Study design and setting
A cross‐sectional study was conducted in the emergency and internal medicine wards of the University of Gondar Specialized Hospital (UOGSH). UOGSH is a teaching referral hospital that serves for 7 million people in northwest Ethiopia. It has both inpatient and outpatient departments. According to UOGSH Statistics and Information Office: Annual Report on Health Services and Employees, emergency and internal medicine inpatient comprised more than 1000 beds, and inpatient health care is given for patients with hypertension, diabetes, asthma, heart failure, and other diseases from the northwest part of Ethiopia.
2.2. Sample size determination and sampling technique
The source population includes all adult (18 years and above) hypertensive crisis patients presenting at emergency and internal medicine wards of the UOGSH, while those patients admitted to emergency and internal medicine wards of the UOGSH during the study period were taken as a study population. All patients’ medical record during the period from January 01, 2013 to December 31, 2017, were included in the study. To identify the patients' medical record, a logbook, containing sequential information of patient medical records with the respective unique number and diagnosis, was reviewed from both emergency and internal medicine wards. Thus, 523 unique numbers with hypertensive crisis diagnosis were identified. Of which only 304 (58.1%) were physically available in the chart room. After excluding 52 patient medical records, 252 were finally included in the study (Figure 1).
Figure 1.
Sampling method, emergency and internal medicine wards, UOGSH, 2018
2.3. Data collection methods and measurements
Data were collected by three trained nurse professionals under the supervision of the principal investigator. Data abstraction format comprised of items focusing on socio‐demography and clinical characteristics, treatment, and outcome of the hypertensive crisis was developed from prior studies, and its content validity was assessed and assured by senior experts from the internal medicine department of University of Gondar. 5 , 6 , 7 , 8 , 22 Socio‐demography and clinical characteristics were recorded from the physician's initial assessment sheet. Whereas, blood pressure readings at admission and discharge were recorded from vital sheets for nursing services. Compliance with treatment, assessed and documented during each patient visit, was recorded from the follow‐up sheet. The mean length of hospital stay was recorded by calculating the time interval between the patient's admission date or time and discharge date or time from emergency and internal medicine wards. On the other hand, blood pressure decrement was recorded by calculating the difference between admission blood pressure measurement and discharge blood pressure measurement. All the information was retrieved from patient medical records. Data collectors directly filled the data abstraction format by searching for relevant information available on patient medical records. For patients with multiple visits with a hypertensive crisis, only the recent visit was included. The data were collected during the period from 01 June 2018 to 28 June 2018.
2.4. Data quality control technique
Data collectors were properly trained on the contents of the instrument, data collection methods, and handling or keeping of the data before the data collection process. The data abstraction format was pre‐tested on 12 randomly selected patient medical records which were not included in the final analysis. Based on the results, details of treatment regimen (dose, frequency, duration), alcohol consumption and smoking status, and certain hemodynamic parameters (respiratory rate, heart rate, and Glasgow coma scale) were omitted.
2.5. Data analysis
The collected data were cleaned, entered to and analyzed using Statistical Package for Social Sciences (SPSS), version 21. Data were also screened for normality using both Shapiro‐Wilk and Kolmogorov‐Smirnov tests, and the corresponding P‐values were less than 0.05 indicating that the data were not distributed normally. Descriptive statistics such as frequency, percentage, mean, and standard deviation were used to summarize continuous and categorical variables. Whereas, chi‐square and Kruskal‐Wallis H tests were used to examine the association among different variables. P‐value less than .05 and 95% confidence interval (CI) were used as cutoff points for determining the statistical significance of associations.
2.6. Operational definitions
2.6.1. Incomplete data
Insufficient data or loss of data regarding type of hypertensive crisis, presenting signs and symptoms, treatment administered, blood pressure readings, and duration of hospital stay.
2.6.2. Unclear data
Information that does not clearly indicate the disease of the patient which could be due to different data written by different physicians or illegible handwriting.
2.6.3. Compliance with treatment
Taking medications and/or nonpharmacological treatments accordingly as per the instructions provided by health professionals.
2.6.4. Outcome
Results described in terms of hospital mortality, length of hospital stay, and blood pressure decrement.
3. RESULTS
During the four weeks of data collection period, 252 patient medical records were included in the final analysis. The mean age of the entire patient was 54 years, with the standard deviation (SD) of 17 years. More than half (n = 147, 58%) of the patients were females and live in Gondar town (n = 136, 54%). Two hundred and nineteen (86.9%) patients have a documented history of hypertension with a mean duration of 37 months. More than two‐thirds (n = 166, 65.9%) of the patients took antihypertensive drugs, with 85 (51.2%) took a single drug, 51 (30.7%) took a two‐drug combination, and 30 (18.0%) took a three or more drug combination.
Antihypertensive treatment includes a diuretic for 116 patients (69.9%), calcium channel blockers for 69 patients (41.6%), angiotensin‐converting enzyme inhibitors for 69 patients (41.6%), and beta‐blockers for 13 patients (7.8%). The distribution of drug types was similar across the two groups, with diuretics being most common, followed by calcium channel blockers and angiotensin‐converting enzyme inhibitors (Table 1).
Table 1.
Patient characteristics, emergency, and internal medicine wards, 2018
| Variables | Category | All patients (N = 252) | Hypertensive Emergency (N = 86) | Hypertensive Urgency (N = 166) |
|---|---|---|---|---|
| Sex, n (%) | Male | 105 (41.7%) | 41 (16.3%) | 64 (25.4%) |
| Female | 147 (58.3%) | 45 (17.8%) | 102 (40.5%) | |
| Age (y), mean (SD) | 54(17) | 56.4 (18) | 53 (17) | |
| Age group (y) n(%) | <30 | 17 (6.7%) | 6 (2.4%) | 11(4.3%) |
| 30‐39 | 33 (13.1%) | 8 (3.2%) | 25(9.9%) | |
| 40‐49 | 41 (16.3%) | 15 (6.0%) | 26(10.3%) | |
| 50‐59 | 37 (14.7%) | 6 (2.4%) | 31(12.3%) | |
| 60‐69 | 74 (29.4%) | 35 (13.9%) | 39(15.5%) | |
| 70‐79 | 36 (14.3%) | 9 (3.6%) | 27(10.7%) | |
| >=80 | 14 (5.6%) | 7 (2.8%) | 7 (2.8%) | |
| Residence, n(%) | Gondar | 136 (54.0%) | 32 (12.7%) | 104 (41.3%) |
| Out of Gondar | 116 (46.0%) | 54 (21.4%) | 62 (24.6%) | |
| Distance from the hospital(Km), mean(SD) | 34 (54) | 45.7 (56.5) | 27.4 (51.1) | |
| History of previous admission, n(%) | Yes | 87 (34.5%) | 43 (17.1%) | 44 (17.4%) |
| No | 165 (65.5%) | 43 (17.1%) | 122 (48.4%) | |
| Preexisting hypertension, n(%) | Yes | 219 (86.9%) | 69 (27.4%) | 150 (59.5%) |
| No | 33 (13.1%) | 17 (6.7%) | 16 (6.4%) | |
| Comorbidity, n(%) | Chronic kidney disease | 45 (17.8%) | 25 (9.9%) | 20 (7.9%) |
| Heart failure | 61 (24.2%) | 25 (9.9%) | 36 (14.3%) | |
| Diabetes | 44 (17.5%) | 6 (2.4%) | 38 (15.1%) | |
| Dyslipidemia | 18 (7.1%) | 0 (0.0%) | 18 (7.1%) | |
| Coronary artery disease | 9 (3.6%) | 4 (1.6%) | 5 (2.0%) | |
|
Migraine |
10 (4.0%) | 4 (1.6%) | 6 (2.4%) | |
| Atrial fibrillation | 4 (1.6%) | 2 (0.8%) | 2 (0.8%) | |
| Asthma | 8 (3.2%) | 0 (0.0%) | 8 (3.2%) | |
| HIV/AIDS | 5 (2.0%) | 0 (0.0%) | 5 (2.0%) | |
| Others a | 7 (2.8%) | 2 (0.8%) | 5 (2.0%) | |
| Duration of hypertension (months), mean (SD) | 37 (67) | 37.3 (55.1) | 36.4 (71.9) | |
| Duration of appointment (weeks), mean (SD) | 4 (2) | 2.8 (1.1) | 3.7 (2.5) | |
| Taking hypertension drug, n (%) | 166 (65.9%) | 59 (23.4%) | 107 (42.5%) | |
| Diuretics | 116 (69.9%) | 40 (24.1%) | 76 (45.8%) | |
| Calcium channel blockers | 69 (41.6%) | 28 (16.9%) | 41 (24.7%) | |
| Beta‐blockers | 13 (7.8%) | 3 (1.8%) | 10 (6.0%) | |
| ACEIs | 69 (41.6%) | 27 (16.3%) | 42 (25.3%) | |
| Monotherapy, n(%) | 85 (51.2%) | 30 (18.1%) | 55 (33.1%) | |
| Taking two‐drug combination therapy, n(%) | 51 (30.7%) | 13 (7.8%) | 38 (22.9%) | |
| Taking ≥ 3 drug combination therapy, n (%) | 30 (18.0%) | 14 (8.4%) | 16 (9.6%) | |
| Compliance to treatment, n (%) | Yes | 154 (61.1%) | 48 (19.0%) | 106 (42.1%) |
| No | 98 (38.9%) | 37 (14.7.%) | 61 (24.2%) |
Abbreviation: ACEIs: Angiotensin‐converting enzyme inhibitors.
Benign prostate hyperplasia, thyroid disorder.
3.1. Type of hypertensive crisis and associated presenting symptoms
In total, one‐third (n = 86, 34.1%) of cases were hypertensive emergencies. Of these, 50% were neurovascular emergencies (ischemic stroke, intracerebral or subarachnoid hemorrhage, hypertensive encephalopathy) (Figure 2). From patients, who were on treatments (drug and/or nonpharmacological treatments), the cause of hypertensive crisis was unknown in the majority (n = 154, 61.1%) of patients, whereas in the remaining (n = 98, 38.1%) patients the cause was attributed to non‐compliance with treatment (Table 1).
Figure 2.
Type of hypertensive emergencies, emergency and internal medicine wards, UOGSH, 2018
The most common presenting symptoms at admission were headache (n = 170, 67.5%), dyspnea (n = 36, 14.3%), vomiting (n = 33, 13.1%), chest pain (n = 33, 13.1%), and blurring of vision (n = 30, 11.9%). The three most frequent symptoms among patients with hypertensive emergencies were headache (n = 53, 21.0% P = .001), extremity weakness 29 (n = 29, 11.5%; P < .001), and vomiting (n = 20, 7.9%; P = .001) (Table 2).
Table 2.
Signs and symptoms of hypertensive crisis at presentation, emergency, and internal medicine wards, 2018
| Presenting symptoms | All patients (N = 252) | Hypertensive Emergency (N = 86) | Hypertensive Urgency (N = 166) | P = value |
|---|---|---|---|---|
| Chest pain | 33 (13.1%) | 10 (4.0%) | 23 (9.1%) | .619 |
| Dyspnea | 36 (14.3%) | 10 (4.0%) | 26 (10.3%) | .385 |
| Headache | 170 (67.5%) | 53 (21.1%) | 117 (46.4%) | .001* |
| Palpitation | 20 (7.9%) | 5 (2.0%) | 15 (5.9%) | .165 |
| Dizziness | 12 (4.8%) | 5 (2.0%) | 7 (2.8%) | .953 |
| Shortness of breath | 22 (8.7%) | 8 (3.2%) | 14 (5.5%) | .817 |
| Vomiting | 33 (13.1%) | 20 (7.9%) | 13 (5.2%) | .001* |
| Extremity weakness | 31 (12.3%) | 29 (11.5%) | 2 (0.8%) | <.001* |
| Blurring of vision | 30 (11.9%) | 10 (4.0%) | 20 (7.9%) | .943 |
| Others a | 27 (10.7%) | 14 (5.5%) | 13 (5.2%) | .101 |
Epistaxis, epigastric pain, vertigo, and tinnitus.
P‐value < .05.
3.2. Testing performed and treatment administered
In the emergency and internal medicine departments, 852 tests were ordered and one‐third (n = 298, 34.9%) of the results were abnormal. The distribution in terms of patients indicated that tests were ordered for almost all patients, and in the majority (n = 186, 74.4%) the results were abnormal (Table 3).
Table 3.
Testing performed, emergency, and internal medicine wards, 2018
| Number (%) of patients (n = 250) | |||
|---|---|---|---|
| Test type | Ordered tests (n = 852) | Abnormal test result (n = 298) | Type of abnormality (No. of patient) |
| Serum creatinine | 82 (32.8%) | 28 (11.2%) | Elevated blood levels (28) |
| Blood urea nitrogen | 66 (26.4%) | 17 (6.8%) | Elevated blood levels (17) |
| Complete blood count | 63 (25.2%) | 6 (2.4%) |
Elevated WBC count (2) Low hemoglobin count (4) |
| Urine analysis | 61 (24.4%) | 26 (10.4%) |
Hematuria (16) Proteinuria (10) |
| Cardiac enzyme(Troponin) | 19 (7.6%) | 10 (4.0%) | Elevated biomarker levels (10) |
| Chest radiography | 72 (28.8%) | 12 (4.8%) |
Cardiomegaly (8) Pulmonary edema and infiltrate (4) |
| CT of head | 30 (12.0%) | 27 (10.8%) | Abnormal brain findings (27) |
| Echocardiogram | 58 (23.2%) | 32 (12.8%) |
Abnormal valve findings (22) Cardiomegaly (10) |
| Electrocardiogram | 54 (21.6%) | 24 (9.6%) |
Heart block (5) Atrial fibrillation (19) |
| Random blood sugar | 125 (50.0%) | 54 (21.6%) |
Hyperglycemia (49) Hypoglycemia (5) |
| Serum electrolyte | 14 (5.6%) | 9 (3.6%) |
Hyperkalemia (9) |
| Lipid profile | 71 (28.4%) | 19 (7.6%) | Elevated blood level of triglycerides and cholesterol (19) |
| Stool examination | 22 (8.8%) | 7 (2.8%) | Positive result for parasitic infestations (7) |
| Blood film | 10 (4.0%) | 0 (0.0%) | NA |
| Liver function tests(ALT, AST) | 79 (31.6%) | 17 (6.8%) | Elevated blood levels (17) |
| Abdominal ultrasound | 26 (10.4%) | 10 (4.0%) |
Renal calculi (6) Abnormal finding on renal vasculature (4) |
Abbreviations: ALT, Alanine aminotransferase; AST: Aspartate aminotransferase; NA, Not applicable.
A total of 568 prescriptions were documented for all, n = 252, patients during their hospital stay. Of which the majority (n = 336, 59.2%) of prescriptions were documented for hypertensive urgency. The treatment approach revealed that more oral administration was favored for hypertensive urgency management (n = 312, 54.9%) compared with hypertensive emergency management (n = 184, 32.4%), P = .001. Captopril (n = 136, 23.9%) was the most commonly prescribed oral drug, P = .048, whereas, hydralazine (n = 43, 7.6%) was the most commonly used intravenous drug. Interestingly, in the majority (n = 189, 75%) of patients, their antihypertensive regimen did not have changed on discharge (Table 4).
Table 4.
Type of antihypertensive treatment administered, emergency, and internal medicine wards, 2018
| Hypertension drug | Hypertensive emergencies (N = 86) | Hypertensive urgencies (N = 166) | P = value |
|---|---|---|---|
| Oral captopril | 39 (45.3%) | 97 (58.4%) | .048* |
| Intravenous hydralazine | 31 (36.0%) | 12 (7.2%) | .345 |
| Oral nifedipine | 13 (15.1%) | 23 (13.8%) | .786 |
| Oral enalapril | 40 (46.5%) | 44 (26.5%) | .001* |
| Oral hydrochlorothiazide | 38 (44.2%) | 91 (54.8%) | .109 |
| Intravenous furosemide | 17 (19.7%) | 12 (7.2%) | .008* |
| Oral amlodipine | 25 (29.0%) | 33 (19.9%) | .166 |
| Oral atenolol | 7 (8.1%) | 7 (4.2%) | .299 |
| Oral omeprazole | 8 (9.3%) | 7 (4.2%) | .101 |
| Oral paracetamol | 8 (9.3%) | 2 (1.2%) | .003* |
| Oral methyldopa | 0 (0.0%) | 6 (3.6%) | .118 |
| Oral spironolactone | 6 (6.9%) | 2 (1.2%) | .013* |
P‐value < .05.
3.3. Outcome of hypertensive crisis
Upon arrival at the emergency and internal medicine departments, the median systolic and diastolic blood pressures were 190‐ and 110‐mm Hg. On discharge, the median systolic and diastolic blood pressures had fallen to 140‐ and 90‐mm Hg with standard deviations of 18‐ and 12‐mm Hg, respectively. The median length of hospital stay was 55 hours. From patients admitted with hypertensive emergency, ten (3.9%) were died in the hospital because of acute renal failure (n = 4, 1.6%), intracerebral or subarachnoid hemorrhage (n = 4, 1.6%), and acute myocardial infraction (n = 2, 0.8%). The difference in the median blood pressure decrement with respect to different patient characteristics was checked using the Kruskal‐Wallis H test. The result showed that there was a significant difference in the decrement of median diastolic blood pressure (DBP) between patients with and without previous history of admission (P = .005), and between hypertensive emergency and urgency patients (P = .010) (Table 5).
Table 5.
Test of statistical significance (Kruskal‐Wallis H test) of median blood pressure decrement by patient characteristics, emergency, and internal medicine wards, 2018
| Variable | Category | SBP difference median(IQR) | P = value | DBP difference median(IQR) | P = value |
|---|---|---|---|---|---|
| Sex | Male | 40 (30‐50) | .709 | 13 (10‐20) | .056 |
| Female | 40 (30‐57) | 20 (10‐30) | |||
| Age group(Years) | <30 | 40 (26‐40) | .014* | 20 (11‐20) | .246 |
| 30‐39 | 40 (30‐50) | 20 (10‐30) | |||
| 40‐49 | 40 (30‐50) | 15 (10‐30) | |||
| 50‐59 | 50 (40‐50) | 20 (10‐30) | |||
| 60‐69 | 40 (30‐50) | 14 (10‐20) | |||
| 70‐79 | 50 (40‐70) | 16 (10‐30) | |||
| ≥80 | 42 (30‐72) | 10 (10‐20) | |||
| Residence | Gondar | 40 (30‐60) | .191 | 20 (10‐27) | .056 |
| Out of Gondar | 40 (30‐50) | 10 (10‐21) | |||
| History of previous admission | Yes | 38 (30‐50) | .034* | 10 (10‐22) | .005* |
| No | 40 (30‐50) | 20 (10‐27) | |||
| Preexisting hypertension | Yes | 40 (30‐50) | .680 | 19 (10‐23) | .289 |
| No | 40 (30‐65) | 20 (10‐30) | |||
| Type of hypertensive crisis | Hypertensive emergency | 40 (30‐50) | 10 (10‐20) | .010* | |
| Hypertensive urgency | 40 (30‐50) | 20 (10‐30) | |||
| Taking hypertension drug | Yes | 40 (30‐50) | .64 | 20 (10‐20) | .436 |
| No | 40 (30‐50) | 19 (10‐30) | |||
| Compliance | Yes | 40 (30‐50) | .271 | 10 (10‐25) | .867 |
| No | 40 (30‐50) | 20 (10‐30) | |||
| Number of antihypertensive drugs given during hospital stay | One | 40 (30‐50) | .178 | 20 (10‐20) | .152 |
| Two | 40 (30‐60) | 20 (10‐27) | |||
| Three | 40 (35‐50) | 13 (10‐30) | |||
| Four and above | 40 (30‐50) | 10 (4‐28) |
Abbreviation: IQR, Interquartile range.
P value < .05.
4. DISCUSSION
The present study provides evidence on hypertensive crisis in the emergency and internal medicine departments for 5 years. This finding has never been reported before and indicates that hypertensive crisis represents an important and common event in the emergency and internal medicine wards, and requires appropriate resources for the diagnosis and appropriate treatment.
Among 252 hypertensive crisis cases, using the operational classification of hypertensive crisis in urgencies and emergencies, we found that hypertensive urgencies (65.9%) were more frequent than hypertensive emergencies. In this regard, comparable findings were reported from Thailand, Italy, USA, and Brazil with a high proportion of hypertensive urgencies 80.5%, 74.5%, 78%, and 60.4%, respectively. 18 , 23 , 24 , 25 Although hypertensive emergencies represent only one‐third of hypertensive crisis, they are by definition characterized by end‐organ damage so that the medical staffs devote a lot of time and effort to these patients.
Approximately one‐fourth of the patients presenting with hypertensive crisis had unknown hypertension, indicating that a hypertensive crisis occurs most commonly in patients with known hypertension. In more than half (61.1%) of the patients, who were on treatments (drug and/or nonpharmacological treatments), the cause of hypertensive crisis was attributed to non‐compliance with therapy. This finding was consistent with the previous report that suggested hypertensive patients did not take medication as prescribed or received inadequate therapy. 4 Based on this finding one can understand compliance with treatment is a critical issue for patients with chronic diseases, as well as for health professionals in resource limiting setups with scarce healthcare facilities for better outcomes. This could be due to the difficulty to sustain motivation for treatment, especially for asymptomatic conditions.
In the present study, there was a difference in the numbers of men and women admitted to emergency and internal medicine departments for hypertensive crisis. The number of women was higher compared to men, which is in agreement with study reports from different parts of the world showing that sex differences among patients admitted to the emergency departments for hypertensive crisis, with a higher proportion of women than men. 18 , 26 , 27 , 28 The majority (86.9%) of the patients have also a documented history of hypertension and took antihypertensive drugs (65.9%) for their illness. Antihypertensive treatment prescribed included diuretics, calcium channel blockers, angiotensin‐converting enzyme inhibitors, and beta‐blockers. This finding was in agreement with the study reports from Italy and France, where 74.9% and 70.1% of the patients took antihypertensive drugs respectively. 23 , 29
Another interesting finding of the present study deals with the frequency of presenting symptoms of hypertensive emergencies and urgencies. Headache, extremity weakness, and vomiting were the most frequent signs and symptoms reported by hypertensive emergency patients, whereas headache, chest pain, and dyspnea were the most frequent signs and symptoms among hypertensive urgency patients. These manifestations are similar to study reports from different parts of the world. 14 , 18 , 23 , 25 , 30 , 31 , 32 , 33 , 34 In contrast to this finding, a study from France reported chest pain and dyspnea as the most frequently reported symptoms from hypertensive emergency patients. 29 This could be due to the present study included several hypertensive urgency patients having cardiovascular diseases as a comorbid condition which could be attributed to chest pain and dyspnea as predominant presenting symptoms.
The most requested complementary examinations by the healthcare team in this study were organ function tests (serum creatinine, blood urea nitrogen, alanine transaminase, and aspartate transaminase), chest X‐ray, and electrocardiogram. The practice was in line with the recommendations found in Gondar University Hospital Cardiology Handbook and Standard Treatment Guideline of Ethiopia, 35 , 36 and some of these examinations were also addressed in studies from USA, France, and Brazil, which emphasize the importance of test results and demand in primary care. 18 , 32 , 37 On the other hand, although some of the first‐line treatment measures taken at the admission of patients were in agreement with the recommendations found in Gondar University Hospital Cardiology Handbook and Standard Treatment Guideline of Ethiopia, 35 , 36 a number of them were not consistent with the current recommendations from American College of Cardiology and Eighth Joint National Committee. 2 , 38 This could be explained by having a shortage of required medications to manage the condition and lack of certain diagnostic equipments which will guide and help the management process.
Hospital mortality was 4% and was entirely attributed to hypertensive emergencies. Overall decrement of blood pressure was 43 mm Hg from systolic blood pressure (SBP) and 18 mm Hg from DBP during the hospitalization period. The reduction in systolic and diastolic blood pressure reported in our study showed a smooth decline to avoid risks of potential complications of a much rapid decline. A rapid decline in blood pressure is associated with acute deterioration in renal function, ischemic, cardiac, or cerebral events, and occasional retinal artery occlusion and acute blindness. 39 However, treatment should be individualized to each patient based on the type and extent of end‐organ damage, degree of BP elevation, and the specific side effects that each medication could have on a patient's preexisting comorbidities. 40 The difference in the decrement of median blood pressure with respect to different patient characteristics was checked using the Kruskal‐Wallis H test. The result showed that there was a significant difference in the decrement of median diastolic blood pressure between patients with and without previous history of admission (P = .005), and between hypertensive emergency and urgency patients (P = .010). The median decrement of DBP among patients with no history of previous admission and hypertensive urgency was significantly higher than those patients with previous history of admission (20 mm HG vs 10mmHG) and hypertensive emergency (20 mm HG versus 10 mm HG).
4.1. Strength and limitations of the study
The present study had the following strengths and limitations. To the best of literature search done, it was the first study to describe the magnitude, characteristics, and outcomes of patients presenting with hypertensive crisis across a healthcare system in north Ethiopia. The limitations were related to the retrospective nature of the study; therefore, the demographic and compliance data obtained through the review of patient medical records lead to lower accuracy than those obtained in a prospective study. Given the data source was patient medical record, the study may not have ascertained all outcomes. Additional events could have occurred in other healthcare systems or homes, and sudden cardiac death at home may not have been captured. Second, the study comprises cases from a single institution with its peculiarities of treatment, which limits the extrapolation of the findings to other situations. The other limitation was related to incomplete and inadequate patient medical records, and the handwriting used by the health professionals made it difficult to grasp the information in many cases.
5. CONCLUSIONS
In the present study, the majority of cases were hypertensive urgencies. The cause of the hypertensive crisis was non‐compliance with treatment in a large proportion of the patients. The most common presenting signs and symptoms at admission were headache, dyspnea, and vomiting. Serum creatinine testing was the most frequently performed testing. During hospitalization, the majority of prescriptions were documented for hypertensive urgency favoring more oral route of administration. Captopril was the most commonly prescribed oral drug. Whereas, hydralazine was the most commonly prescribed intravenous drug. All hospital mortality was attributed to a hypertensive emergency. Acute renal failure, intracerebral or subarachnoid hemorrhage, and acute myocardial infarction were identified as causes of death. Furthermore, there was a statistically significant difference in the decrement of median diastolic blood pressure between patients with and without previous history of admission, and between hypertensive emergency and urgency patients. These findings justify better treatment and follow‐up for these patients. Most importantly, to improve compliance with treatment health professionals should provide education to the patients.
CONFLICT OF INTEREST
The authors declare that they have no competing interests.
AUTHOR CONTRIBUTIONS
Both authors involved in the design and write up of the manuscript. Both of them read and approved the final version of the manuscript. Begashaw Melaku Gebresillassie involved in conception, design, literature search, defining contents and terms, preparation of data collection tool/checklist, supervision of data collection, data quality control, data analysis, manuscript drafting, editing and critical review, and approval of final the final version. Yabsira Belayneh Debay involved in literature search, data analysis, manuscript drafting, editing and critical review, and approval of the final version.
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
The study was conducted after an ethical clearance letter received from the research and ethics review committee of the School of Pharmacy, University of Gondar, Hospital Clinical Director, and Head of the Emergency and Internal Medicine departments of UOGSH.
ACKNOWLEDGMENTS
The authors acknowledge the School of Pharmacy, University of Gondar, Statistics and Information Office, and coordinators of the Internal Medicine and Emergency wards for their cooperation during the conduct of the study.
Gebresillassie BM, Debay YB. Characteristics, treatment, and outcome of patients with hypertensive crisis admitted to University of Gondar Specialized Hospital, northwest Ethiopia: A cross‐sectional study. J. Clin. Hypertens. 2020;22:2343–2353. 10.1111/jch.14056
DATA AVAILABILITY STATEMENT
The materials and data of this study are available from the corresponding author upon request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The materials and data of this study are available from the corresponding author upon request.