Hypertensive Urgency in the Office: Should You Send the Patient to the ER?

You’re in the office seeing a patient, and take a look at the vitals.  Blood pressure 190/110. Being the diligent physician you are, you recheck the blood pressure manually, in both arms, after having the patient relax in a quiet room for 5 minutes.  190/110. There are no symptoms. What do you do? The situation I just described is known as hypertensive urgency, which is a systolic pressure over 180 or a diastolic pressure over 110 without any evidence of end-organ damage. And what to do with patients in this situation is a clinical grey area that, thanks to a manuscript appearing in JAMA Internal Medicine, may finally be seeing the light of day.

For the video version of this post, click here.

The Methods

The study, out of the Cleveland Clinic, gives us some really important data. Here’s how it was done. The researchers identified everyone in that Healthcare system who had an outpatient visit with hypertensive urgency over a 6-year time frame. Of over 1 million visits – just under 60,000, about 5% - had blood pressures consistent with hypertensive urgency. Now, some of those individuals were sent to the hospital for evaluation, the rest were sent home. What percent do you think went to the hospital?

If you answered “less than 1%”, you’re spot on and a way better guesser than I am. I actually assumed the rate would be much higher.  Now, how can we evaluate whether sending someone to the hospital is the “right” move. And let’s not fall into the assumption that sending someone to the hospital is a “safe” option. Those of us who work in hospitals will quickly disabuse anyone of that notion.

The problem is that those who got sent to the hospital were doing worse than those who got sent home. They had higher blood pressures in the “urgency” range, with a mean systolic of 198 compared to 182 in those sent home.

To create a fair assessment of the effects of sending someone to the hospital, the authors performed a propensity-score match.  Basically, they matched the people who got sent to the hospital with people of similar characteristics that didn't. Comparing the matched groups, they found… nothing.

No increased risk of major adverse cardiovascular events.  In other words, the people sent home weren’t having strokes during the car ride.

A curious finding

One thing I did note was that those sent to the hospital were much more likely to have a hospital admission sometime in the next 8 – 30 days compared to those who got to go home.  This either means that some bad stuff happens in that initial hospital referral that leads them to bounce back later in the month or, and I’m favoring this interpretation here, the propensity match didn’t catch some factors that predisposed the hospitalized people to hospitalization in general – factors like socioeconomic status, for instance. If that’s true, then we’d actually expect the hospitalized group to do worse than their controls. The fact that they didn’t may argue that the hospital actually did something beneficial. But we are way down the causality rabbit hole here.

Conclusion

In the end I take home two things from this study.  First, the shockingly low rate of referral to hospital for hypertensive urgency.  Seriously – is this just a Cleveland Clinic thing? Feel free to let me know in the comments.  And two – that for the right patient, a dedicated outpatient physician can probably do just as much good as a costly trip to the ED.

Migraine: A New Cardiovascular Risk Factor?

I’m going to get personal here.  I had my first migraine - in my life - about three weeks ago. For those of you who have been longtime sufferers, I am truly sorry.  I was literally testing my own neck stiffness to make sure I didn’t have meningitis. But aside from the blistering pain knocking you out of commission for several hours (or several days), a new study appearing in the BMJ suggests there is something else migraine sufferers need to worry about – cardiovascular disease.

For the video version of this post, click here.

Researchers used data from the Nurses Health Study 2, a large, questionnaire-based prospective cohort study that began back in 1989 and enrolled over 100,000 nurses. The idea here was that the nurses (all female by the way) would be more reliable when answering health-related questionnaires than the general public.

In 1989, 1993, and 1995 the questionnaire asked if the women had been diagnosed, by a physician, with migraine. That’s it. No information on treatment, severity, or the presence of aura – a factor that has been associated with cardiovascular disease in the past.

This response was linked to subsequent major cardiovascular events including heart attack, stroke, and coronary interventions.

The researchers found a higher rate of this outcome among those who had been diagnosed with migraine. In fact, even after adjusting for risk factors like age, cholesterol, diabetes, hypertension, smoking, and more, the risk was still elevated by about 50%. So those of us with migraines – is it time to freak out?

Not too much.  The overall rate of major cardiovascular events in this cohort was just over 1% - not exactly common. That means the absolute risk increase is 0.5%, which doesn’t sound quite as dramatic as the 50% relative risk increase.  Putting that another way, for every 200 patients in this cohort with migraine, there was one extra case of cardiovascular disease.  Not exactly a risk factor to write home about.

But, to be fair, cardiovascular disease gets more common as we age – had the study had even longer follow-up, we might have seen a higher event rate.

Other studies have found similar findings with migraine. The women’s health study, for instance, found a nearly two-fold increased risk in cardiovascular events, but only in those who had migraine with aura – a covariate missing from the current dataset.

Should women with migraine take precautions against cardiovascular disease? The jury is out. Since we don’t know the mechanism of the link, if any, we don’t know the best way to treat it.  But clearly any studies of migraine therapy would do well to keep an eye on cardiovascular endpoints.

Being a woman versus being womanly: the implications after heart attack

For the video version of this post, click here. There are two elements you can expect to see in almost any study: the first is some effect size - a measure of association between an exposure and outcome. The second is a subgroup analysis - a report of how that effect size differs among different groups. Sex is an extremely common subgroup to analyze - lots of things differ between men and women. But a really unique study appearing in the Journal of the American College of Cardiology suggests that sex might not matter when it comes to coronary disease. What really matters is gender.

The study, with cumbersome acronym GENESIS-PRAXY, examined 273 women and 636 men of age less than 55 who were hospitalized with Acute Coronary Syndrome (ACS). Sex was based on self-report, and was binary (man or woman). But gender isn’t sex. Gender is a social construct that represents self-identity, societal roles, expectations and personality traits, and can be a continuum - think masculine and feminine.

The authors created a questionnaire that attempted to assign a value to gender. Basically, questions like - “how much of the child-rearing do you perform” or “are you the primary breadwinner for your household” - in other words these are based on traditional gender norms - but that’s as good a place to start as any. A score of 100 on the gender scale was “all feminine”, and a score of 0 “all masculine”.  Most of the males in the study clustered on the masculine end of the spectrum, while the females were more diverse across the gender continuum.

What was striking is that the primary outcome - recurrence of acute coronary syndrome within a year, was the same regardless of sex - 3% in men and women.  But a greater degree of “femininity” was significantly associated with a higher recurrence rate. Feminine people (be they male or female) had around a 5% recurrence rate compared to 2% of masculine people. This was true even after adjustment for sex, so we’re not simply looking at sex in a different way - gender is its own beast.

What does it all mean?  Well, it shows us that our binary classification of sex may be too limited in the biomedical field. Of course, there will always be hard and quantifiable physiologic differences between men and women. But what is so cool is that it’s the more difficult to quantify gender-related differences that may matter most when it comes to health and disease.

Of course, this conclusion is way too big to be supported by one small study with a 3% event rate. But given the surprising and really interesting nature of the results, I’m sure we’ll have many more studies of this sort following close behind. 

Soul food is bad for the heart

For the video version of this post, click here. What diet do you ascribe to?  If you answered “I have no idea what you mean”, then you can join the rest of the 80% of Americans who don’t follow a specified diet regime. Sure, lots of us try to avoid fat, or sugar, or meat, but when it comes to defining the health benefits of a particular dietary pattern, it’s hard to label people.

Now an article appearing in Circulation from researchers at the University of Alabama at Birmingham suggests that a “Southern” style diet may significantly increase the risk of heart disease.

Before we get our pitchforks and charge over to Paula Deen’s house, let’s take a minute to look how this study was done. The data comes from the “REGARDS” study, which was a large cohort study primarily designed to look at stroke risk factors.  About half of the REGARDS cohort, 15,000 people, were eligible for this analysis and provided dietary data in the form of a food frequency questionnaire.

What’s cool about this study is that they derived the dietary patterns without any preconceived notions.  Using a technique called factor analysis, they let the data speak for itself, and find which foods tend to “hang together” in the diets of individuals.  Five major patterns emerged:  the Southern diet (which is the focus of the study) was characterized by fried foods, eggs, organ meats, and sugar-sweetened beverages. Other dietary patterns included a “plant-based” pattern, a “convenience” food pattern, a “sweets” pattern and, my favorite, an “alcohol and salad" pattern.

What I like about this study is that it doesn’t force individuals into a specific category.  The analysis allows your dietary pattern to be part Southern, part plant-based, for example. So we’re not in the situation of trying to label each person with one, and only one, diet.

After follow-up of around 6 years, greater “adherence” to the Southern diet increased the risk of incident coronary heart disease by around 35%. To stop one heart attack per year, you’d need to convert roughly 1200 fried-organ meat gourmands to a healthier option, but that assumes there were no confounders at play.  Clearly there were, as the southern dietary pattern was associated with male sex, black race, lower income, and diabetes.  The authors adjusted for these factors, but it’s likely that other socio-economic factors including access to health care may play a significant role here.

In unfortunate news, the “Alcohol and Salads” dietary pattern, which describes my eating habits pretty darn well, had no relationship to heart disease in either direction.  This may hurt sales of my upcoming diet book “Alcohol and Salads: 20 blurry days to a better you”.

The analysis doesn’t allow for too much subtlety - describing anyone’s dietary habits using 5 criteria is limiting.  In addition, the lack of signal in the “sweets” dietary pattern runs counter to a lot of prior research linking high processed carbohydrate consumption to heart disease. That said, I for one, am going to forgo that second helping of chicken-fried steak tonight.