2024年美國心臟學會將 hypertensive urgency 及 hypertensive crisis 刪除. 急性高血壓的治療不依照高血壓數值分類. 應依照病患的風險等級給予相應的處置. 目的是要避免發生併發症
(下面這段是張志華主任臉書的文字)
(下面這段是張志華主任臉書的文字)
New AHA 2024 guidelines have omitted these terms: hypertensive urgency and hypertensive crisis. These terms created ambiguity and inconsistent treatment. The new approach prioritizes risk stratification over solely focusing on blood pressure numbers. Effective management of elevated blood pressure remains the goal to prevent complications.
2024 AHA Scientific Statement on Management of Elevated Blood Pressure
AHA全文
Abstract
Over the past 3 decades, a substantial body of high-quality evidence has guided the diagnosis and management of elevated blood pressure (BP) in the outpatient setting. In contrast, there is a lack of comparable evidence for guiding the management of elevated BP in the acute care setting, resulting in significant practice variation. Throughout this scientific statement, we use the terms acute care and inpatient to refer to care received in the emergency department and after admission to the hospital. Elevated inpatient BP is common and can manifest either as asymptomatic or with signs of new or worsening target-organ damage, a condition referred to as hypertensive emergency. Hypertensive emergency involves acute target-organ damage and should be treated swiftly, usually with intravenous antihypertensive medications, in a closely monitored setting. However, the risk-benefit ratio of initiating or intensifying antihypertensive medications for asymptomatic elevated inpatient BP is less clear. Despite this ambiguity, clinicians prescribe oral or intravenous antihypertensive medications in approximately one-third of cases of asymptomatic elevated inpatient BP. Recent observational studies have suggested potential harms associated with treating asymptomatic elevated inpatient BP, which brings current practice into question. Despite the ubiquity of elevated inpatient BPs, few position papers, guidelines, or consensus statements have focused on improving BP management in the acute care setting. Therefore, this scientific statement aims to synthesize the available evidence, provide suggestions for best practice based on the available evidence, identify evidence-based gaps in managing elevated inpatient BP (asymptomatic and hypertensive emergency), and highlight areas requiring further research.
High blood pressure (BP) remains the leading modifiable risk factor for cardiovascular disease (CVD) in the United States, and a large body of high-quality evidence guides the diagnosis and management of elevated BP in the outpatient setting. However, fewer data are available for the management of elevated BP in the acute care setting. Throughout this scientific statement, we use the terms acute care and inpatient to refer to care received in the emergency department (ED) and after admission to the hospital. The presence of elevated BP in the acute care setting in the United States is exceptionally common. One study found that elevated inpatient BP, with or without evidence of new or worsening target-organ damage, was present in up to 72% of hospital admissions.1
Elevated inpatient BP can be broadly categorized into 2 groups: asymptomatic elevated BP and elevated BP with signs of new or worsening target-organ damage, also known as hypertensive emergency. Although the recommendation to treat hypertensive emergency in a timely manner is well accepted, there is less clarity about the risks and benefits of treating asymptomatic elevated inpatient BP with antihypertensive medication. Despite its ubiquity, there are no randomized trials on the risks and benefits of treating asymptomatic elevated inpatient BP with antihypertensive medication, and recent observational studies suggest potential harms.
This scientific statement synthesizes the available evidence for treatment of elevated inpatient BP (asymptomatic and hypertensive emergency), outlines the evidence gaps for management of elevated inpatient BP, and sets forth potential hypotheses to be tested in future high-quality studies.
DEFINITIONS
Figure 1 presents the terminology used to define elevated inpatient BP (≥130 mm Hg systolic BP [SBP] or ≥80 mm Hg diastolic BP [DBP]) to be consistent with the 2017 Hypertension Clinical Practice Guidelines definition of hypertension.2 Historical terms such as hypertensive crisis (markedly elevated BP, eg, SBP/DBP >180/110–120 mm Hg, with or without new or worsening target-organ damage) and hypertensive urgency (markedly elevated BP without evidence of new or worsening target-organ damage) fail to acknowledge the nuances of treatment decisions and, through the use of subjective emotive language such as crisis and urgency, may encourage unnecessary antihypertensive treatment. Therefore, we propose the following objective terminology: hypertensive emergency (SBP/DBP >180/110–120 mm Hg with evidence of new or worsening target-organ damage), asymptomatic markedly elevated inpatient BP (SBP/DBP >180/110–120 mm Hg without evidence of new or worsening target-organ damage), and asymptomatic elevated inpatient BP (SBP/DBP ≥130/80 mm Hg without evidence of new or worsening target-organ damage). It is imperative to underscore that BP-related target-organ damage might manifest even when BP is below the 180/110 to 120 mm Hg threshold in particular contexts, indicating that this benchmark should not be perceived as an unequivocal aspect of the definition criteria. BP-related target-organ damage refers to the acute harmful effects of elevated BP on vital organs. Specifically, it is defined by any symptom, sign, or diagnostic finding indicative of acute damage, including but not limited to injuries to the brain (eg, hypertensive encephalopathy, intracranial hemorrhage, and acute ischemic stroke), heart (eg, acute myocardial infarction, unstable angina, acute left ventricular failure with pulmonary edema), large vessels (dissecting aortic aneurysm), kidneys, and the microvasculature. Microvasculature manifestations may include conditions such as high-grade retinopathy, acute kidney injury, or microangiopathic hemolytic anemia and thrombocytopenia.
Figure 1. Terminology of elevated inpatient BP in the acute care setting. The blood pressure (BP) classifications depicted in this figure are based on established thresholds from recent hypertension guidelines, including the 2017 Hypertension Clinical Practice Guidelines, the 2018 European Society of Cardiology/European Society of Hypertension (ESH) clinical practice guidelines for the management of arterial hypertension, and the 2023 ESH guidelines on arterial hypertension management. Markedly elevated BP is defined by the 2017 Hypertension Clinical Practice Guidelines as systolic BP (SBP) >180 mm Hg or diastolic BP (DBP) >120 mm Hg in scenarios without new or worsening target-organ damage. The 2023 ESH guidelines categorize hypertensive emergency or urgency as grade 3 hypertension (SBP ≥180 mm Hg or DBP ≥110 mm Hg) without differentiating severity based solely on BP values among those showing no signs of target-organ damage progression. The depicted ranges for inpatient elevated BP align with recommendations for outpatient high BP management as the definition of stage I hypertension. Readers are encouraged to consult individual guidelines for detailed definitions and clinical context.
EPIDEMIOLOGY
In 2012, hypertension was the primary diagnosis for 1 040 000 ED visits, with ≈23% resulting in hospitalization.3 Data from the Nationwide Emergency Department Sample for 2006 to 2013 indicate that hypertensive emergencies occurred in ≈2 in 1000 adult ED visits overall and 6 in 1000 for individuals with a previous diagnosis of hypertension.4 Rates of hypertensive emergencies have increased over the past 20 years; however, mortality rates have decreased and range from 0.2% to 11%.4,5
Asymptomatic elevated inpatient BP is more common than hypertensive emergency, although the prevalence varies. In a systematic review involving 9 studies, asymptomatic elevated inpatient BP was present in 50% to 72% of hospitalizations.1 A multihospital study of 224 265 adults admitted for reasons other than hypertension found that 10% had asymptomatic markedly elevated inpatient BP.6 In another study, the presence of at least 1 elevated BP, defined as SBP >140 mm Hg, was seen in 78% of 22 834 adults admitted to a medicine service for noncardiac diagnoses.7 Certain patient populations appear to be more prone to hypertensive emergencies or asymptomatic elevated inpatient BP. These include older individuals, Black adults, and those with comorbidities such as diabetes, chronic kidney disease, and CVD.4,6,8 In addition, socioeconomically disadvantaged individuals who are underinsured or who live in low-income areas and individuals who are nonadherent to antihypertensive medication also face an increased risk for being hospitalized for hypertension.9–11 The prevalence of elevated inpatient BP likely varies by region as a result of challenges such as shortages of health care professionals in rural areas and other resource availability unique to specific geographies. Furthermore, sex and gender may also play a role. The prevalence of outpatient hypertension is lower in women until about the fifth decade of life and is higher later in life compared with men. However, there is no evidence suggesting that the threshold for initiating antihypertensive medication or indicating the type or combinations of antihypertensive medications to use should differ according to sex or gender. The management of hypertension in pregnancy in the inpatient setting has special requirements, and we refer the readers to recent guidelines and scientific statements on the management of hypertension in pregnancy.12,13
BP MEASUREMENT IN THE ACUTE CARE SETTING
The 2019 American Heart Association (AHA) scientific statement on BP measurement described best practices for outpatient BP measurement in and out of the office setting.14 However, BP measurement in the acute care setting was not addressed in that statement, largely because of the limited data on this topic. Although the contexts are different, the general principles of proper BP measurement technique apply as outlined in the AHA scientific statement on measuring BP.14 Most studies examining elevated inpatient BPs have relied on BP measurements taken during routine care and recorded in the electronic health record. However, BP recordings in the electronic health record typically omit critical contextual factors contributing to variability and inaccuracy (Figure 2). These factors may include the device type, validation and calibration status of the device, BP cuff placement, cuff size, patient position (eg, supine, seated), and situational factors (eg, anxiety, pain, patient woken up for BP measurement). The available data suggest significant variation in current BP measurement practices in the acute care setting, including discrepancies in patient position, arm support, relative position to the heart, leg crossing, and incorrect cuff sizing.14 For instance, 1 report found that 36 of 100 inpatient BP measurements in a UK hospital were performed with an inappropriately sized cuff.15 In addition, the technique and variability of inpatient BP measurements may differ depending on the hospital unit where the BP is measured. In the intensive care unit, BP is often measured with an arterial line; however, erroneous readings can occur because of movement artifacts or calibration errors.16 This variation in measurement practices can contribute to inaccurate BP readings and subsequent unnecessary treatment. However, arterial lines are preferred for hypertensive emergencies and for intravenous antihypertensives. Studies have found that when BPs are >180/100 mm Hg in critical care or surgical inpatient populations, oscillometric devices may underestimate BP by as much as 50/30 mm Hg compared with BP from an arterial line.17,18 Even research-quality manual auscultatory methods with aneroid or mercury devices exhibit notable discrepancies compared with arterial line readings.19,20 Thus, arterial lines are preferred for monitoring the rate of BP decline and the use of intravenous antihypertensive medications for hypertensive emergency. In asymptomatic elevated BP, when feasible, using standardized BP measurements in the acute care setting before making BP management decisions is reasonable and may help minimize variability and ensure appropriate treatment. Special populations, including pregnant individuals, older individuals, or patients with obesity, pseudohypertension, arrhythmias, pulseless syndromes, and left ventricular assist devices, require particular attention when BP is measured. For these special populations, we direct readers to the 2019 AHA scientific statement on the measurement of BP in humans.14 Another special population for BP management in the inpatient setting is patients in the perioperative period. BP management in this setting is influenced by many factors such as pain, anxiety, anesthesia, and procedural variables. Although this topic is beyond the scope of our current statement, it merits attention and a dedicated review because of its distinct clinical challenges. Furthermore, the timing of BP measurements, relative to the time of day and proximity to stressors such as blood draws and diagnostic tests, along with geographic practices and staffing considerations, can influence BP measurement quality in the acute care setting.
Hypertensive Emergency
Distinguishing hypertensive emergencies from asymptomatic elevated inpatient BP is the critical first step in management. After an accurate BP measurement is performed with the appropriate technique, the next step is to assess the severity of the reading and assess for evidence of new or worsening target-organ damage, the hallmark of hypertensive emergency. The BARKH acronym (brain, arteries, retina, kidney, heart) assists in quickly identifying potential target organs at risk (Table 1).21 A comprehensive evaluation of markedly elevated BP includes a thorough history and physical examination. A comprehensive history includes information on chronic hypertension, the patient’s current antihypertensive medications and adherence to the regimen, and ascertainment of any available outpatient BP readings. The physical examination includes a focus on comparing bilateral pulses, auscultating the heart and lungs, and performing a fundoscopic examination. Further diagnostic investigations include a basic metabolic panel, a complete blood count, a chest radiograph, a 12-lead ECG including heart rate, and an assessment of volume status and risk of orthostasis. If the BP reading is confirmed and evidence of new or worsening target-organ damage is present, then the treatment pathway for hypertensive emergency as outlined in the 2017 Hypertension Clinical Practice Guidelines should be promptly initiated.2
