Hypertension-related CVD Most Common ED Presentation in the US

Essential hypertension was the most common reason for visits to an emergency department (ED) among women and the second most common for men according to a study of more than 20 million ED visits published in the Journal of the American Heart Association.

Overall, according to investigators, 13% of all cardiovascular (CV)-related diagnoses in the ED, representing more than 2.7 million individuals, were for essential hypertension.

Of the 15 CVD conditions detailed in the study, approximately 30% were hypertension-related diagnoses.

“These presentations rarely resulted in inpatient admission (<3%), and there were few associated deaths—less than 0.1%, suggesting that these visits mostly related to routine management of uncomplicated hypertension,” wrote authors, led by Mamas A. Mamas, MD, a professor of cardiology at Keele University in Stoke-on-Trent, and a consultant cardiologist at University Hospitals of North Midlands NHS Trust, both in the UK.

“The use of the ED in this context is likely a reflection of limited access to more appropriate primary care services within the US health care system,” they added.

“These presentations rarely resulted in inpatient admission (<3%), and there were few associated deaths—less than 0.1%, suggesting that these visits mostly related to routine management of uncomplicated hypertension...The use of the ED in this context is likely a reflection of limited access to more appropriate primary care services within the US health care system.”

The difference between men and women in the leading cause for CV-related ED visits also reflects the study’s wider findings on sex differences in ED presentation and likelihood of subsequent hospital admission and death.

Nationally representative sample

Mamas and colleagues studied ED encounters in adults with a primary CVD diagnosis from the Nationwide Emergency Department Sample (NEDS) between 2016 and 2018, including >20.6 million nationally representative ED encounters in the United States. They first grouped CVD into 15 diagnostic categories, evaluating men and women separately. Further analysis was of sex differences in 2 key clinical outcomes of hospitalization and death separately for each CVD category, while adjusting for baseline sociodemographic and clinical factors.

The sample included 48.7% women and median age was 67 years (men 64 years, women 69 years). Baseline comorbidity burden was greater among men than women although rates of obesity, hypertension, and cerebrovascular disease were higher among women, according to the study.

Looking at sex differences in initial presentation the researchers report that the most common ED encounters for women were essential hypertension (16.0%), hypertensive heart or kidney disease (14.1%), and atrial fibrillation/flutter (10.2%). The most common encounters for men were hypertensive heart or kidney disease (14.7%), essential hypertension (10.8%), and acute myocardial infarction (10.7%).

Significant differences between sexes

Overall, the authors write, women were more likely to present with essential hypertension, hypertensive crisis, atrial fibrillation/flutter, supraventricular tachycardia, pulmonary embolism, or ischemic stroke. Men were more likely to present with acute myocardial infarction or cardiac arrest.

In analyses using logistic regression models adjusted for baseline covariates, compared with men, women with intracranial hemorrhage (ICH) had higher risk of hospitalization and death than men with the bleed. Women presenting with pulmonary embolism or deep vein thrombosis were less likely to be hospitalized. Women with aortic aneurysm/dissection had higher odds of hospitalization and death. The odds of mortality were higher for men than women following presentations with hypertensive heart or kidney disease, heart failure, atrial fibrillation/flutter, acute myocardial infarction, or cardiac arrest.

Women were less likely than men to present with late‐stage end‐organ consequences of hypertension: specifically, hypertensive heart or kidney disease, which required hospitalization in over three-quarters of cases.

More high-quality data needed

The authors in a lengthy discussion suggest potential reasons for and offer evidence in support of the observed sex differences in the distribution of CVD presentations to the ED, hospitalization rates, and risk of death. “Our study contributes an important step toward describing, from an epidemiologic perspective, sex differences in emergency cardiovascular encounters and outcomes.”

They call for additional high-quality data to help better characterize specifics “driving differences in the CV health care experiences of men and women.”

They suggest also that their findings “may be useful to inform planning and provision of health care services.”

Among the study’s limitations Mamas et al note the use of ICD-10 codes which introduce potential for coding and misclassification errors and also point out that their analysis would not have accounted for incorrect labeling in the ED of patients with non-CVD diagnosis.

“We did not track deaths outside of the hospital setting,” added the team. “Given past evidence that women are more likely to be inappropriately discharged from the emergency department, and strong evidence for the systemic undertreatment of women, further study is warranted to track outcomes beyond the emergency department visit.”

Reference: Raisi-Estabragh Z, Kobo O, Elbadawi A, et al. Differential patterns and outcomes of 20.6 million cardiovascular emergency department encounters for men and women in the United States. J Am Heart Assoc. 2022;0:e026432 doi:10.1161/JAHA.122.026432