Outcomes of Patients with Hypertensive Emergency Managed in Intensive versus Intermediate Care Settings: A Multi-hospital Retrospective Cohort Study

Abstract Background Hypertensive emergency is characterized by end-organ dysfunction due to markedly elevated blood pressure. Though guidelines recommend rapid blood pressure lowering with intravenous anti-hypertensives and continuous monitoring in an intensive care unit (ICU), many patients are managed in intermediate care (IMC) settings. In this study, we compare outcomes of hypertensive emergency patients admitted to ICU versus IMC settings. Methods Adult patients in the emergency departments of three hospitals were included if they had ≥2 systolic blood pressure measurements 180 mmHg within 12-hours of one another, were treated with continuous intravenous anti-hypertensive medications, and were subsequently admitted to an ICU or IMC setting. We excluded patients receiving mechanical ventilation in the ED and those presenting with acute coronary syndrome, aortic dissection, or acute cerebrovascular accident. The primary outcome was hospital length of stay (LOS) penalized for death and adjusted for baseline patient features. Secondary outcomes included ICU and IMC LOS, and hospital mortality. Process outcomes included arterial line usage, frequency of blood pressure measurements in the first 24 hours, and escalations of care. Lastly, we report the proportion of patients reaching blood pressure targets and/or episodes of hypotension in each setting. Results ICU patients (n = 649) were younger with a male predominance, and more frequently received non-invasive respiratory support or were dialysis dependent than IMC patients (n = 629). In an adjusted analysis there was no difference in time to hospital discharge between patients admitted to ICU versus IMC settings (absolute difference: +0.29 days 95%CI: -0.07, 0.70). Similarly, there was no difference in ICU versus IMC LOS, hospital readmission rate, or hospital mortality. Blood pressures were more frequently measured in the ICU, but there was no difference in time to target blood pressure goal. Any hypotensive episode in the first 24 hours was more common in the ICU. Conclusions In this retrospective observational study of patients with hypertensive emergency, we did not observe significantly different LOS outcomes between patients admitted to ICU versus IMC settings, nor did we detect a signal of harm among those admitted to IMC. IMC settings may be a reasonable alternative to ICU admission for select patients with hypertensive emergency.