Prehospital medical treatment of hypertensive emergencies in patients with suspected acute coronary syndrome or heart failure – a pilot real-world observational study

Background

According to the ESC hypertension guidelines, a hypertensive emergency is defined as a blood pressure of ≥180/110 mmHg associated with acute hypertension-mediated organ damage, often in the presence of symptoms. The standard operating procedures of the National Ambulance Service in our country align with the ESC guidelines enable the daily application of international recommendations.

Purpose

In this pilot study, we aimed to analyse the real-life, prehospital practices of medical treatment for hypertensive patients with suspected acute coronary syndrome or acute heart failure from the digital case report database of the National Ambulance Service in our country.

Methods

From January 1, 2023, to June 30, 2024, we collected data on 9,250 structured digital case reports of patients treated by advanced-level ambulance units. Inclusion criteria were an ICD code indicating acute coronary syndrome or heart failure, as well as a systolic blood pressure of 180 mmHg or higher or a diastolic blood pressure of at least 110 mmHg. We analysed key demographic and clinical variables, along with relevant drug therapies. Our analysis focused on identifying the most frequently used medications and combinations, as well as trends in medication indications based on different levels of elevated blood pressure.

Results

The median of the first measured systolic blood pressure was 190 mmHg (IQR 181-200), the last measured systolic blood pressure was 160 mmHg (IQR 149-175), and the difference is statistically significant (Wilcoxon rank-sum test p<0.001).

Patients frequently received only sublingual captopril (n=1,906, 20.6%) or nitroglycerin (n=1,750, 18.9%). For cases requiring intravenous drug treatment, the nitroglycerin-furosemide-morphine combination was the most preferred (n=1,411, 15.3%).

In patients with the highest initial systolic blood pressure values (mainly above 200 mmHg SBP), urapidil was typically required, and no other monotherapy was used among the patients with the highest blood pressure.

Conclusions

Although guidelines for managing hypertensive emergencies primarily recommend intravenous medications, our observational study revealed that non-intravenous antihypertensive agents may also be valuable during prehospital care. If the initial therapy is ineffective, timely escalation of treatment is essential. Further targeted investigations and complex statistical analyses are necessary to determine the target blood pressure, taking into account the duration of the prehospital period, and whether sublingual antihypertensive medications can effectively manage some hypertensive patients presenting to ambulance care with chest pain or heart failure until hospital admission.Violin plots: blood pressure changesTable:Medical treatment strategies