MIA 2012: Levy P et al. Subclinical hypertensive heart disease in black patients with elevated blood pressure in an inner-city emergency department. Ann Emerg Med. 2012 Oct;60(4):467-74.e1.

Bottom Line

In asymptomatic black patients who presented to the ED with elevated blood pressure, subclinical hypertensive heart disease was detected in 9 of every 10 patients.

Why It’s Important for Emergency Medicine

Hypertension contributes more than any other factor to racial differences in cardiovascular disease survival. Hypertension is extremely common in blacks- especially poorly controlled hypertension. For many, their underlying hypertensive heart disease won’t be detected until it is at a very advanced stage. Uncontrolled blood pressure means an increased risk for MI’s, CHF, CKD, stroke, blindness, etc. So knowing that up to 90% of asymptomatic hypertensive individuals are at increased risk over time for death or other adverse events means that we need to be more proactive in up-titrating BP meds in the ED, ensuring outpatient follow-up, and empowering patients by educating them on diet, exercise, smoking cessation, and medication compliance.

Major Points

The majority of patients with subclinical hypertensive heart disease had diastolic dysfunction (89.7%). LVH was also common (61%). Evidence of systolic dysfunction with an EF<50 15.5="15.5" in="in" o:p="o:p" of="of" patients.="patients." seen="seen" was="was">

Design

• Prospective cross-sectional study. 
• Included patients who presented to the ED with BP ≥ 140/90 mm Hg on 2 measurements, 35 years or older, no history of cardiac or renal disease, and were asymptomatic from a cardiovascular perspective (ie, no dyspnea or chest pain). 
• Study cohort was a convenience sample of ED patients obtained Mon-Fri 9 am-4 pm. 
• 200 consented to participate in study; 20 failed to return for echo; 19 had prior documented heart disease; 161 included in final study cohort. 
• Hypertensive heart disease was defined as: LVH, systolic or diastolic dysfunction on echo

Criticisms

This study did not include a control group of normotensive individuals so we don’t know how much of the structural heart disease is due to racial differences alone and how much is due to the effects of uncontrolled hypertension. The specific group studied makes the results unable to be generalized to other populations.

Reviewed by A. Odunmbaku

Reference
Levy P, Ye H, Compton S, Zalenski R, Byrnes T, Flack JM, Welch R. Subclinical hypertensive heart disease in black patients with elevated blood pressure in an inner-city emergency department. Ann Emerg Med. 2012 Oct;60(4):467-74.e1. Pubmed

MIA 2012 = Most Interesting Articles series of 2012