Acute Severe Hypertension has High Morbidity, Mortality, and Readmission Rates: Results from the STAT Registry

CB Granger, J Gore, J Katz, K Kleinschmidt, A Wyman, F Peacock, F Anderson, on behalf of the STAT Investigators. Presented at the European Society of Cardiology Annual Meeting, September 2, 2008. Sponsored by a grant from The Medicines Company to the Center for Outcomes Research, University of Massachusetts Medical School

STAT Steering Committee Albert Einstein College of Medicine Alan S Multz Cleveland Clinic W Frank Peacock Columbia University Stephan A Mayer Duke University Christopher Granger* Eric Peterson Ohio State University Joseph F Dasta Uniformed Services University Andrew F Shorr University of California Alpesh Amin

www.outcomes.org/stat

University of Massachusetts Fred Anderson Joel Gore University of Pennsylvania Charles Pollack University of Southern California Gene Yong Sung University of Texas at Houston James Ferguson Joseph Varon University of Texas Southwestern Kurt Kleinschmidt

Project and data coordinated by and analyzed by Center for Outcomes Research, University of Massachusetts, Worcester, MA *Chair 2

Participating Investigators in STAT (25 US Centers) Sacramento, CA Joseph Varon Phil Levy Richard Nowak John Devlin Jim Froehlich Brian O'Neil Marc Lapoint Kurt Kleinschmidt W Frank Peacock Joel M Gore Charles Pollack Jon Schrock Chandler, AZ Lala Dunbar John Cienki Stephan S Mayer Anthony Gerlach Royal Oak, MI Ann Arbor, MI Detroit, MI (3) Deborah Diercks Cleveland, OH Adam Singer Gene Yong Sung Jason Katz Stony Brook, NY New York, NY Philadelphia, PA Columbus, OH Winston-Salem, NC Worcester MA Durham, NC Namarata Patil David Cline Icima Fergus Brian Tiffany Charleston, SC Boston, MA Dallas, TX New Orleans, LA Houston, TX

www.outcomes.org/stat

Miami, FL

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Background

 Acute severe hypertension is common – occurring in 1-2% of the 72 million US patients with hypertension, and comprising up to 25% of visits in busy urban emergency departments  Contemporary patient features, management and outcomes are not well known  Traditional definitions of who needs intensive therapy have been based on target organ dysfunction www.outcomes.org/stat 4

Goal

Improve understanding of clinical conditions of acute severe hypertension managed in a critical care setting and treated with IV antihypertensive drugs www.outcomes.org/stat 5

Inclusion Criteria

  >18 years of age Presenting to the hospital with acute severe HTN    Treated in a critical care setting Acute severe HTN treated with an IV agent Severe hypertension – At least one SBP >180 mmHg and/or – At least one DBP >110 mmHg  SAH patients with SBP >140 and/or DBP >90 www.outcomes.org/stat 6

Study Population

Patients Age - median (IQR) Female sex Black race White race Qualifying BP (mmHg) Systolic Diastolic LOS - median (IQR) 1,588 58 (49, 70) 49% 56% 34% 200 (186, 220) 110 (93, 123) 5 days (2, 9) www.outcomes.org/stat 7

Patient Demographics

Medical history Hypertension Tobacco or alcohol use Diabetes Chronic kidney disease End stage renal disease Previous hospitalization for HTN Neurological event Drug abuse % 89 38 35 31 11 27 23 15 www.outcomes.org/stat 8

Predisposing Factors Contributing to Hypertensive Event (35%)

Factors Medication non-adherence Chronic Current Missed or incomplete dialysis Anxiety/psychosocial reaction Drug abuse % 25 16 10 3 2 11 www.outcomes.org/stat 10

Primary Admitting Diagnosis Hypertension Subarachnoid hemorrhage MI/ACS Acute heart failure/PE Hemorrhagic stroke Ischemic stroke Renal failure Subdural hematoma Aortic dissection 2% 2% 4% 3% 0%

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8% 7% 10% 11% 10% 20% 27% 30%

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Resource Use

Procedure/care Brain imaging (CT, MRI) Admitted to ICU Echocardiography Arterial line Mechanical ventilation Funduscopic exam % 48 48 45 25 18 13 www.outcomes.org/stat 12

100% Time from Qualifying BP to Initiation of IV Therapy 100.0% 97.0% 88.5% 80% 74.2% 60% 46.6% 40% 20% 0% Within 1 hr Within 3 hrs

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Within 6 hrs Within 12 hrs Within 24 hrs

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First IV Antihypertensive Labetolol Metoprolol Nitroglycerin Hydralazine Nicardapine Sodium nitroprusside 5% 8% Other 0%

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8% 10% 17% 15% 15% 20% 30% 32% 40%

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Number of Different IV Antihypertensives During Hospitalization by First Received One Two Three or more Labetolol (n=501) 32% 42% 25% Metoprolol (n=277) 40% 37% 23% 41% 27% 32% Nitroglycerin (n=241) Hydralazine (n=235) Nicardapine (n=121) Sodium nitroprusside (n=82) 22% 41% 51% 45% 28% 32% Percent of Patients 46% 14% 21%

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-10 0 Median Systolic BP Over 24 h by First IV Antihypertensive Enalaprilat* Labetolol* Nicardipine* Nitroglycerin* Hydralazine* Metoprolol* Sodium Nitroprusside* -20 -30 -40 0 2 4 6 8 10 12 14 16 Time since IV initiation (h)

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18 20 22 24

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STAT Results

    Median time to SBP of <160 mmHg: 4 hrs 60% increased to >180 after initial control 4% had iatrogenic hypotension 29% had recurrent, severe HTN necessitating reinstitution of parenteral therapy  65% had no documentation of follow-up appointment being either scheduled or attended www.outcomes.org/stat 17

Patient Outcomes 50% 40% 30% 37.0% 20% 11.0% 10% 9.3% 6.9% 0% In-hospital death* Admit to 90-day death* 90-day readmission† 90-day readmission due to HTN† *n=1588 (all patients); †n=1415 (all patients alive at discharge and with 90-day follow-up)

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Short-Term (2 to 6 month) Outcomes

Acute Condition ACS 1,2,3 CHF 4 Severe Hypertension 5 Death 5-7% 8.5% 11% Rehospitalization 30% 26% 37% 1. OASIS-5

NEJM

2006 2. GUSTO IIb

NEJM

1996 3. GRACE

JAMA

2007 4. IMPACT-HF

J Cardiac Failure

2004 5. STAT Registry results www.outcomes.org/stat 19

Summary

 Acute severe hypertension – Recurrent condition – Associated with poor medical adherence – Heterogeneous management: ICU admission, drugs used, BP targets – Alarmingly low rates of follow-up – High mortality and morbidity, especially with new or worsening end-organ damage  Major need to improve prevention and treatment of this understudied condition www.outcomes.org/stat 20