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.

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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.

Huge Chinese Study Suggests 20% of Heart Disease due to Low Fruit Consumption

A 柚子 a day keeps the doctor away? Appearing in the New England Journal this week is a juicy study  that suggests that consuming fresh fruit once daily can substantially lower your risk of cardiovascular disease. In fact, the study suggests that 16% of cardiovascular death can be attributed to low fruit consumption. For those of you keeping score, that's pretty similar to the 17% of cardiovascular deaths that could be prevented if older people stopped smoking.

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What we're dealing with here is a prospective, observational cohort of over 500,000 Chinese adults without a history of cardiovascular disease.  At baseline, they were asked how often they consumed a variety of foods, and gave a qualitative answer. Most of the analyses compare people eating fruit "daily" to those who ate fruit "rarely or never".

Those fruit-eaters were substantially different from the non-fruit eaters, but not, perhaps, in the way you might expect.  For example, waist circumference and BMI were higher in the fruit-eaters and fruit-eaters were much more likely to live in urban rather than rural areas. Fruit-eaters also ate more meat, all suggesting that, in China at least, eating more fruit might be a marker of better nutrition overall. Reporting the cardiovascular effects of more frequent eating of other foods would reveal whether this is the case, but that data was not shown.

More in line with our Western expectations, fruit-eaters had a substantially higher income, more education, and were less likely to smoke or drink alcohol.

After more than 3 million person-years of follow-up, there were 5,173 cardiovascular deaths. If you followed a group of 1000 fruit-eaters for a year, you'd expect less than 1 cardiovascular death. Following a similar-sized group of never-fruit eaters, you'd expect 3.7 deaths.

These observations withstood adjustment for socioeconomic factors, smoking, physical activity, BMI and consumption of other types of food, though unmeasured confounding always plays a role in dietary studies.

Why does it work? We don't know.  Though the frequent fruit-eaters had lower blood pressure and lower blood sugar, these factors did not explain the protective effects of the fruit.

Indeed, maybe it's not something in fruit that is beneficial at all, but something that isn't. Like sodium.  Fresh fruit isn't salty and salt-intake was not captured in this study. Missing data like that makes it hard to trust that the observed relationship is truly causal.

Still, there isn't much harm in advising patients to eat fresh fruit more regularly, which is I suppose, what makes studies like these so appealing.