Challenges to establish causality between hypertensive retinopathy and Grade III hypertension: A retrospective cohort analysis

Abstract

Background: Accelerated/Malignant hypertension (A/MH) is a hypertensive emergency, clinically defined by the European society of Hypertension/European society of cardiology (ESH/ESC) as the presence of very high BP associated with target organ damage (TOD) [retina, kidney, heart or brain]. The 5 years survival rate reported after the diagnosis of A/MH has improved significantly which could be due to earlier diagnosis, lower BP targets and availability of new classes of antihypertensive agents. Objective: To estimate the incidence of A/MH and evaluate its prognosis and management. Methods: A retrospective cohort analysis was carried out at our 2500 bedded tertiary care teaching hospital on patients admitted with essential HTN (during 2008 - 2012) with ICD - 10 (I.10) coding with no comorbidities with age >=40 were considered for the study. Results: Of the 305 in-patients diagnosed with essential HTN, 17 (5.8%) were found to have Grade III HTN (ESH/ESC 2013) which were documented as A/MH. Male predominance was found to be higher with 53% with a mean age for 58 years (+/-10 SD) and mean BMI of 23.8 (+/-4.7 SD). TOD identified in 17 patients were: 2 patients (12%) ophthalmic, 9 (53%) left ventricular failure and none reported in 6 (35%). All patients except one were treated with amlodipine (88%) either as monotherapy or with other classes including ARBs, ACEi, diuretics, beta blockers or clonidine. Readmissions were reported in 5 (29%) with only 1(6%) being diagnosed with CAD on the first readmission. Conclusion: Going by the standard criteria for diagnosing A/MH where BP is >=180/ 110, through our study we could safely conclude that 14 patients (83%) were either not reported with visual changes or not being referred for ophthalmic evaluation. This could also.