Intended for healthcare professionals

Rapid response to:

Practice Guidelines

Management of hypertension: summary of NICE guidance

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4891 (Published 25 August 2011) Cite this as: BMJ 2011;343:d4891

Rapid Response:

The re examination of acute hypertension

I read with interest your recent publication of the NICE guidelines
for Hypertension. The guidelines are comprehensive yet it is
disappointing that there is little guidance on the management of acute
hypertension. Acute hypertension is rarely mentioned in current
guidelines and recommendations. Current consensus is that hypertension is
best left alone in an acute setting and as a consequence it is often
undertreated.

I wanted to draw your attention to the recent research carried out by the
STAT registry in America. This research found that the treatment of acute
hypertension is in consistent and varies considerably. As a result many
patients do not receive treatment in time, have variable responses in
their blood pressure and often develop hypotension. Many patients started
on intravenous antihypertensives subsequently needed multiple drug
therapy. It took around 4 hours to reduce systolic blood pressure to
below 160 mmHg with 60% experiencing a 'reelevation' of blood pressure to
over 180 mm Hg. 63% developed hypotension as a consequent of
antihypertensive treatment .

The STAT study also found that a third of patients with severe
hypertension were readmitted to hospital within 90 days and over a quarter
of these admission were for another episode of acute hypertension . A
survey of patients with severe hypertension found that they were not being
treated aggresively enough .
Further research was carried out on the cardiovascular sequlae of acute
hypertension in kidney disease . They studied outcome in patients
hospitalised with acute severe hypertension. Of these patients, Chronic
kidney disease sufferers were at greater risk of developing heart failure,
non ST elevation myocardial infarcts. Those with acute kidney injury were
also at risk of heart failure as well as cardiac arrest. The medical
consequences of untreated acute hypertension has been greatly
underestimated.

The emergence of clevidipine as a new and possibly safer, more effective
treatment of acute hypertension should prompt us to re-examine this area
of acute medicine. Clevidipine has a short duration of action and short
half life allowing its use in acute settings. It also does not cause
iatorgenic hypotension. Given the need to reduce severe hypertension
quickly and effectively in those with target organ damage there is an
impetus to develop more anti-hypertensive medications for acute
hypertension with reliable and safe blood pressure reduction. At present
such blood pressure reduction is unpredictable, almost unreliable with
variable results and attendant unwanted effect of hypotension.
NICE and other regulatory bodies need to seriously re-examine the area of
hypertension treatment in an acute setting. Physicians delivering acute
medical care need more guidance in this area. The evidence for clinical
sequelae of acute hypertension needs to be researched. Current management
of acute hypertension is inconsistent and inadequate.

Krause T, Lovibond K, Caulfield M, McCormack T, Williams B; on behalf of
the Guideline Development Group. Management of hypertension: summary of
NICE guidance. BMJ2011;343:d4891

Devlin JW; Dasta JF; Kleinschmidt K; Roberts RJ; Lapointe M; Varon J;
Anderson FA;
Wyman A; Granger CB Patterns of antihypertensive treatment in patients
with acute severe hypertension from a nonneurologic cause: Studying the
Treatment of Acute Hypertension (STAT) registry. Pharmacotherapy, November
2010, vol./is. 30/11(1087-96), 0277-0008;1875-9114 (2010
Nov)

Katz JN; Gore JM; Amin A; Anderson FA; Dasta JF; Ferguson JJ;
Kleinschmidt K;
Mayer SA; Multz AS; Peacock WF; Peterson E; Pollack C; Sung GY; Shorr A;
Varon J;
Wyman A; Emery LA; Granger CB Practice patterns, outcomes, and end-organ
dysfunction for patients with acute severe hypertension: the Studyingthe
Treatment of Acute hyperTension (STAT) registry. : American Heart Journal,
October 2009, vol./is. 158/4(599-606.e1), 0002-8703;1097-6744
(2009 Oct)

Gore JM; Peterson E; Amin A; Anderson FA Jr; Dasta JF; Levy PD;
O'Neil BJ; Sung GY;
Varon J; Wyman A; Granger CB Predictors of 90-day readmission among
patients with acute severe hypertension. The cross-sectional
observational. Studying the Treatment of Acute hyperTension (STAT) study
American Heart Journal, September 2010, vol./is. 160/3(521-527.e1),
0002-8703;1097-6744 (2010 Sep)

Borzecki AM; Kader B; Berlowitz DR The epidemiology and management of
severe hypertension. Journal of Human Hypertension, January 2010, vol./is.
24/1(9-18), 0950-9240;1476-5527
(2010 Jan)

Szczech LA; Granger CB; Dasta JF; Amin A; Peacock WF; McCullough PA;
Devlin JW;
Weir MR; Katz JN; Anderson FA Jr; Wyman A; Varon J Acute kidney injury and
cardiovascular outcomes in acute severe hypertension. Circulation, May
2010, vol./is. 121/20(2183-91), 0009-7322;1524-4539 (2010 May 25)

Competing interests: No competing interests

15 September 2011
sripurna basu
junior doctor
basildon hospital