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PREVALENCE PATTERN AND OUTCOME OF HYPERTENSIVE EMERGENCIES AMONG ADULT MEDICAL PATIENTS ADMITTED TO BUGANDO MEDICAL CENTRE

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PREVALENCE PATTERN AND OUTCOME OF HYPERTENSIVE EMERGENCIES AMONG ADULT MEDICAL PATIENTS ADMITTED TO BUGANDO MEDICAL CENTRE BY GRAHAME MTUI (MD) A DISSERTATION TO BE SUBMITTED IN PARTIAL FULFILMENT FOR
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PREVALENCE PATTERN AND OUTCOME OF HYPERTENSIVE EMERGENCIES AMONG ADULT MEDICAL PATIENTS ADMITTED TO BUGANDO MEDICAL CENTRE BY GRAHAME MTUI (MD) A DISSERTATION TO BE SUBMITTED IN PARTIAL FULFILMENT FOR REQUIREMENT OF THE AWARD OF MASTERS OF MEDICINE (INTERNAL MEDICINE) OF CATHOLIC UNIVERSITY OF HEALTH AND ALLIED SCIENCES BUGANDO, MWANZA TANZANIA 2014 CERTIFICATION The undersigned certify that they have ready and hereby recommend acceptance for examination by Catholic University of Health and Allied Sciences (CUHAS) a dissertation entitled: Prevalence pattern and outcome of hypertensive emergencies among adult medical patients admitted to Bugando Medical Centre. Prof. Johannes B Kataraihya MD, MMED (Internal Medicine) Date Associate Professor Catholic University of Health and Allied sciences Dr. Robert N Peck MD, MMED (Internal Medicine) Date Senior Lecturer Catholic University of Health and Allied Sciences i DECLARATION & COPYRIGHT I, Grahame Geofrey Mtui, hereby declare that this dissertation is my own original work and that it has not been presented and will not be presented to any other university for a similar or any other degree award. Signature Date This dissertation is a copyright material protected under the Berne Convention, the copyright Act of 1999 and other international and national enactments, on that behalf, on intellectual property. It may not be reproduced by any means, in full or in part, except for short extracts in fair dealing, for research or private study, critical scholarly review or discourse with acknowledgement, without the written permission of the Director of Graduate studies, on behalf of both the author and the Catholic University of Health and Allied Studies (CUHAS) ii TABLE OF CONTENTS CERTIFICATION...i DECLARATION & COPYRIGHT... ii TABLE OF CONTENTS... iii LIST OF FIGURES... vi LIST OF TABLES...vii ACKNOWLEDGEMENTS... viii OPERATIONAL DEFINITIONS... ix ABBREVIATIONS... xi ABSTRACT... xiii CHAPTER 1: INTRODUCTION BACKGROUND STATEMENT OF THE PROBLEM AND RATIONALE RESEARCH QUESTION HYPOTHESIS STUDY OBJECTIVES Broad Objective: Specific objectives:... 5 CHAPTER 2: LITERATURE REVIEW Prevalence of hypertension and hypertensive emergencies... 6 iii 2.2 Factors associated with hypertensive emergencies Outcome of hypertensive emergencies CHAPTER 3: METHODOLOGY STUDY AREA STUDY DESIGN STUDY POPULATION Inclusion Criteria Exclusion criteria: SAMPLE SIZE DATA COLLECTION DATA PROCESSING AND ANALYSIS: ETHICAL CONSIDERATION CHAPTER 4: RESULTS Enrolment Baseline socio-demographic and clinical characteristics Prevalence of hypertensive emergencies Outcomes Factors associated with hypertensive emergencies Predictors of in-hospital fatality rates Predictors of 3 months fatality rates CHAPTER 5: DISCUSSION iv 5.1 Prevalence of hypertension and hypertensive emergencies Patterns of hypertensive emergencies Factors associated with hypertensive emergencies Fatality Predictors of in-hospital and 3-months fatality CHAPTER SIX CONCLUSION LIMITATIONS RECOMENDATIONS REFERENCES APPENDICES APPENDIX 1: QUESTIONNAIRE APPENDIX 2: INFORMED CONSENT ENGLISH VERSION APPENDIX 3: INFORMED CONSENT KISWAHILI VERSION APPENDIX 4: ETHICAL CLEARANCE CERTIFICATE v LIST OF FIGURES Figure 1: Overview of study enrolment vi LIST OF TABLES Table 1: Baseline characteristics of 647 patients admitted to BMC from October 2013 until December Table 2: Types of hypertensive emergencies among 82 consecutive adults admitted to BMC with hypertensive emergency Table 3: Overlap between hypertensive emergencies among 82 consecutive adults admitted to BMC with hypertensive emergency Table 4: In hospital, 1 month and 3 months post-discharge outcomes among 82 adults admitted with hypertensive emergency Table 5: Factors associated with hypertensive emergencies among 82 adults admitted with hypertensive emergencies to BMC by Univariate Analysis Table 6: Factors associated with hypertensive emergencies among 82 adults admitted to BMC by Multivariable logistic regression Table 7: Baseline Predictors of in hospital mortality among 82 adults admitted to BMC with hypertensive emergencies and followed up until discharge by univariate logistic regression Table 8: Baseline Predictors of in hospital mortality among 82 adults admitted to BMC with hypertensive emergencies and followed up until discharge by Multivariable logistic regression Table 9: Baseline Predictors of 3 month mortality among 82 adults admitted to BMC with hypertensive emergencies and followed up until 3 months after discharge by univariate logistic regression Table 10: Baseline Predictors of 3 month mortality among 82 adults admitted to BMC with hypertensive emergencies and followed up until 3 months after discharge by multivariable logistic regression vii ACKNOWLEDGEMENTS I wish to express my sincere gratitude to all who have made the completion of this dissertation possible. I would like to thank very much my supervisors Prof J. Kataraihya and Dr R. Peck for their tireless efforts in the supervision of my work from the beginning to the end. Their guidance, comments, critiques, support and patience have enabled the completion of this difficult job. I would like to express my sincere gratitude to all members of the department of Internal Medicine BMC/CUHAS, for their constructive comments, cooperation, support and assistance in all stages of this study. Also to my colleagues especially Dr Taibali Abderasul and Dr Missana Yango for being hand in hand from beginning of the study to the end especially during data collection, without forgetting Ms Rim Elchaki (Medical student from Weill Cornell) for her assistance during data entry. I greatly appreciate the help from Ms Eugenia for processing my samples as well as Dr Hassani (Opthalmologist) for his assistance during fundus examination. Special thanks to my family (my lovely wife Lilian Shao, my daughter Charisma) and my parents for being supportive throughout my research. viii OPERATIONAL DEFINITIONS Hypertension: Defined by the average of two systolic blood pressures (SBP) 140 and/or diastolic blood pressures (DBP) 90 mmhg and/or current use of antihypertensive medications at the time of admission. Severe Hypertension: Defined as average systolic blood pressure (SBP) 180 and or diastolic blood pressure (DBP) 110 mmhg. Hypertensive Emergency: Is severe hypertension associated with end organ damage. Acute Kidney Injury defined as an absolute increase in serum creatinine concentration of 26.4umol/L from baseline or percentage increase in serum creatinine concentration of 50% or decreased urine output less than 0.5mls/kg/hr for more than six hours (1). In the absence of baseline creatinine RIFLES criteria will be used which suggest back-calculating an estimated baseline creatinine concentration using the four variable MDRD equation, assuming a baseline GFR of 75ml/min/1.73m 2 (2). Renal dysfunction: Defined as egfr 60ml/min/1.73m 2 (calculated using Chronic Kidney Disease Epidemiology equation). Acute myocardial infarction: Was defined according to the previous World Health Organization s criteria for acute, evolving or recent myocardial infarction which requires combination of two of three characteristics: typical symptoms (i.e. chest discomfort), typical rise and gradual fall of troponin or more rapid rise and fall of CK-MB, and ECG changes indicative of ischemia (ST segment elevation or depression) involving the development of pathological Q-waves. ix Hypertensive Encephalopathy: Patients who had severe hypertension and alteration of mental status with no focal neurological deficits which resolve after lowering the blood pressure were considered as hypertensive encephalopathy. Acute Pulmonary Oedema: Defined as presence of dyspnoea and bilateral basal crackles confirmed by chest x-ray by radiologist. Hypertensive Retinopathy: Acute onset of blurred vision with retinal changes by fundoscopy classified into mild, moderate, and severe. Mild - Retinal arteriolar narrowing, wall thickening or opacification, and arteriovenous nicking (nipping). Moderate - Hemorrhages, either flame or dot-shaped, cotton-wool spots, hard exudates, and microaneurysms. Severe - Some or all of the above, as well as papilledema. Hypertensive Stroke: severe hypertension with sudden onset of neurological deficits and confirmed by CT scan of the brain whether ischemic, hemorrhagic or both. x ABBREVIATIONS BMC...Bugando Medical Centre BMI...Body Mass Index BP...Blood Pressure CKD...Chronic kidney disease CT scan...computed Tomography Scan CUHAS...Catholic University of Health and Allied Sciences CVS...Cardiovascular System CXR...Chest X-ray DBP...Diastolic Blood Pressure ECG...Electrocardiography egfr...estimated glomerular filtration rate GCS...Glasgow Coma Scale GFR...Glomerular filtration rate HF...Heart Failure HIV...Human Immunodeficiency Virus HTN...Hypertension ICU...Intensive Care Unit JNC...Joint National Committee xi KDOQI... Kidney Disease Outcome Quality Initiative LOC...Loss of Consciousness LVH...Left Ventricular Hypertrophy MAP...Mean Arterial Blood Pressure MDRD...Modification of Diet in Renal Disease SBP...Systolic Blood Pressure SSA...Sub Saharan Africa STEMI...ST Elevation Myocardial infarction USA...United States of America WHO...World Health Organisation xii ABSTRACT Background: Hypertension is increasingly common in sub-saharan Africa (SSA) and hypertensive emergencies are among the medical emergencies that cause morbidity and mortality among hypertensive patients. In Tanzania, the prevalence of hypertension is high with low levels of detection, treatment and control. Data regarding the types of hypertensive emergencies, associated factors and outcomes are lacking. Objectives: To determine prevalence, patterns, predictors and outcome of hypertensive emergencies among adult patients admitted to Bugando Medical Centre (BMC). Methodology: This was an analytical cross-sectional study with a prospective followup to determine the outcomes conducted on all adult patients admitted in medical wards as well as in adult intensive care unit (AICU) between October and December These patients were interviewed using a modified WHO STEPS questionnaire and screened for signs and symptoms of hypertensive emergencies. Patients with severe hypertension underwent fundoscopy, chest x-ray, 12 lead electrocardiogram, and serum creatinine. Brain CT scan was requested in those with stroke/altered mental status and an echocardiogram for those with heart failure or acute myocardial infarction. These patients were then followed up until discharge and three months thereafter. Results: A total of 647 patients were enrolled into the study with a median age of 45 years [ ] and females were 48.2%. Eighty-two patients (12.7%) met the criteria for hypertensive emergency, the majority (85.4%) had more than one emergency and the commonest type was hypertensive retinopathy (62.2%). Hypertensive emergency xiii was significantly associated with female gender and age above 45 years. During hospitalisation 30% of patients with hypertensive emergencies died, and by three months more than 50% were dead. Hypertensive emergency with impaired renal function was found a statistically significant predictor of fatality both in hospital and at three months. Conclusion: Hypertensive emergency is one among the common causes of admission in medical wards of BMC associated with high fatality. Associated factors include female gender and age above 45 years. Hypertensive emergency with impaired renal function was significantly associated with both in hospital and three months case fatality rates. xiv CHAPTER 1: INTRODUCTION 1.1 BACKGROUND Hypertension is an established risk factor for cardiovascular, cerebrovascular, and renal disease (3). Acute elevations in blood pressure (BP) can result in acute endorgan damage with significant morbidity and mortality. Prompt recognition, evaluation, and appropriate treatment of these conditions are crucial to prevent permanent end organ damage. Worldwide, hypertension is still an important public challenge and its prevention, detection, treatment and control should receive high priority (4). However in sub- Saharan Africa (SSA) most countries are still battling with infectious diseases such as Human Immunodeficiency Virus (HIV), malaria, and tuberculosis, and most governments in the region have limited resources and health budgets. An increasing burden of hypertension in this region is therefore likely to be of grave consequence. Treatment and control rates are likely to be even lower than the dismal rates in Europe and North America. In Tanzania, the prevalence of hypertension is also high with low levels of detection, treatment and control (5,6). Recent analysis of data from Bugando Medical Centre (BMC) indicate that hypertension related diseases were the number one cause of death, admission and hospital days in patients over the age of 50 years, accounting for 28.9% of deaths, 28.5% of admissions and 27.8% of hospital stay in this age group and that hypertensive emergencies were the most common reason for admissions among persons with hypertension (7). 1 Hypertensive emergency is a situation in which uncontrolled hypertension is associated with acute end-organ damage such as hypertensive encephalopathy, retinopathy, dissecting aortic aneurysm, ischemic heart disease, acute pulmonary oedema, and acute kidney injury. Most commonly hypertensive emergencies occur in the setting of severe elevations in BP, such as diastolic BP (DBP) 130 mmhg. Most patients presenting with hypertensive emergency have chronic hypertension, although the disorder can present in previously normotensive individuals. Hypertensive emergencies most commonly occur due to poor treatment, noncompliance with or withdrawal from prescribed antihypertensive agents as well as acute accelerated hypertension in a patient with existing primary as well as secondary hypertension. However in Africa, adverse socio-economic status, obesity, cigarette smoking and poor compliance to antihypertensive agents have been associated with poor BP control hence complications (8). The presentation of hypertensive emergencies depends on the organs involved. For hypertensive encephalopathy, patients may present with headache, nausea and vomiting, visual disturbances, confusion, rarely focal or generalised weakness etc. If not adequately treated cerebral haemorrhage or stroke, coma and death occur, but with proper treatment it can be completely reversible. Hypertension has profound effects on various parts of the eyes. Classically, elevated blood pressure results in a series of retinal microvascular changes called hypertensive retinopathy, comprised of generalized and focal retinal arteriolar narrowing, arteriovenous nicking, (more closely related to aging than to BP), retinal haemorrhages, microaneurysms and, in severe cases, optic disc and macular oedema. Fundoscopy is a useful tool in recognising these changes. The cardiovascular system is affected as increased cardiac 2 workload leading to cardiac failure; this is accompanied by left ventricular hypertrophy, congestive heart failure (with impaired or preserved left ventricular ejection fraction), myocardial ischemia, and/or myocardial infarction. The renal system is impaired when high BP leads to arteriosclerosis, fibrinoid necrosis, and an overall impairment of renal protective auto regulatory mechanisms. This may manifest as worsening renal functions or decreased urine output. Morbidity and mortality depend on the extent of end organ damage on presentation and degree to which blood pressure is controlled subsequently. Therefore treatment of these emergencies requires immediate, accurate diagnosis and therapy to interrupt ongoing or prevent impending target-organ damage. Delay in initiating effective therapy or too rapid reduction of BP can produce severe complications involving these target organs. It is recommended to use short acting intravenous antihypertensive agents, with a goal to reduce mean arterial pressure (MAP) by 20-25% over four to six hours (9). 3 1.2 STATEMENT OF THE PROBLEM AND RATIONALE Hypertension is increasingly common in SSA. In a recent study at Bugando, hypertension-related conditions were 2 nd only to HIV as a cause of admission, death and hospital days among adult medical inpatients. Hypertensive emergency was the most common hypertension-related condition but the types of hypertensive emergencies and the out-of-hospital outcomes could not be determined from this study (7). Data regarding the types of hypertensive emergencies seen in sub-saharan Africa, the presenting features and the outcomes are lacking. The prevalence and clinical picture and outcome of hypertensive emergencies in East Africa have not been clearly described. Data on these patterns are important for improving clinicians awareness. Addressing the risk factors to the community will also improve awareness, overall morbidity and mortality among these patients will be improved. Therefore there is an essential need to conduct an epidemiological profile on the prevalence, predictors, and outcome of hypertensive emergencies in Tanzania. 1.3 RESEARCH QUESTION What are the prevalence, patterns, associated factors and outcome of hypertensive emergencies among adult patients admitted in BMC? 1.4 HYPOTHESIS We hypothesized that 10% adult admissions to BMC meet criteria for hypertensive emergency and most common hypertensive emergencies are pulmonary oedema and encephalopathy but hypertensive renal dysfunction is commonly undiagnosed. We also hypothesized that adherence to anti-hypertensives at 3 months after discharge is less or equal to 25%. 4 1.5 STUDY OBJECTIVES Broad Objective: To determine prevalence, pattern, associated factors and outcome of hypertensive emergencies among adult patients admitted to BMC Specific objectives: 1. To determine the prevalence of hypertensive emergencies among adults admitted to the medical wards of BMC. 2. To determine the pattern of hypertensive emergencies (i.e. types of emergencies) among adults admitted to BMC. 3. To determine factors associated with hypertensive emergencies among adults admitted to BMC. 4. To determine the case fatality rates both in-hospital and after 3 months among hypertensive patients admitted to BMC 5. To determine the predictors for fatality among patients with hypertensive emergencies admitted to BMC. 5 CHAPTER 2: LITERATURE REVIEW 2.1 Prevalence of hypertension and hypertensive emergencies More than quarter of the world s adult population had hypertension in 2000 and this proportion will increase to 29% (1.56 billion) by 2025 (4). According to the seventh joint national committee for hypertension, JNC VII (3), hypertension is the most common primary diagnosis in USA affecting almost 25% of the people. About 30% are unaware they have hypertension, and control rate is still below 50%. Hypertension is also considered a major public health problem in SSA with low levels of detection, treatment and control (5,10). A study done among civil servants in Accra Ghana involving seven ministries showed the prevalence of hypertension to be 30.2 % and BP control to below 140/90 mmhg was only 11.4%. This study also showed 47.5% of hypertensive patients had target organ damage associated with high SBP and DBP. Hypertensive retinopathy accounted for 70% of the target organ damage with 1% having grade 3 retinopathy, and none had grade 4 retinopathy. In addition, 13.4% of the participants had albuminuria ( mg/d) (11). Hypertensive emergency is one of the most common complications of hypertension worldwide. A retrospective study done in Brazil to assess the prevalence of hypertensive crisis among adult patients attending emergency unit of the universityaffiliated hospital showed the proportion of hypertensive emergencies among hypertensive crisis as high as 39.6%. Most cases of hypertensive emergencies corresponded to cerebrovascular lesions (58%),
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