Hypertensive retinopathy in Dutch emergency departments: a multicenter retrospective cohort analysis

Abstract

Suspected hypertensive emergencies account for approximately one in every 200 emergency department (ED) visits in the Netherlands. One manifestation of hypertensive-mediated organ damage (HMOD) is hypertensive retinopathy. A rapid and aggressive reduction in blood pressure in these patients can result in severe cerebral complications, however a clear clinical definition is lacking, resulting in a heterogeneous patient population and ongoing debate regarding the necessity of intravenous therapy in these cases. This descriptive study aims to assess adherence to the ESC guidelines regarding fundoscopy and to determine the incidence of hypertensive retinopathy. Furthermore this study seeks to provide insights into the current clinical practice and the therapeutic strategies for patients with suspected hypertensive emergencies. A retrospective, multicenter cohort study was performed across four large nonacademic teaching hospitals in the Netherlands. All nonpregnant patients between 2019 and 2020 with a suspected hypertensive emergency referred to the ED were included. Primary outcome measures included the proportion of fundoscopy performed and incidence of grade III/IV retinopathy. Secondary aim encompassed the impact of oral antihypertensive treatment on blood pressure and on the incidence of neurological complications during the ED visit or within 30 days postdischarge. 1057 patients were enrolled in the study. 396 patients (40.2%) with indication for fundoscopy underwent fundoscopy. Of these patients 41 (10.4%) had grade III/IV retinopathy. 642 patients (60.7%) received oral antihypertensive drugs. Blood pressure reduction was less than 25% in all blood pressure derivatives. One complication was observed in the ED and 7 within 30 days. Our findings highlight the gap between current guidelines and show partial guideline adherence and low incidence of retinopathy. Furthermore oral antihypertensive drugs appeared to induce a gradual decrease in blood pressure in the ED with a relatively low rate of complications. Further prospective studies are needed to refine clinical definitions, improve the identification of patients at risk for neurological deterioration, and critically evaluate the role of fundoscopy in emergency settings.

Keywords: Emergency department; Fundoscopy; Hypertensive emergency; Retinopathy.