Assessment of the level of adherence to the ACC/AHA 2017 guidelines in the management of hypertensive crisis at the Kenyatta national hospital.
Abstract
Background
Hypertensive crisis is a medical emergency that requires prompt diagnosis and management. It
encompasses both hypertensive urgency and emergency. Hypertensive urgency is defined as a
systolic blood pressure of ³180 mmHg and/or diastolic blood pressure of ³120mmHg with no
evidence of acute end organ damage. Hypertensive emergency on the other hand is
characterized by the same level of blood pressure and evidence of acute end organ damage.
The American Heart Association hypertensive crisis management guidelines were then
recently updated in 2017 and had been adopted by different countries to assist in appropriate
management of hypertensive crisis.
This study hoped to audit the adherence to the AHA/ACC 2017 hypertensive crisis
management guidelines at the Kenyatta National Hospital.
Methodology
The objective was to assess the level of adherence to the ACC/AHA 2017 hypertensive crisis
management guidelines at the Kenyatta National Hospital. The study was a descriptive cross-sectional study done at the accident and emergency, medical intensive care unit, renal unit and
the medical wards. The study population comprised all hypertensive patients presenting in
hypertensive crisis. The sample size calculation was for finite population and gave a sample
size of 214. Consecutive sampling was used as the sampling technique. The lead researcher
and research assistants reviewed files of patients presenting with hypertension at the different
departments at the end of each day and identified those in crisis. A questionnaire based on the
AHA/ACC standard hypertensive crisis guideline was used to document the practice in
management and conformity to the guidelines. The frequencies of different sought symptoms,
signs and investigations were calculated and represented in tables while the management was
analyzed against the standard of care and represented in charts.
Results
Out of 420 files of hypertensive patients screened, 229 were found to fit into the hypertensive
crisis criteria with 102 (45%) as urgencies and 127 (55%) as emergencies. The mean age was
found to be 51 years with the youngest being 15 years and the oldest at 89 years. The
commonest emergency was ischemic stroke at 41 (32.2%) followed by acute kidney injury at
34 (26.7%). None of the patients with a diagnosis of hypertensive emergency were admitted in
ICU during the acute phase of management as expected from the AHA/ACC guideline.
Challenges in evaluation of the patients by examination and investigations were evident with
fundoscopy and electrocardiography being poorly done at 2.6% and 18% respectively.
Management did not adhere to the AHA/ACC guidelines with oral calcium channel blockers
being predominantly prescribed instead of guideline directed medication in both emergencies
and urgencies. These did not achieve the desired outcome in lowering the blood pressure.11
Conclusion
The audit highlighted the challenges in adequacy of diagnostic work up as well as the
inappropriateness and ineffectiveness of management of hypertensive crisis as observed at the
Kenyatta National Hospital. Patients in hypertensive urgency were poorly evaluated while
those in emergencies were neither admitted in ICU/HDU nor managed acutely by parenteral
antihypertensive therapy. This shows poor adherence to the 2017 ACC/AHA hypertensive
crisis management guidelines.
Publisher
University of Nairobi
Rights
Attribution-NonCommercial-NoDerivs 3.0 United StatesUsage Rights
http://creativecommons.org/licenses/by-nc-nd/3.0/us/Collections
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