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.