Severe hypertension: some symptoms make end-organ damage more likely.

Clinical bottom line (level 4)

  1. Patients with severe hypertension who have a headache, epistaxis, a cardiac arrhythmia or psychomotor agitation are very likely to have end-organ damage.
Zampaglione et al: Hypertension 1996; 27 (1): 144-147
Expires Unknown Month 2001

The study

Setting: emergency department, acute hospital, Italy

449 patients (aged mean 64 years, 58% female) with diastolic blood pressure 120 mmHg or more and one of:
  • hypertensive emergency: associated evidence of end-organ damage: hypertensive encephalopathy; stroke (cerebral infarction or intracerebral or subarachnoid haemorrhage; acute pulmonary oedema, congestive heart failure, left ventricular failure or aortic dissection; acute MI or unstable angina; progressive renal insufficiency; eclampsia
  • hypertensive urgency: no end-organ damage


Excluded if
  • <18 years old
  • diastolic blood pressure <120 mmHg


    • Patients were monitored in the emergency department for at least 24 hours, and treated with nifedipine, captopril, clonidine, sodium nitroprusside or frusemide as required.
    Independent unblinded reference standard, applied in some patients from a consecutive appropriate spectrum.
    Reference standard:
    • blood and urine chemistry, fundoscopy, ECT, Chest X-ray, and CT or USS as required
    Diagnostic test: clinical findings
    • All patients had blood and urine chemistry, fundoscopy, ECT, Chest X-ray, and CT or USS as required.Blood pressure taken by mercury sphygmomanometer twice in the recumbent position. Average of two readings taken 30 seconds apart used.

    The evidence

    pre-test probability of end-organ damage: 24%, (95% CI: 20% to 28%)

    diagnostic test end-organ damage no end-organ damage LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    headache 3 75 0.1
    (0.04 to 0.4)     		4% 1.25
    (1.16 to 1.33)     		28%
    epistaxis 0 58 0
    (0 to 0.2)     		0% 1.20
    (1.14 to 1.26)     		28%
    chest pain 29 31 3.0
    (1.9 to 4.7)     		48% 0.80
    (0.71 to 0.91)     		20%
    dyspnoea 24 31 2.4
    (1.5 to 4.0)     		44% 0.86
    (0.77 to 0.95)     		21%
    psychomotor agitation 0 34 0
    (0 to 0.2)     		0% 1.1
    (1.07 to 1.15)     		26%
    arrhythmia 0 20 0
    (0 to 0.2)     		0% 1.06
    (1.03 to 1.09)     		25%
    total 108 341

    • No other clinical findings were significantly associated with end-organ damage.

    Comments

    1. Very difficult to estimate how the small numbers, lack of observer agreement measures and subjective nature of complaints may bias results.
    2. Patients with hypertensive emergencies were older than those with urgencies.

    Citation

    1. Zampaglione B, Pascale C, Marchisio M, et al: Hypertensive urgencies and emergencies: prevalence and clinical presentation. Hypertension 1996; 27 (1): 144-147
    Contributor: Nick Shenker and Chris Ball, Unknown Month 2000
    Reviewer: Janice L Zimmerman

    Clinical Question.
    Patient severe hypertension
    Intervention or Exposure symptoms
    Outcome end-organ damage