Clinico-epidemiological characteristics and survival outcome of patients with hypertensive crisis at Kassala Hospital, Eastern Sudan

Introduction: Hypertensive crisis (HC) is recognized consequence of inadequate blood pressure (BP) control. A hypertensive crisis is further divided into hypertensive emergency (HT-E) and hypertensive urgency (HT-U). Method: Using a cross-sectional hospital-based study design, patients who had been diagnosed as having HC between January and October 2017 were consecutively recruited in the study. The criteria proposed by the Seventh Joint National Committee were used for the defi nition of HC. Result: A total of 81 (.81%) patients newly diagnosed as having HC were enrolled in the study. Of these patients, 50 (61.7 %) patients met criteria for HT-E, while 31 (38.3%) patients had HTU. Renal impairment (16%), stroke (30.8%), acute coronary syndrome (13.6%) and heart failure (22.2%) were predominant complications associated with HT-E. Out of 81 study subjects, 13 (16%) patients died. Although there was no signifi cant difference in residence, history of smoking, Diabetes mellitus and history of alcohol consumption between groups, old age (P=.o22), male gender(.046), history of hypertension(.007), history of non-governmental employee(.003), poor compliance (p=.002) and high case fatality rate (p=.041) were signifi cantly associated with hypertensive emergency (HT-E). Conclusion: This study showed that HT-E has high case fatality rate among patients admitted with hypertensive crisis at kassala teaching Hospital. Therefore early detection of hypertension and appropriate management are the main stay for reducing morbidity and mortality among patients with hypertensive crisis. Research Article Clinico-epidemiological characteristics and survival outcome of patients with hypertensive crisis at Kassala Hospital, Eastern Sudan TajEldin M Abdallah1*, Abdalazeem A Ibrahem2, Ezeldein A Ali3, Elbashir G Ahmed1 and AbdelAziem A Ali4 1Department of Medicine, Faculty of Medicine, University of Kassala, Sudan 2Department of Cardiology, Yesbyty Gwynedd, UK 3Prince Sultan Military City, Riyadh 4Department of Obstetrics and Gynecology, Faculty of Medicine, University of Kassala, Sudan *Address for Correspondence: TajEldin Mohammedein Abdallah, P.O. Box 496, Department of Medicine, Faculty of Medicine, Kassala University, Kassala, Sudan, Tel: +249912820929; Fax: +249411823501; Email: tajeldinmm@yahoo.com Submitted: 22 October 2018 Approved: 30 October 2018 Published: 31 October 2018 Copyright: © 2018 TajEldin M Abdallah, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited


Introduction
Hypertension is a major health problem nationwide that necessitate special emphasis. Hypertension is the third leading cause of death globally, and round seven million people die each year as a result of hypertension. In sub-Saharan Africa the prevalence of hypertension was estimated by 30% among general population. In the Eastern Mediterranean Region, the prevalence of hypertension was reported as 26% [1,2]. The prevalence of Hypertension among non-communicable diseases has been accounted for 23.6 % and 39.6% in central and Northern Sudan respectively [3,4]. Hypertension represents one of the 10 leading causes of death in Sudan and responsible for 1.3% of the outpatients visits [5].
It has been estimated that around 1% of patients with hypertension develop a hypertensive crisis during their lifetime, as consequence of inadequate blood pressure (BP) control. Hypertensive crisis (HC), is de ined as extreme and symptomatic rising in BP (usually ⩾180/120 mm Hg). According to criteria proposed by the Seventh Joint National Committee HC was classi ied into either a hypertensive emergency (HT-E) or hypertensive urgency (HT-U) depending on evidence of target organ damage; HT-E is manifested by rapid worsening of target organs such as heart, brain, kidneys and arteries. HT-U is characterized by severe elevation of the blood pressure without evidence of end organ damage that need to be treated with oral anti-hypertensive drug, in order to reduce the BP within 24 hours [6][7][8].
Although HC is well described worldwide, there is no published data regarding the characteristics of individuals with HC in Sudan. Therefore this study aimed to analyze the clinico-epidemiological pro ile and survival outcome among patients presenting to kassala teaching Hospital with HC.

Methods
A total of 81 Patients aged ⩾18 years having been admitted to the outpatient clinic at kassala teaching hospital during January and through October 2017 with features suggestive of HC were enrolled in this study. The criteria proposed by the Seventh Joint National Committee were adopted for the de inition of HC [7].

Defi nitions
Hypertensive emergency : HEs are characterized by severe elevations in the Blood Pressure complicated by evidence of progressive Target organ damage (TOD), such as (hypertensive encephalopathy, hemorrhagic and ischemic strokes, acute myocardial infarction, acute left ventricular failure with pulmonary edema, unstable angina, dissecting aortic aneurysm and acute or chronic renal insuf iciency).
Hypertensive Urgency: HT-Us are those conditions associated with severe elevations in BP without evidence of end organ damage.
Hypertensive pseudocrisis: Hypertensive pseudocrisis is a condition characterized by transient elevation in BP due to any stressful event, such as migraine, vertigo, also may be a manifestation of panic disorder [7].
Detailed history was taken and proper physical examination was performed at the time of admission after signing an informed consent previously approved by the ethics research committee, kassala state. In the absence of circumstances that acceptable for signing, participation was authorized by the parents or guardians.
Diagnostic tests such as (blood for chemistry, urine analysis, lipid pro ile, ECG, chest X ray). Troponin was performed when acute coronary syndrome was suspected, and Brain computed tomography was done when brain damage suspected. BP was measured using standard technique as recommended, in lying down as well as in standing position and average of three BP measurements obtained with a mercury sphygmomanometer and conducted by trained medical of icer [9].

Exclusion criteria
This study excluded, hypertensive patients with pseudocrisis and those with BP <180\120 mm Hg. female patients presenting with preeclampsia and eclampsia, patients and patients <18 years of age.

Ethics
The study was conducted in con irmation of the national and international ethical guidelines for scienti ic research involving human beings (declaration of Helsinki) [10]. Ethical clearance of this study is obtained from the Research ethics committee at the ministry of health kassala state. Informed written consent was taken from the study subjects. The patients were managed according to the hospitals protocol for hypertension. It was clearly explained to the patients that refusing participation in the study will not affect their care and management.

Stistical analysis
Data was enter into computer data base using SPSS version 16, student t-test and chi-square test were used to compare between mean and proportions respectively, P< 0.05 was considered signi icant.

Results
From January to October 2017, 9900 Patients admitted to the emergency room at kassala teaching hospital. Of them 81(.81%) patients met criteria for hypertensive crisis and enrolled in this study. Their age ranging between 28 to 85 years and the mean age ±SD was 58± (12.7). Of these, 50 (61.7 %) patients were diagnosed as having HT- Among 50 patients who presented with features suggestive of HT-E during the study period, (Figure 1), 18(22.2%) patients had heart failure, 11(13.6%) patients had acute coronary syndrome , stroke was detected in 25(30.8% ) patients, of them 18(22.2%) patients had hemorrhagic stroke while 7(8.6%) patients had ischemic stroke, 13(16% )patients were identi ied to have renal failure, retinopathy was noticed in 9(11.1%) and only 2(2.5% ) patients presented with features suggestive of hypertensive encephalopathy.
History of smoking was found in19 (23.5%) patients, history of hypertension in 36 (44.4%) patients and history of DM was observed in 9(11.1%) patients. HC hypertensive crisis, SBP is systolic blood pressure on admission to Emergency room; DBP is diastolic blood pressure on admission to Emergency room. HT-E hypertensive Emergency and HTU is the hypertensive urgency. Concerning the outcomes 68(84.0 %) patients discharge home while 13(16.0 %) patients died and causes of death were (stroke (9.9%) patients, ACS (2.5%) patients, renal failure (3.7%) patients).

Discussion
The main indings of this study was that the prevalence of hypertensive crisis among patients admitted to the medical emergency room at kassala teaching hospital was .81%, which is comparable to other study conducted by Carrillo et al., who reported a prevalence of HC of 0.6% among patients brought to the clinical emergency department in a Spanish university-af iliated hospital [11]. However it is inconsistent with the studies from Italy, Brazil, Bosnia and Pakistan where estimated prevalence of HC was reported as 3%,16%,47.2%and 56% respectively [1,[12][13][14]. The difference in the prevalence rate of HC between the later studies and our result may be justi ied by inclusion of hypertensive pseudocrisis which may mimic hypertensive urgency, which may alter the inal results of the study. AS confusion may occur in differentiating HT-U from hypertensive pseudocrisis, AS Nobre et al., have reported that 64.5% of hypertensive patients, with typical clinical manifestations of hypertensive pseudocrisis, were diagnosed incorrectly in the emergency room as having a hypertensive crisis [15].
The current study showed high prevalence of hypertensive emergency than hypertensive urgency, with approximately 2/3 of the cases corresponding to hypertensive emergency, these indings in keeping with study conducted by Manjhvar, et al. who reported hypertensive emergencies and hypertensive Urgencies as (72%) and (28%) respectively. By contrast other investigators reported high prevalence of hypertensive Urgencies [16,17].
Reasons for greater prevalence of patients with hypertensive emergency in this setting may be attributed to many reasons, like Lack of awareness about control of hypertension, poor compliance to antihypertensive drugs and inability of the poor people to have an access for healthcare may be implicated also.
Similar to other study, We found that patients with hypertensive emergencies were older, 61.9 ±( 11.8),P ≤.001 than those with HT-U. Likewise the current study demonstrated that, History of hypertension p.007, history of poor compliance to antihypertensive drugs p .001 and nongovernmental employee p.003 were signi icantly associated with HT-E [18,19].
In compare to other previously published studies, our data showed that Women had a higher frequency of hypertensive crises than men, particularly for hypertensive urgencies, this observation may be explained by greater number of women in the hypertensive population in general, also women are more sensitive of their clinical 22  status and more frequently seek health care [18][19][20][21]. On the other hand the current study revealed that men were signi icantly associated with HT-E; this fact may be attributed to the differences noted in the hemodynamic status between women and men, as women, until menopause, have lower peripheral vascular resistance, hence, they have lower blood pressure levels than men at the same age. Similarly Martin et al., in his study reported high prevalence of hypertensive emergency among male [17,22].
In comparison with the study by Vilela et al., in Brazil, The present study showed that, among hypertensive emergencies, cerebrovascular accidents were the most frequent, and, among these, hemorrhagic stroke was the most common, followed by ischemic stroke, left ventricular failure, acute coronary syndrome and renal failure [23].
Regarding the clinical manifestations and according to the clinical presentation of HC the present study demonstrated that in order of frequency the clinical symptoms were headache, dizziness, neurological de icits, and dyspnea and chest pain. Such indings are in agreement with the results of many previous studies [15,24,25]. The greater case fatality rate shown in this study was comparable to that reported by many other studies [26][27][28].
Limitations; Firstly the sample size was small and taken from a single-tertiary care hospital, hence it represents people visiting this hospital, and not representative of the whole inhabitants.
Secondly many other risk factors like sedentary lifestyle, obesity were not considered in this study, therefore large samples size study is needed.
Thirdly retinopathy dif icult to be assessed in considerable numbers of patient's particularly very thick patients and those losing their consciousness.

Conclusion
This study showed that HT-E has high case fatality rate among patients admitted with hypertensive crisis at kassala teaching Hospital. Therefore many efforts should be directed towards early detection and appropriate management of hypertension so as to reduce morbidity and mortality among patients with hypertensive crisis.