Honolulu, HI - The enormous inadequacy in the management of patients with acute hypertension has been highlighted by a new registry study, which found that despite having a mortality rate similar to acute coronary syndromes or acute heart failure, many patients with this condition are not even followed up after their initial treatment.

Lead author of the study, Dr Chris Granger (Duke University Medical Center, Durham, NC), explained that acute hypertension is defined as blood pressure over 180/110 mm Hg, and the recommended treatment is IV antihypertensive drugs to get the blood pressure down to target levels. "This is a really understudied and undertreated condition—there is really very little information out there on the best way to treat it. So we conducted a registry to better understand acute hypertension. We wanted to find out who these patients are, how they are managed, what their outcomes are like, and what the causes and consequences of acute hypertension are. This is the first time this has been looked at in a multicenter study," he told heartwire.

Initial results from the STAT registry, sponsored by The Medicines Company, were presented last week at the 37th Critical Care Congress of the Society of Clinical Care Medicine (SCCM), held February 2-6, 2008 in Honolulu, HI. The study is aiming to collect data for as many as 120 consecutive patients in each of 25 US hospitals (with a target enrollment of more than 1500 patients), and to date, 982 patients have been enrolled from 21 hospitals.

Granger noted that their most important finding was that this is a major problem, and there are major opportunities to improve care. In some areas of the southeastern US, as many as 25% of patients in some urban emergency departments have acute hypertension, he reported. He said the population involved was "more or less what we would expect"—around half were African American, the average age was 58, 90% had a history of chronic hypertension, 25% were nonadherent to prescribed medication, 30% had had a prior hospitalization for acute hypertension, and most presented to the emergency department with symptoms such as chest pain, shortness of breath, and symptoms of stroke, and one-third of them were actually having a stroke.

Many IV drugs were used for treatment, including labetalol, metoprolol, hydralazine, nitroglycerin, nicardipine, and sodium nitroprusside, and two or three different drugs were often used in the same patient. Despite this, it took a long tome to get the blood pressure down—for patients without subarachnoid hemorrhage, the median time to achieve a systolic pressure of below 160 mm Hg was four hours, and there was a high rate of overshooting, with 4% of patients developing hypotension, necessitating intervention. There was also a very high rate of recurrence, with 52% of patients having reelevation of systolic blood pressure to over 180 mm Hg after initial control.

For the 92 patients presenting with subarachnoid hemorrhage, the median time to achieve a systolic pressure below 140 mm Hg was 1.5 hours, and 6.5% developed hypotension. There was considerable variability in blood-pressure response over time, based upon the initial antihypertensive agent selected. The median duration of IV therapy was 10.5 hours, and most patients (58%) had evidence of target-organ injury associated with their hypertensive episode.

These patients had a very high rate of mortality—8% at 90 days, which Granger points out is the same as for acute coronary syndromes or acute heart failure. In addition, 40% of patients were rehospitalized within 90 days.

He added that "a very concerning finding" was that 60% of these patients either had no evidence of a follow-up appointment or did not attend the follow-up appointment. "So despite the fact these patients have a life-threatening condition, they are not being followed up well at all. There is room for a large improvement here," he commented.

In another presentation at the SCCM meeting, researchers led by Dr Joseph Dasta (Ohio State University, Columbus) described a survey of current treatment patterns for acute hypertension. The web-based survey of 243 intensive-care-unit (ICU) physicians suggested that an average of 4.9 patients were admitted to each ICU per month with a hypertensive emergency. Of the respondents, 27% reported that a guideline exists in their institution for the treatment of hypertensive emergency in acute-hemorrhagic stroke patients, while only 10% had guidelines for the nonstroke patient. Systolic blood pressures used to initiate IV antihypertensives were 180 mm Hg in nonstroke and 167 mm Hg in acute hemorrhagic stroke patients. The most common duration of IV therapy was 24 to 48 hours in both populations. Intermittent IV labetalol (21.3%), nicardipine (19.6%), and sodium nitroprusside (18.7%) were the top three drugs of choice in nonstroke patients, while nicardipine (34.7%), continuous IV labetalol (21.0%), and sodium nitroprusside (16.4%) were selected in acute hemorrhagic stroke patients. The researchers concluded that these data provide a rationale for developing a national guideline for the pharmacotherapy of acute hypertension.

Other data presented at the meeting focused on subgroup analysis of the VELOCITY study of The Medicines Company's new drug for acute hypertension, clevidipine. Overall results of this study, reported last year, showed promise of the new drug—with 89% of patients (104 of 117) achieving target pressures within half an hour. The current subgroup analyses showed the drug was similarly effective in patients with acute heart failure or renal dysfunction.

Also at the SCCM meeting, Dr Solomon Aronson (Duke University Medical Center, Durham, NC) presented a new study validating previous findings that blood-pressure control during cardiac surgery is related to mortality. The ECLIPSE trial of clevidipine in cardiac surgery, reported last year, showed a significant association between "blood-pressure excursions"—how much and how long systolic pressure went above or below predefined acceptable perioperative ranges—and 30-day mortality risk. "Now we have validated that finding in another independent database," Aronson explained to heartwire. In the current study, funded by The Medicines Company, Aronson and his colleagues analyzed automated continuous blood-pressure recordings from around 10 000 patients undergoing cardiac surgery at Duke University over the past 10 years. Blood pressures during cardiopulmonary bypass were excluded. Results showed that the degree and amount of time that blood pressure was outside the predefined range (>135 or <95 mm Hg) was predictive of 30-day mortality.

Dr James Ferguson (The Medicines Company, Houston, TX) commented to heartwire that people are now recognizing that acute hypertension is a real problem that is not being managed effectively. "The drug therapies available at present all have drawbacks. We hope that newer treatments may do better." Clevidipine, a calcium antagonist with an ultrashort half-life, is awaiting approval from the FDA. The Medicines Company is hoping for approval "within the next few months."