Hypertensive crisis is defined as systolic pressure higher than 180 mmHg or diastolic pressure higher than 120 mmHg and can be the first manifestation of arterial hypertension. In a hypertensive emergency there is evidence of organ damage in addition to severe blood pressure elevation, while in hypertensive urgency there is no organ damage. Patients with hypertensive crisis require thorough clinical assessment to exclude secondary causes of arterial hypertension. Pulse wave velocity is the measure of arterial stiffness which is directly connected to cardiovascular risk and hypertension-mediated organ damage. The aim of this study was to show the measurement of arterial stiffness in an emergency room setting as a noninvasive method of assessing cardiovascular risk in patients with hypertensive urgency. Arterial stiffness was measured for all patients with a noninvasive method using the Agedio B900 device operating on the principle of oscillometry. This study showed that the patients presenting to the Emergency Room with hypertensive urgency had higher pulse wave velocity values when compared with the reference range and to patients with resistant hypertension. Noninvasive measurement of arterial stiffness is a novel method in the diagnostic algorithm for patients with hypertensive crisis.
Hipertenzivna se kriza definira kao vrijednost sistoličkoga tlaka višeg od 180 mmHg ili dijastoličkog tlaka višeg od 120 mmHg te može biti prva manifestacija arterijske hipertenzije. U hipertenzivnoj su emergenciji, uz ozbiljno povišenje arterijskoga tlaka, također primjetni i dokazi da je prisutno oštećenje organa, dok u hipertenzivnoj urgenciji nema oštećenja organa. Bolesnici s hipertenzivnom krizom trebaju temeljitu kliničku procjenu kako bi se isključili sekundarni uzroci arterijske hipertenzije. Brzina pulsnog vala mjera je krutosti žila, koja je izravno povezana s kardiovaskularnim rizikom i oštećenjima organa uzrokovanih hipertenzijom. Svrha je ovog istraživanja bila prikazati mjerenje krutosti žila u hitnoj službi kao neinvazivnu metodu procjene kardiovaskularnog rizika u bolesnika s hipertenzivnom urgencijom. Krutost žila izmjerena je u svih bolesnika s pomoću neinvazivne metode primjenom uređaja Agedio B900, koji djeluje na principu oscilometrije. Ovo je istraživanje pokazalo da su bolesnici primljeni u hitnu službu s hipertenzivnom urgencijom imali više vrijednosti brzine pulsnog vala u usporedbi s referentnim rasponom i onima s rezistentnom hipertenzijom.
Arterial hypertension is one of the main risk factors for morbidity and mortality worldwide. (
Hypertensive crisis is defined by systolic blood pressure values over 180 mmHg or diastolic blood pressure values higher than 120 mmHg. It can develop de novo or as a complication of existing primary or secondary arterial hypertension. Hypertensive crisis can be divided into hypertensive urgency (HU) and hypertensive emergency (HE) regarding target organ damage. Hypertensive emergency includes damage to the cardiovascular, renal, and/or cerebrovascular system in addition to high blood pressure values. In hypertensive urgency, end organ damage is not present.
The exact mechanism of hypertensive crisis is unknown. It is believed that the sudden elevation in blood pressure in hypertensive crisis comes from a sudden increase of systemic vascular pressure, which is connected to the action of humoral vasoconstrictors leading to intimal proliferation and fibrinoid necrosis of the blood vessel wall. (
According to the ESC (European Society of Cardiology) and ESH (European Society of Hypertension) guidelines from 2018, arterial stiffness is recognized as a risk factor for development of hypertension-mediated organ damage (HMOD) with a pulse wave velocity (PWV) >10 m/s. (
Today’s hypertension guidelines suggest PWV measurement in order to determine the best candidates for renal denervation procedures. Pulse wave velocity is a predictor of total cardiovascular mortality, which associates PWV with diminished response on renal denervation procedure. (
The aim of this study was to evaluate the measurement of pulse wave velocity in the emergency room as a noninvasive method of assessing cardiovascular risk in patients with hypertensive urgency.
This study included 23 patients who presented to the emergency room of the Clinic for Internal Diseases of the University Hospital “Merkur” in Zagreb over the course of 3 inconsecutive months in 2018/2019, who were included in a study of diagnosing hypertensive emergency approved by the Ethics Committee of the University Hospital “Merkur”. Patients whose pulse wave velocity was measured had hypertensive urgency. The study included patients with newly diagnosed hypertension and HU, patients with earlier diagnosed hypertension and HU, and patients with resistant hypertension and HU. After being admitted to the emergency room, three consecutive measurements of blood pressure were performed for all patients and oral antihypertensive therapy was given. Most patients were given 30 or 60 mg of urapidil or a fixed combination of oral antihypertensives (ACE inhibitor + calcium channel blocker). After the patients were informed about participating in a clinical study and gave their informed consent, pulse wave velocity was measured.
The device used for measuring pulse wave velocity was the Agedio B900 Pulse Wave Analysis System (Germany). The device works on the principle of oscillometry. It includes a cuff, which comes in three different sizes – small, medium, and large, depending on the size of the arm which is measured in advance, the measuring device itself, and an Apple iPad with a software that shows the results. It allows for brachial blood pressure and arterial stiffness to be measured in a single procedure. Arterial stiffness is quantified as PWV and expressed in m/s. (
Arithmetic mean and standard deviation were used to present the data which followed normal distribution, and median value was used for the rest. The data were analyzed using parametric and nonparametric tests (Student’s t-test, Mann-Whitney U test). Pearson’s correlation coefficient was calculated to determine correlation. The program used for statistical analysis was MS Excel.
Average age of patients was 64.0±10.76 years. 61.87% were women (14 patients) and 39.13% were men (9 patients). Female patients were older than male patients (F 67.00±10.52 years, M 59.33±9.92 years, p=0.05).
The most common signs and symptoms the patients presented with were headache (30%), epistaxis (18%), chest pain (17%), dyspnea (15%), psychomotor agitation (10%), cardiac arrhythmias (6%), and paresthesia (4%).
Average brachial systolic blood pressure was 190.87±9.61 mmHg, i.e. higher than 180 mmHg, which is a criterion for hypertensive crisis. Average brachial diastolic pressure was 108.91±16.23 mmHg. Average central systolic blood pressure was 155.34±19.61 mmHg, and average central diastolic blood pressure was 102.86±17.14 mmHg (
| 1 | 61 | 182 | 74 | 134 | 77 | 9.6 | 9 | M |
| 2 | 56 | 182 | 95 | 159 | 101 | 9.4 | 9 | M |
| 3 | 58 | 195 | 105 | 153 | 110 | 9.3 | 9 | M |
| 4 | 68 | 200 | 120 | 154 | 108 | 11.0 | 9 | M |
| 5 | 48 | 180 | 130 | 153 | 122 | 8.1 | 9 | M |
| 6 | 53 | 212 | 130 | 140 | 112 | 8.5 | 8 | M |
| 7 | 48 | 192 | 136 | 156 | 122 | 8.2 | 9 | M |
| 8 | 63 | 180 | 90 | 152 | 80 | 10.3 | 9 | F |
| 9 | 73 | 186 | 92 | 156 | 94 | 11.9 | 9 | F |
| 10 | 82 | 203 | 96 | 181 | 102 | 15.0 | 9 | F |
| 11 | 75 | 180 | 100 | 146 | 100 | 11.8 | 9 | F |
| 12 | 77 | 180 | 100 | 130 | 67 | 12.4 | 9 | F |
| 13 | 69 | 190 | 100 | 141 | 85 | 10.7 | 8 | F |
| 14 | 53 | 190 | 110 | 114 | 81 | 7.3 | 0 | F |
| 15 | 61 | 201 | 115 | 120 | 94 | 10.0 | 3 | F |
| 16 | 66 | 212 | 121 | 188 | 128 | 12.1 | 9 | F |
| 17 | 77 | 185 | 129 | 160 | 104 | 12.9 | 9 | F |
| 18 | 51 | 197 | 126 | 179 | 127 | 9.6 | 7 | F |
| 19 | 63 | 187 | 110 | 169 | 113 | 10.9 | 8 | M |
| 20 | 76 | 188 | 108 | 166 | 111 | 12.9 | 9 | F |
| 21 | 66 | 192 | 86 | 185 | 91 | 11.8 | 8 | F |
| 22 | 49 | 185 | 122 | 167 | 126 | 8.9 | 5 | F |
| 23 | 79 | 191 | 110 | 170 | 111 | 13.7 | 9 | M |
| BBP – brachial blood pressure, CBP- central blood pressure, sys. - systolic, dias. – diastolic. | ||||||||
Values of PWV were higher than reference values for their age in all patients, averaging at 10.71±1.96 m/s. Student’s t-test showed a statistically significant difference between PWV measured in men and women (M 9.85±1.78, F 11.26±1.94; p=0.05). Other values that were measured did not show statistically significant difference. The median value of increased vascular age compared with biological age of patients was 7.91±2.27 years. PWV values show positive correlation with age (r=0.9461, p<0.0001). Central systolic blood pressure showed a weak positive correlation with PWV (r=0.4659, p=0.025). Other compared variables showed no statistically significant correlation.
The primary factor affecting the stiffness of the arterial wall is aging, which was also confirmed by the results of this study. Difference in pulse wave velocity between men and women in this study can therefore be explained by the higher age at which women present with hypertensive urgency. Average values of PWV measured in this pilot study were higher than 10 m/s, which is a borderline value for HMOD. (
Patients presenting to the emergency room with hypertensive urgency have elevated values of PWV compared with reference values and compared with patients with resistant hypertension. Although hypertensive urgency does not imply target organ damage, patients have increased cardiovascular risk, which is directly connected to PWV. Additional research is required on the long-term predictive value of PWV measured during hypertensive crisis.