Cardiac Complications of Hypertensive Emergency

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This entry is adapted from the peer-reviewed paper 10.3390/jcdd9080276

While mortality in patients with hypertensive emergency has significantly improved over the past decades, the incidence and complications associated with acute hypertension-mediated organ damage have not followed a similar trend. Hypertensive emergency is characterized by an abrupt surge in blood pressure, mostly occurring in people with pre-existing hypertension to result in acute hypertension-mediated organ damage. Acute hypertension-mediated organ damage commonly affects the cardiovascular system, and present as acute heart failure, myocardial infarction, and less commonly, acute aortic syndrome. Elevated cardiac troponin with or without myocardial infarction is one of the major determinants of outcome in hypertensive emergency.

hypertensive emergency epidemiology pathophysiology cardiac acute hypertension-mediated organ damage myocardial injury diagnosis classifications

1. Introduction

Systemic hypertension is the most prevalent non-communicable disease and remains the leading preventable cause of premature death globally, accounting for more than 50% of cases of myocardial infarction, heart failure, and stroke ^[1]. Since 1990, the number of people living with systemic hypertension has doubled across the world, with low- and middle-income-countries (LMICs) accounting for most of this increase. Globally, there were roughly 1.4 billion people with systemic hypertension in 2010, and this is projected to exceed 1.6 billion by the year 2025 ^[2]. Approximately 1.04 billion (75%) of the global population of people with hypertension reside in LMICS ^[2]. South Africa has a hypertension prevalence of 35% and has the highest burden of uncontrolled hypertension amongst countries of sub-Saharan Africa ^[3]

The most common acute complication of systemic hypertension leading to emergency room visits is hypertensive emergency. Hypertensive emergencies represent a heterogenous group of disorders characterized by (1) acute severe blood pressure (BP) elevation, often ≥180/120 mmHg, (2) acute hypertension-mediated organ damage, and (3) the need for a prompt but contextual, system-specific lowering of the BP to avert catastrophic outcomes ^[4]. The organs commonly affected by acute hypertension-mediated organ damage include the heart and aorta, brain, kidneys, and retina. Concurrent occurrence of acute hypertension-mediated organ damage in multiple organs has been demonstrated, suggesting a common pathophysiologic mechanism across vascular beds ^[5]. Patients with severe BP elevation without evidence of acute hypertension-mediated organ damage are categorized as having hypertensive urgency, and this, along with hypertensive emergency, constitutes the syndrome of hypertensive crisis. However, the European Society of Cardiology (ESC) Council on hypertension recently proposed replacing the term hypertensive urgency with “uncontrolled hypertension”, therefore rendering the umbrella term hypertensive crisis (hitherto used to describe hypertensive emergency and hypertensive urgency) unnecessary ^[4].

Cardiac complications are the most prevalent acute hypertension-mediated organ damage in hypertensive emergencies. The three major cardiac acute hypertension-mediated organ damage syndromes include acute heart failure/cardiogenic pulmonary oedema, acute coronary syndrome (ACS), and less commonly, acute aortic syndrome (primarily acute aortic dissection) ^[6]^[7]^[8]^[9]. Mortality in hypertensive emergency is substantially elevated, especially among patients admitted into coronary care units when compared to patients without hypertensive emergencies ^[10]. One of the prognostic factors for major adverse cardiac events (MACE) and cerebrovascular events in patients with hypertensive emergency is raised cardiac troponin levels, with or without proven ACS ^[11]^[12].

2. Epidemiology

Although the availability of effective and well-tolerated antihypertensive medications has significantly improved outcomes in patients with hypertensive emergencies, the incidence remains unchanged ^[13]^[14]. An estimated 2–3% of hypertensive patients will develop hypertensive emergency in their lifetime ^[15]^[16]. Data on gender differences in patients with hypertensive emergency have been inconsistent, with some studies showing a predominance of males ^[7]^[8]^[17]^[18], and others showing comparable prevalence in males and females ^[6]^[15]^[19]. Similarly, reports of age distribution compared with patients having acute severe hypertension without acute hypertension-mediated organ damage has been contradictory ^[9].

Studies report a varying prevalence of cardiac acute hypertension-mediated organ damage, depending on demographics and comorbidities, among others; however, cardiac involvement predominates in most of the studies, with a cumulative prevalence ranging from 3.6 to 91% (Table 1). Reasons for this marked variation in prevalence include: (1) selection bias due to preferential referrals to specialized centers; (2) variation in the exclusion criteria applied; (3) selective use of cardiac troponin assays resulting in underdiagnosis of atypical cases of myocardial infarction; (4) the non-inclusion of patients managed at primary and secondary care levels without referral to tertiary centers where most of the studies were carried out. A recent systematic review reported a composite prevalence of 52% for cardiac involvement in patients with hypertensive emergencies ^[9]. Epidemiology of the different cardiac acute hypertension-mediated organ damage is further discussed in the section for specific cardiac complications of hypertensive emergency.

Table 1. Prevalence of cardiac acute hypertension-mediated organ damage in hypertensive emergencies.

Author, Year, Country	Design	AHF (%)	AMI (%)	AAS (%)	Cumulative (%)	NIMI (%)	Comments
Fragoulis ^[6], 2021, Greece	Prospective	58	22.6	2	82.6	NR	National cardiac referral centre registry data. Potential for bias towards cardiac complications.
Rubin ^[18], 2019, France	Prospective	31	NR	NR	31%	63	Excluded myocardial infarction from their cohorts and 63% had elevated troponin while 83% had left ventricular hypertrophy.
Zampaglione ^[15], 1996, Italy	Prospective	36.8	12	2	50.8	NR	Cerebral infarction was the most common acute hypertension-mediated organ damage. However, composite of cardiac complications occurred in 50.8%.
Kim ^[12], 2022, Korea	CS	NR	40.5	NR	40.5	60.4	Focused on prognostic role of cardiac troponin in acute severe hypertension. Elevated (occurred in 41.6%) and detectable (occurred in 36.5%) cardiac troponin associated with higher mortality at 3 years.
Guiga ^[20], 2017, France	CS	37.4	13.8	1.8	53	NR	Reported higher mortality in hypertensive emergency than hypertensive urgency (12.5 vs. 1.8%).
Salvetti ^[8], 2021, Italy 2008 data 2015 data	Prospective	34 37.5	25 25	1 0.5	60 63	NR NR	Excluded resuscitated cardiac arrest and patients requiring urgent cardiac catheterization.
Pacheco ^[7], 2103, Mexico	Prospective	25.2	59.5	6.3	91	NR	Their cohorts composed of a high-risk group admitted into coronary care unit. Reported high rate of acute coronary syndrome and acute aortic syndrome.
Martin ^[17], 2004, Brazil	Retrospective	25	13	0	33	NR	Reported unstable angina (5%) separately from myocardial infarction (8%).
Vilela-Martin ^[21], 2011, Brazil	CS	30.7	25.1	3.5	47.2	NR	Reported unstable angina (12.1%) separately from myocardial infarction (13%).
Nkoke ^[19], 2020, Cameroon	CS	44.6	3.6	0	48.2	NR	Myocardial infarction occurred in 3.6% of their cohorts. Low rate of detection of myocardial infarction may be related to lack of facilities including low rates of ECG and cardiac troponin assay.
Acosta ^[22], 2020, USA	Retrospective	NR	1	0	1	15	Assessed acute myocardial injury using serial cardiac troponin assay. Excluded acute coronary syndrome from their cohorts.
Pattanshetty ^[23], 2012, USA	Retrospective	20.5	11.7	2.3	34.5	NR	Obstructive coronary artery disease present in 76.5% of their cohorts with elevated cardiac troponin that had angiogram.

AAS, acute aortic syndrome; AHF, acute heart failure; AMI, acute myocardial infarction; CS, cross-sectional; NIMI, non-ischemic myocardial injury; NR, not reported; USA, United State of America.

3. Pathophysiology

The exact pathophysiologic mechanisms of hypertensive emergency remain incompletely understood. However, a sudden rise in BP serves as a common denominator underlying the various forms of acute hypertension-mediated organ damage, and most hypertensive emergencies occur in people with pre-existing hypertension ^[4]. Although triggers for the surge in BP are also not clearly understood, nonadherence to antihypertensive medications, stress, and increased salt intake have been identified as major risk factors ^[6]. Three intrinsically interwoven processes operating in concert play an important role in the pathophysiology. These include the failure of vascular autoregulation, endothelial dysfunction, and activation of the renin angiotensin aldosterone system (RAAS).

The principal function of vascular autoregulation is to ensure uninterrupted blood flow to vital organs during fluctuations in BP and perfusion pressure, and this is accomplished via the appropriate modification of the peripheral vascular resistance (PVR) ^[24]^[25]. Vascular resistance is constantly modified by metabolic, myogenic, and endothelial modulators acting in concert ^[26]. During increased BP and perfusion pressure, vascular resistance increases to mitigate hyper perfusion-induced organ injury, while in the face of hypotension and reduced perfusion pressure, vasodilation results in reduced vascular resistance to maintain flow to vital organs. In hypertensive emergency, a surge in BP and increased intravascular shear stress results in the disruption of vascular autoregulation and endothelial damage. This causes increased vascular permeability, perivascular oedema, exposure of subendothelial contents to circulating blood, and thrombogenesis ^[27]. The ensuing microvascular damage and thrombotic occlusion results in hemolysis, hypoperfusion, release of cytokines and proinflammatory molecules, ischemia, and activation of the RAAS ^[27]^[28].

Heightened activation of the RAAS and increased levels of angiotensin II is nearly ubiquitous in patients with hypertensive emergency and correlates with the extent of microvascular damage ^[28]. Angiotensin II is a potent mediator of vasoconstriction, inflammation, endothelial dysfunction, remodeling, and vascular fibrosis, and stimulates the secretion of aldosterone ^[29]. In addition to its principal role of volume expansion and BP maintenance, aldosterone causes cardiovascular and renal inflammation, fibrosis, and remodeling ^[30]. Recent studies demonstrated the expression of mineralocorticoid receptors in endothelial and vascular smooth muscle cells, resulting in aldosterone-induced vascular inflammation, fibrosis, and remodeling, as well as vascular smooth muscle cell hypertrophy and proliferation ^[31]^[32]^[33]. RAAS also exerts stimulatory effects on the cerebral sympathetic nervous system and potentiates the release of norepinephrine ^[34]. Increased levels of norepinephrine are associated with natriuresis, volume contraction, and the activation of RAAS, thus, establishing a vicious cycle.

Fibrinoid necrosis of small muscular arteries and arterioles, characterized by medial smooth muscle cell necrosis and the focal deposition of proteinaceous material occurs in malignant hypertension, a form of hypertensive emergency ^[35]. This is succeeded by proliferative endarteritis, characterized by intimal thickening, hyperplasia of the intimal fibroblasts, generation of collagen fibers, and atrophy of the media. Fibrinoid necrosis and proliferative endarteritis are considered the histological hallmark (but not pathognomonic) of malignant hypertension, and both may result in impaired perfusion and ischemia ^[35]. These changes have been demonstrated in various organs including the kidney, brain, intestine, and pancreas ^[36]. In one proof-of-concept study, the intravenous injection of angiotensin II in an experimental model of hypertension resulted in increased endothelial permeability and necrosis of cardiac myocytes and intramyocardial arterioles, with sparing of the epicardial coronary arteries ^[37].

The constellation of pathophysiologic events described above does not occur in any preferential order, but rather, evolves concurrently in a variety of sequences with overlaps and widespread involvement of the vascular beds across various organs. The combined effects of autoregulatory failure, endothelial dysfunction and RAAS activation establishes a vicious cycle of BP elevation and progressively worsening acute hypertension-mediated organ damage. A summary of the pathophysiological mechanisms is presented in Figure 1.

Figure 1. Summary of the pathophysiologic processes in acute hypertension-mediated organ injury. ACS; acute coronary syndrome; AKI, acute kidney injury; aHMOD, acute hypertension-mediated organ damage; BP, blood pressure; HELLP, hemolysis, elevated liver enzymes, low platelets; NSAID, nonsteroidal anti-inflammatory drug; PRES, posterior reversible encephalopathy syndrome; RAAS, renin–angiotensin–aldosterone system; TMA, thrombotic microangiopathy; VSMC, vascular smooth muscle cell; * Not listed as acute hypertensive target organ damage in guidelines; † presence of retinal exudates, hemorrhage ± papilledema.

4. Specific Cardiac Complications of Hypertensive Emergency

The different cardiac complications of hypertensive emergency are presented in Table 2.

Table 2. Cardiac complications of hypertensive emergency.

Acute hypertension mediated-organ damage

Acute heart failure/acute pulmonary edema *

Acute coronary syndrome *

ST-elevation myocardial infarction

Non-ST-elevation myocardial infarction

Unstable angina

Acute aortic syndrome

Acute aortic dissection *

Intramural hemorrhage/hematoma

Penetrating atherosclerotic aortic ulcer

Aortic aneurysm

Aortic rupture

Sub-clinical cardiac target organ injury ^§

Acute myocardial injury

* Commonly reported cardiac complications; ^§ Not included as a complication in guidelines.

5. Challenges in Evaluation, Classifications, and Treatment of Cardiac Complications of Hypertensive Emergencies

5.1. Sub-Clinical Acute Target Organ Damage

Based on current guidelines, the measurement of cardiac troponin in patients with hypertensive emergency is recommended only when there are symptoms/features of myocardial ischemia. Asymptomatic/sub-clinical myocardial injury occurs in more than one-third of patients with hypertensive emergency ^[13] and there is evidence for an increased risk of MACE and poor renal outcome in patients with myocardial injury ^[38]. Notwithstanding, current guidelines on the evaluation of hypertensive emergency do not include assessment of subclinical acute target organ damage/dysfunction. The selective use of cardiac troponin assays can result in missed and mis-diagnoses of atypical acute myocardial infarction (including silent myocardial infarction), and subclinical myocardial injury.

5.2. Nomenclature and Classification

The nomenclature and classification of cardiac complications of hypertensive have not been consistent. Many studies used acute heart failure and acute pulmonary oedema (or cardiogenic pulmonary oedema) interchangeably, whereas some reported the two separately.

The universal definition categorizes myocardial infarction into five types ^[39]. However, most studies on the cardiac complications of hypertensive emergency fall short of defining the different subtypes of ACS or myocardial infarction despite differences in their underlying pathophysiologic mechanisms and outcomes/prognosis. It is unclear as to what proportion of patients with ACS had ST-elevation myocardial infarction, non-ST-elevation myocardial infarction or unstable angina, and it remains debatable as to what extent unstable angina will be considered a true acute hypertension-mediated organ damage as defined in current guidelines.

5.3. Treatment

There are no randomized controlled trials to guide treatment in most cases of hypertensive emergencies, and the choice of medications, as well as the rate and magnitude of BP reduction is mainly based on expert opinion ^[5]. The ESC Council on hypertension recommends intravenous medications with close hemodynamic monitoring in an intensive care unit, which may not be available in low-resource settings, especially in LMICs. Evidence is emerging for the efficacy of orally administered medications in the treatment of hypertensive emergencies. In one study involving patients with malignant hypertension, the cohorts were treated with sequential administration of oral renin–angiotensin system blockers, calcium blockers, thiazide diuretic and spironolactone as required, without the need for admission into intensive care unit ^[19]. This cost-effective approach to treatment will appeal to LMICs with limited resources.

Presently, there are no well-validated systems for risk stratification or consensus regarding the best management options for high-risk groups, including patients with subclinical target organ damage. Based on the results of the DEMAND MI study, patients with suspected Type 2 myocardial infarction should be subjected to routine assessment of their coronary arteries (invasive or computed tomography) and be given the benefit of evidence-based treatments to improve outcomes ^[40]. This is, however, based on a single study and there is still a need for further clinical trials including patients with hypertensive emergency, to determine outcomes.

5.4. Biomarkers of Subclinical Myocardial Injury

Cardiac troponin is undoubtedly the best indicator of myocardial injury. However, new biomarkers of myocardial injury are being increasingly identified. Cardiac myosin-binding protein C is a novel biomarker of myocardial injury that is more sensitive and has the advantage of rising and falling more quickly than cardiac troponin ^[41]. This allows for more efficient tracking of the onset and resolution of acute hypertension-mediated organ damage, especially following intervention. Cardiac myosin-binding protein C has not been studied in hypertensive emergencies. It may be worthwhile to explore this and other biomarkers of myocardial injury including cardiac magnetic resonance imaging in the diagnosis of subclinical cardiac acute hypertension-mediated organ damage.

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