Review
Hypertensive emergencies and urgencies in emergency
departments: a systematic review and meta-analysis
Anna Astarita a,, Michele Covella b,, Fabrizio Vallelonga a, Marco Cesareo a, Silvia Totaro c,
Luca Ventre d, Franco Aprà e, Franco Veglio a, and Alberto Milan a
Objectives: The prevalence of hypertensive emergencies
and urgencies and of acute hypertension-mediated organ
Downloaded from https://journals.lww.com/jhypertension by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3MA/yA2SpdlFk3yKI1d5iy2Wij92EEJ281rCyXb69sCk= on 07/06/2020
damage (aHMOD) in emergency departments is unknown.
Moreover, the predictive value of symptoms, blood
pressure (BP) levels and cardiovascular risk factors to
suspect the presence of aHMOD is still unclear. The aim of
this study was to investigate the prevalence of
hypertensive emergencies and hypertensive urgencies in
emergency departments and of the relative frequency of
subtypes of aHMOD, as well as to assess the clinical
variables associated with aHMOD.
Methods: We conducted a systematic literature search on
PubMed, OVID, and Web of Science from their inception
to 22 August 2019. Two independent investigators
extracted study-level data for a random-effects meta-
analysis.
Results: Eight studies were analysed, including 1970
hypertensive emergencies and 4983 hypertensive
urgencies. The prevalence of hypertensive emergencies and
hypertensive urgencies was 0.3 and 0.9%, respectively
[odds ratio for hypertensive urgencies vs. hypertensive
emergencies 2.5 (1.4–4.3)]. Pulmonary oedema/heart
failure was the most frequent subtype of aHMOD (32%),
followed by ischemic stroke (29%), acute coronary
syndrome (18%), haemorrhagic stroke (11%), acute aortic
syndrome (2%) and hypertensive encephalopathy (2%). No
clinically meaningful difference was found for BP levels at
presentations. Hypertensive urgency patients were younger
than hypertensive emergency patients by 5.4 years and
more often complained of nonspecific symptoms and/or
headache, whereas specific symptoms were more frequent
among hypertensive emergency patients.
Conclusion: Hypertensive emergencies and hypertensive
urgencies are a frequent cause of access to emergency
departments, with hypertensive urgencies being significantly
more common. BP levels alone do not reliably predict the
presence of aHMOD, which should be suspected according
to the presenting signs and symptoms.
Keywords: acute organ damage, emergency departments,
hypertensive emergencies, hypertensive urgencies, meta-
analysis
Abbreviations: aHMOD, acute hypertension-mediated
organ damage; BP, blood pressure; CI, confidence interval;
OR, odds ratio
Journal of Hypertension
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
INTRODUCTION
H
ypertensive emergencies are potentially life-threat-
ening conditions in which a symptomatic acute rise
in BP levels leads to the development of acute
organ damage [1]. The term hypertensive urgencies, tradi-
tionally used to define a symptomatic rise in BP in the
absence of organ damage, should be abandoned in favour
of the term ‘uncontrolled hypertension’ [1] as these patients
do not require hospitalization. A close outpatient follow-up
is recommended to ensure BP control is achieved.
Although both conditions are potentially linked to
increased morbidity and mortality, their management
remains challenging because of lack of evidence. Firstly,
in contrast to the ascertained burden of chronic arterial
hypertension, the relative prevalence of hypertensive emer-
gencies and hypertensive urgencies in emergency depart-
ments and the frequency of each form of aHMOD remains
debated, in part, because of heterogeneous diagnostic crite-
ria and paucity of publications. Moreover, though BP values
have a central role in making the diagnosis, it is uncertain if
the presence of aHMOD should be suspected solely based on
elevated BP levels, and if there is a relationship between
presenting symptoms and presence of aHMOD. Lastly, the
differences in terms of cardiovascular risk factors between
patients presenting with hypertensive emergency and hyper-
tensive urgency are poorly investigated.
Given these uncertainties, we conducted a systematic
review and meta-analysis to assess the prevalence of hyper-
tensive emergencies and hypertensive urgencies in emer-
gency departments and the prevalence of each subtype of
aHMOD. In addition, through a comparative analysis
Journal of Hypertension 2020, 38:1203–1210
a
Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences,
AO ‘Città della Salute e della Scienza’ University Hospital, Turin, bEmergency Depart-
ment, U.Parini Hospital, Aosta, cEmergency Division, Department of Medical Sciences,
AO ’Città della Salute e della Scienza’ University Hospital, Turin, dOphthalmology
Division, ‘Città della Salute e della Scienza’ University Hospital, Turin and eHigh
Dependency Unit, San Giovanni Bosco Hospital, Turin, Italy
Correspondence to Anna Astarita, MD, Hypertension Unit, Division of Internal
Medicine, Department of Medical Sciences, AO ‘Città della Salute e della Scienza’
University Hospital, Turin, Italy. Tel: +39 3331925112; fax: +39 116336931; e-mail:
astarita.unito@gmail.com

Anna Astarita and Michele Covella are joint first authors.
Received 5 December 2019 Accepted 3 January 2020
J Hypertens 38:1203–1210 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights
reserved.
DOI:10.1097/HJH.0000000000002372
www.jhypertension.com 1203
Astarita et al.
between hypertensive emergency and hypertensive
urgency patients, we sought to investigate the role of BP
levels, symptoms and cardiovascular risk factors to predict
the presence of aHMOD.
METHODS
Study selection
This systematic review and meta-analysis adhered to Pre-
ferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) Statement [2].
We included studies assessing the prevalence of hyper-
tensive emergencies by enrolling consecutive patients pre-
senting to the emergency departments. In order to be
considered eligible, the following data had to be reported:
definition of hypertensive emergency/hypertensive urgency
adopted, BP values at presentation and subtype of aHMOD.
We excluded the following types of publications: studies
investigating hypertensive emergencies in pregnant women
or in patients 18 years old or less; enrolment taking place in
any setting other than the emergency departments or setting
not clearly specified; retrospective studies in which the
diagnosis of hypertensive emergency was based on Interna-
tional Classification of Diseases codes at discharge.
Data regarding patients with uncontrolled hypertension in
the absence of aHMOD (i.e. hypertensive urgencies) were
also extracted to perform a comparative analysis of hyperten-
sive emergencies and hypertensive urgencies. Data regarding
presenting symptoms were extracted when provided.
Search strategy
Two independent authors (A.A. and M.C.) conducted a
comprehensive search without language restrictions trough
PubMed, OVID and Web of Science Medline databases
from their inception to August 22 2019 using the following
search terms: hypertensive emergencies, hypertensive cri-
sis, hypertensive urgencies, malignant hypertension, accel-
erated hypertension, myocardial ischemia, myocardial
infarction, unstable angina, coronary artery disease, hyper-
tensive encephalopathy, posterior reversible encephalopa-
thy, posterior leukoencephalopathy syndrome, intracranial
hypertension, pulmonary oedema, heart failure, congestive
heart failure, ischemic stroke, intracranial/subarachnoid
haemorrhage, haemorrhagic stroke, papilloedema, optic
papilla oedema, hypertensive retinopathy, aortic dissection
(see text document, Supplement Digital Content 1, http://
links.lww.com/HJH/B257, which reports the full search
strategy used). The research was extended by a manual
review of the references from selected studies.
Data extraction
Two reviewers (A.A. and M.C.) initially screened titles and
abstracts and then reviewed the full text of selected pub-
lications; a third reviewer (A.M.) concluded controversies.
In case of studies conducted by the same research group,
we investigated the possibility of overlap of the study
sample and if it was confirmed, we considered the most
recent one. The following data were extracted from the
eligible studies: number of patients admitted for hyperten-
sive emergencies and hypertensive urgencies, number of
total emergency department visits, prevalence of each
1204 www.jhypertension.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
aHMOD, BP levels and symptoms at presentation, clinical
characteristics of hypertensive emergency and hyperten-
sive urgency patients (age, sex, cardiovascular risk factors).
Figure 1 details the research process.
Data analysis
The first part of the analysis aimed to assess the epidemiology
of hypertensive emergencies in terms of: overall prevalence,
subtype of aHMOD and relative frequency compared with
hypertensive urgencies.
The prevalence of hypertensive emergencies was com-
puted for each study as the number of cases divided by the
total number of emergency departments visits over the same
time period and expressed as a percentage [95% confidence
interval (CI)]. The relative prevalence of each subtype of
aHMOD was calculated as the number of cases divided by the
total number of patients with hypertensive emergencies.
These frequencies were then meta-analysed across studies
to calculate the average frequency. The relative frequencies
of hypertensive emergency and hypertensive urgency were
compared by calculating the odds ratio.
The second part of the analysis involved only publications
reporting data for both hypertensive emergency and hyper-
tensive urgency patients. Baseline BP values, age, prevalence
of known hypertension and frequency of presenting symp-
toms were meta-analysed across studies and compared
between hypertensive emergencies and hypertensive urgen-
cies. Continuous variables (BP, age) were compared by
calculating the mean difference; categorical variables (pre-
viously known arterial hypertension, presenting symptoms)
were compared by calculating odds ratios (OR).
The proportion of variability explained by true hetero-
geneity (i.e. between-studies variability) was estimated by
calculating the I2 for each analysis. Random-effect models
were used because of high heterogeneity of the study
samples. All statistical analyses were performed with R
software version 3.3 [3] with the Metafor package version
2.1 [4].
RESULTS
Characteristics of the studies
Eight study samples (five prospective [5–8], three retro-
spective [9–11]) from seven different publications were
included in the final analysis, for a total of 1970 hyperten-
sive emergency patients and 4983 hypertensive urgency
patients. The definition of hypertensive emergencies
always included the presence of aHMOD, but varied with
regard to the BP levels considered, with older studies only
considering DBP for inclusion. Five studies [5,6,8,10] were
conducted in European countries, one in Thailand [9] and
two in Brazil [7,11]. The characteristics of the studies
included in the final analysis are shown in Table 1.
Prevalence of hypertensive emergency and
hypertensive urgency
The mean prevalence of hypertensive emergencies was
0.3% [0.14–0.46] whereas the prevalence of hypertensive
urgencies was 0.94% [0.29–1.59] (see Figures, Supplemen-
tal Digital Content 2 and 3, http://links.lww.com/HJH/
B258). Both estimates showed high variability across the
Volume 38  Number 7  July 2020
 Hypertensive emergencies and urgencies

Records identified through database searching:

n = 4094
• PubMed: n = 1663
• OVID: n = 1538
• Web of Science: n = 893

Records after duplicates removed:

n = 2105

Records excluded:
n = 2001

Record retrieved for more detailed evaluation:

n = 104

Full-text articles excluded:

n = 97
• convenient sampling: n = 18
• missing data: n = 23
• other setting than EDs: n = 13
• overlapping population: n = 1
• unofficial definition of HE: n = 4
• case-control studies: n = 33
• ICD-codes: n = 5

Articlesinincluded:
Studies included n = 7synthesis:
quantitative
Studies included in quantitative analysis: n = 8
n= 9
FIGURE 1 Flow chart for the selection of the included records. ICD, International Classification of Diseases.

different studies, with prevalence ranging between 0.08 and
0.76% for hypertensive emergencies (I2 99.7%) and
between 0.24 and 2.4% for hypertensive urgencies (I2
100%). Hypertensive urgencies were more common than
hypertensive emergencies in most studies (OR for hyper-
tensive urgencies vs. hypertensive emergencies: 2.5 [1.4–
4.3]; Fig. 2).
Prevalence of each subtype of acute
hypertension-mediated organ damage
The prevalence of each subtype of aHMOD was assessed
separately (see Figures, Supplemental Digital Content
4– 9, http://links.lww.com/HJH/B259); the overall preva-
lence is shown in Fig. 3. Acute pulmonary oedema/heart
failure was the most common aHMOD [32%; (28 –36);
I2 72.6%], followed by ischemic stroke [29%; (23 – 35); I2
87.9%], acute coronary syndrome [18%; (14 –22); I2 83.3%],
haemorrhagic stroke [11%; (7 –14); I2 86.8%], acute
aortic syndrome [2%; (0– 5); I2 82.7%] and hypertensive
encephalopathy (2%; [0– 5]; I2 98.7%). For this latter
aHMOD, the prevalence ranged between 0 and 5% in
seven studies, up to 17% in the remaining one [8] (see
Figure, Supplemental Digital Content 6, http://links.
lww.com/HJH/B259).

Journal of Hypertension www.jhypertension.com 1205

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
 1206
Astarita et al.

TABLE 1. Main characteristics of the studies included in the analysis

First author, Known
year Entry BP hyper-
[reference Exclusion Patients levels Age Males tension

www.jhypertension.com
number] Country Enrollment HEs definition HUs definition criteria Prevalence ¥ (n) (mmHg) (years) (%) (%)
Kotruchin, Thailand Retrospective, SBP >180 or DBP SBP >180 or DBP Pregnancy; HEs: 15.5/100 000 HEs: 172 HEs: 200  18/ HEs: HEs: n.a. HEs: 63
2018 [9] years 2012– >120 with aHMOD >120 without known HUs: 48.5/100 000 HUs: 537 110  15 61  13 HUs: 40.3 HUs: n.a.
2017 aHMOD secondary HUs: n.a. HUs: n.a.
hypertension
Guiga, 2017 France Retrospective, SBP >180 or DBP SBP >180 or DBP Pregnancy; n.a. HEs: 385 HEs: 197  21/ HEs: 7  18 HEs: 47 HEs: 77
[10] year 2015 >10 with aHMOD >110 without acute kidney HUs: 285 99  20 HUs: HUs: 42 HUs: 82
aHMOD injury HUs: 199  24/ 67  15
98  18
Salvetti, 2015 Italy Prospective, SBP >180 or DBP SBP >180 or DBP Pregnancy; HEs: 271/100 000 HEs: 187 HEs: 193  16/ HEs: HEs: 55 HEs: 83
[5] year 2015 >120 with aHMOD >120 without resuscitated HUs: 1486/100 000 HUs: 1027 98  15 73  13 HUs: 40 HUs: 71
aHMOD cardiac arrest HUs: 189  12/ HUs:
94  15 69  15
Pinna, 2014 [6] Italy Prospective, SBP >220 or DBP SBP >220 or DBP Pregnancy HEs: 117/100 000 HEs: 391 HEs: 204  29/ HEs: HEs: 53 HEs: 79
year 2009 >120 with aHMOD >120 without HUs: 346/100 000 HUs: 1155 115  18 70  14 HUs: 47 HUs: 76
aHMOD HUs: 204  27/ HUs: 69 
115  16 15
Vilela-Martin, Brazil Prospective, DBP >120 with DBP >120 with Pregnancy; HEs: 290/100 000 HEs: 231 HEs: 202  30/ HEs: 63  HEs: 51 HEs: 86
2011 [7] year 2006 aHMOD symptoms and no pseudocrisis HUs: 164/100 000 HUs: 131 130  15 13 HUs: 43 HUs: 92
aHMOD HUs: 205  33/ HUs: 57 
132  18 16
Salvetti, 2008 Italy Prospective, SBP >180 or DBP SBP >180 or DBP Pregnancy; HEs: 411/100 000 HEs: 317 HEs: 193  15/ HEs: 71  HEs: 54 HEs: 78
[5] year 2008 >120 with aHMOD >120 without resuscitated HUs: 1599/100 000 HUs: 1234 102  15 14 HUs: 41 HUs: 73
aHMOD cardiac arrest HUs: 189  13/96 HUs: 70 
 13 16
Vilela-Martin, Brazil Retrospective, DBP >120 with DBP >120 with None HEs: 233/100 000 HEs: 179 HEs: 193  26/ HEs: 60  HEs: 55 HEs: 84
2004 [11] year 2000 aHMOD symptoms and no HUs: 356/100 000 HUs: 273 129  12 15 HUs: 38 HUs: 80
aHMOD HUs: 191  27/ HUs: 50 
127  14 19
Zampaglione, Italy Prospective, DBP >120 with DBP >120 without None HEs: 760/100 000 HEs: 108 HEs: 210  32/ HEs: 67  HEs: 49 HEs: 92
1996 [8] years aHMOD aHMOD HUs: 2400/100 000 HUs: 341 130  15 16 HUs: 40 HUs: 72
1992–1993 HUs: 210  27/ HUs: 60 
126  10 14

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

aHMOD, acute hypertension-mediated organ damage; BP, blood pressure; HEs, hypertensive emergencies; HUs: hypertensive urgencies; n.a., data not available.

Volume 38  Number 7  July 2020

 Hypertensive emergencies and urgencies

FIGURE 2 Forest plot of the odds ratio for prevalence of hypertensive urgencies vs. hypertensive emergencies.

SBP and DBP values: comparison between
hypertensive emergency and hypertensive
urgency
SBP at presentation did not differ between hypertensive
emergencies and hypertensive urgencies (1.4 mmHg; [ 0.8
to 3.6]; I2 63.1%), whereas DBP was slightly higher in
hypertensive emergency patients (2.3 mmHg; CI [0.3–
4.3]; I2 78.1%; Figs. 4 and 5).
Symptoms: comparison between hypertensive
emergency and hypertensive urgency
In accordance to the current guidelines [1], we distin-
guished two groups of presenting symptoms complained
by comparison between hypertensive emergency and
hypertensive urgency patients: ‘specific symptoms’ (chest
pain, dyspnoea, focal neurological symptoms and head-
ache) and ‘nonspecific symptoms’. The main symptoms
complained by hypertensive emergency patients were neu-
rological symptoms [35% (0.27–0.42)] and dyspnoea [31%
(0.25–0.36)] whereas in hypertensive urgency patients pre-
sented more frequently with headache [22% (0.09–0.35)]
and ‘nonspecific symptoms’ [48% (0.34–0.62)]. The preva-
lence of ‘nonspecific symptoms’ in hypertensive emergency
patients were 24% [0.14–0.35].
We assessed the predictive value of each symptom
with regard to the presence of aHMOD by calculating
odds ratios of being diagnosed with hypertensive
urgency vs. hypertensive emergency for each presenting
symptom. Hypertensive urgencies were more likely in the
presence of headache [OR 2.5 (1.4– 4.5)] and nonspecific
symptoms [OR 3.1 (1.4 –6.5)]. Hypertensive urgencies

FIGURE 3 Forest plot of the prevalence of each subtype of acute hypertensive-mediated organ damage in hypertensive emergencies.

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Astarita et al.

FIGURE 4 Forest plot of the SBP difference between hypertensive emergencies and urgencies.

were less likely when patients presented with focal neu-
rological symptoms (OR 0.12 [0.07 –0.19]), chest pain (OR
0.43 [0.22 – 0.83]) and dyspnoea [OR 0.27 (0.13 –0.54)]. In
Fig. 6, the summary of prevalence and OR of hypertensive
emergency and hypertensive urgency symptoms (see
Figures, Supplement Digital Content 10– 24, http://link-
s.lww.com/HJH/B260, which detail the prevalence and
the OR for each symptom).
Cardiovascular risk factors: comparison
between hypertensive emergency and
hypertensive urgency
The prevalence of known arterial hypertension in hyper-
tensive emergency patients was 82.5% (78.6–86.3) I2 79%
whereas in hypertensive urgency patients was 78% [72.5–
83.6] I2 94.6% without a statistical difference between the
two groups (OR hypertensive emergencies vs. hyperten-
sive urgencies: 0.8 [0.5–1.2]; I2 87.4%). Among hyperten-
sive emergency patients, there was a higher percentage of
men (52 vs. 42% for hypertensive urgency), hypertensive
urgency patients were on average younger than hyper-
tensive emergency patients by 5.4 years (2.6–8.3) I2
90.4% (see Figures, Supplement Digital Content 25–28,
http://links.lww.com/HJH/B261, which detail the analy-
sis of known arterial hypertension and age). No other
quantitative analysis was performed because of lack
of data.
DISCUSSION
The current review and meta-analysis was designed to
assess the epidemiology of hypertensive emergencies

FIGURE 5 Forest plot of the DBP difference between hypertensive emergencies and urgencies.

1208 www.jhypertension.com Volume 38  Number 7  July 2020

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FIGURE 6 Histogram of the prevalence and the odds ratio of symptoms in hypertensive emergencies and urgencies.
and hypertensive urgencies in emergency departments and
the main variables associated with aHMOD.
Across the eight included studies, the combined preva-
lence of hypertensive emergencies and hypertensive
urgencies in emergency departments was approximately
1.2% with hypertensive urgencies being significantly more
common than hypertensive emergencies [OR 2.5 (1.4–4.3)].
However, prevalence varied widely across studies (range:
0.08–0.76% for hypertensive emergencies and 0.24–2.4%
for hypertensive urgencies). This is at least in part explained
by the different definitions of hypertensive emergencies/
hypertensive urgencies adopted, making it difficult to
assess the contribution of additional variables, such as
ethnicity, prevalence of hypertension in the population
and ease of access to healthcare. The results of our analysis
are similar to those of the largest USA database on hyper-
tensive emergencies (STAT Registry) that estimated a prev-
alence of 0.2% for hypertensive emergencies [12].
Acute pulmonary oedema/heart failure was the most
common subtype of aHMOD, as previously reported in
other retrospective studies [13,14]. Heterogeneity across
studies was highest for aortic syndromes and for hyperten-
sive encephalopathy. Although this is partly justified by the
rare occurrence of these two forms of organ damage, in the
case of hypertensive encephalopathy, we observed a very
wide range of prevalence (0–17%) suggesting a lack of
uniformity in diagnostic criteria and in the utilization of
diagnostic imaging. The growing availability of MRI and
newer methods for ocular fundus examination [15], could
improve the detection of this specific aHMOD, otherwise
probably underestimated.
In the second part of the analysis, we compared hyper-
tensive emergency and hypertensive urgency patients with
respect to their BP levels, symptoms at presentation and
baseline characteristics (age, sex, cardiovascular risk factors)
Journal of Hypertension
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Hypertensive emergencies and urgencies
to identify variables that could predict the presence of organ
damage. Since the definition of uncontrolled hypertension
provided in the most recent ESC/ESH consensus document
[1] was not adopted in any of the studies included in the
analysis, patients with BP levels above a certain threshold in
the absence of organ damage were defined as having a
hypertensive urgency. BP levels were overall similar
between hypertensive emergency and hypertensive urgency
patients. Although a statistically significant difference was
found for DBP in favour of hypertensive urgency [2.3 mmHg
(0.3–4.3)], the small magnitude of such difference makes this
finding irrelevant for clinical practice. This data suggests that,
despite the widely known linear association between BP
levels and the development of aHMOD [16], others factors,
such as the rate of BP rise, play a more important role in the
development of the aHMOD.
In accordance with the current ESC/ESH Guidelines [1],
we distinguished two groups of symptoms at presentation –
specific and nonspecific – to assess their predictive value
with regard to the presence of organ damage. Seventy-six
percent of patients with hypertensive emergency presented
with specific symptoms. Chest pain, dyspnoea and focal
neurological symptoms were strongly associated with the
presence of acute organ damage. By contrast, headache
carried a more benign prognosis, making the diagnosis of
hypertensive urgency approximately 2.5 times more likely.
Nonspecific symptoms were the most common presentation
for patients with hypertensive urgency (48%). However, a
significant proportion of patients with aHMOD (24%) com-
plained of nonspecific symptoms as well, highlighting the
need to perform a comprehensive clinical evaluation and to
maintain a low threshold for ordering diagnostic tests in
patients with acute hypertensive disorders.
Hypertensive urgency patients were on average younger
than hypertensive emergency patients [5.4 years (2.6–8.3)]
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Astarita et al.
whereas the prevalence of known arterial hypertension was
similar between the two groups. No other cardiovascular
risk factors were investigated, because of lack of data.
Previous studies [12,13,17], mostly retrospective, identified
correlations between known cardiovascular risk factors
(diabetes, cardiac diseases, renal insufficiency, smoking,
alcohol abuse and nonadherence to antihypertensive ther-
apy [18]) and hypertensive emergencies.
With the exception of one publication [10], no data
regarding inpatient and outpatient outcomes were avail-
able. Previous reports, based on small samples [12,19–21],
have shown significant mortality and morbidity for both
hypertensive emergencies and hypertensive urgencies.
This study has several limitations. Firstly, as the defini-
tions of hypertensive emergency and hypertensive urgency
changed over time, the studies included in our analysis
adopted different BP levels as the cut-off for the diagnosis
of both hypertensive emergencies and hypertensive urgen-
cies, contributing to the heterogeneity of the results. Sec-
ondly, protocols for the evaluation for organ damage were
not standardized across studies, and availability of diagnos-
tic tools as well as the definitions of some of the subtypes of
aHMOD varied during the study period. Reporting of
presenting symptoms was not consistent as well, and some
of the publications omitted data on cardiovascular risk
factors whose analysis could have better elucidated the
different profile of patients with hypertensive emergency
and hypertensive urgency.
Lastly, the included publications were heterogeneous with
regard to geographical setting, study design and year of
publication: three studies were retrospective [9,10,11] and five
studies were conducted before the year 2010 [5–8,11]; both
aspects increase the heterogeneity of the results because of
measured and unmeasured confounding factors. Despite
these limitations, this meta-analysis represents the first attempt
to quantitatively analyse the epidemiology of hypertensive
emergencies and hypertensive urgencies in the emergency
department setting and the main predictors of aHMOD.
Our results demonstrate the high prevalence of hyper-
tensive emergencies and hypertensive urgencies in emer-
gency departments, with hypertensive urgencies being
significantly more common. BP levels alone do not reliably
predict the presence of aHMOD, which should be sus-
pected according to the presenting signs and symptoms.
If more comprehensive data became available, a risk strat-
ification tool for patients with acute hypertensive disorders
could be developed. Quality publications based on larger
populations are needed to gain a deeper knowledge of the
epidemiology of acute hypertensive disorders, which will
help standardize management and guide decision-making
for these conditions.
ACKNOWLEDGEMENTS
We acknowledge Dr G. Pinna and Dr C. Pascale for the
scientific contribution in the field of hypertensive
emergencies.
Conflicts of interest
There are no conflicts of interest.
1210 www.jhypertension.com
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Volume 38  Number 7  July 2020