Hypertensive Crises in the Emergency department: true story or chasing the white rabbit? Prevalence and clinical picture in patients with severe elevations of arterial blood pressure

Purpose: One to two percent of patients with hypertension have acute elevations of arterial blood pressure (BP) that require urgent medical treatment in their life. Currently, patients with a systolic BP (SBP) >179 mm Hg or a diastolic BP (DBP) > 109 mm Hg are considered to be having a "hypertensive crisis" (HC), distinguishing complicated by acute end-organ damage (Hypertensive Emergency, HE) from uncommon severe but uncomplicated elevations of BP (Hypertensive Urgency, HU). Zampaglione and colleagues (Hypertension, 1995) reported that HC (76% urgencies and 24% emergencies) represented more than one fourth of all medical urgency-emergency. Is it a true story in the real ED word or we are chasing the white rabbit? The aim of the present study is to evaluate the prevalence of HC in an urban public ED and the related clinical picture. Methods: All patient (>18 years) presented to the ED, in the year 2011, with a hypertensive crisis (SBP≥180 mmHg e/o DBP≥ 110 mmHg) were included in analysis. In the absence of end-organ damage all other HC were considered HU; situations in which the patient presents elevated BP due to an emotionally charged, painful, with no evidence of lesion of target organs, characterized a pseudo-crisis. Results: A total of 53926 ED visits were made during period of study: 1593 patient (920 females, 57.8%) had a diagnosis of HC. Of whom 411 (26%) were HE, 304 (19%) were HU, while 878 patients (55%) was classified as a pseudo-crisis (no life-threatening). The overall proportion of the HC was 1%, representing 3% of all emergency visits. The pattern of end-organ damage included cerebral ischemia (22,1%), hemorrhagic stroke (9,9%), acute coronary syndrome (25,3%) and acute heart failure manifestations (40,9%). In the HE the most frequently signs of presentation were dyspnoea (41.6%), acute neurological deficit (28.5%) and chest pain (24.7%), while in HU were headache (20%), acute neurological deficit (20%) and chest pain (16.4%). Discussion: HC represented only the 1% of all the visits in an urban ED, the 3% of all the emergency visits. The frequent clinical picture of presentation was common to the other emergency syndrome (prevalently cardio-vascular and cerebral vascular acute disease). The emergency physicians daily take care of patient with HC in the while they are likely to manage the acute emergency syndromes in emergengy setting. Therefore, the management of HC by the physicians of the ED could be a true story of real life while they are chasing the white rabbit (or trying to boost a myth).