Original Article
Trends in Hospitalization for Hypertensive Emergency,
and Relationship of End-Organ Damage With In-Hospital
Mortality
Mahek Shah,1 Shantanu Patil,2 Brijesh Patel,1 Shilpkumar Arora,3 Nilay Patel,4
Lohit Garg,1 Sahil Agrawal,5 Larry Jacobs,1 Susan P. Steigerwalt,6 and Matthew W. Martinez1
BACKGROUND
There are no comprehensive guidelines on management of hyper-
tensive emergency (HTNE) and complications. Despite advances in
antihypertensive medications HTNE is accompanied with significant
morbidity and mortality.
METHODS
We queried the 2002–2012 nationwide inpatient sample database to
identify patients with HTNE. Trends in incidence of HTNE and in-hos-
pital mortality were analyzed. Logistic regression analysis was used to
assess the relationship between end-organ complications and in-hos-
pital mortality.
RESULTS
Between 2002 and 2012, 129,914 admissions were included. Six hun-
dred and thirty (0.48%) patients died during their hospital stay. There
was an increase in the number of HTNE admissions (9,511–15,479;
Ptrend  <  0.001) with concurrent reduction of in-hospital mortality
(0.8–0.3%; Ptrend < 0.001) by the year 2012 compared to 2002. Patients
who died during hospitalization were older, had longer length of stay,
higher cost of stay, more comorbidities, and higher risk scores. Presence
Hypertension is an important modifiable risk factor for car-
diovascular disease. In the United States, nearly 1 out of 3
adults have elevated blood pressure, with the highest rates
among African Americans. Within adults with hyperten-
sion, 82% are aware of their disease and only 53% have their
blood pressure controlled to target levels.1,2 Hypertension
remains the commonest encountered problem in primary
care and is the most important modifiable risk factor when
it comes to prevention of myocardial infarction, stroke, and
renal failure.3
A majority of patients with severely elevated blood pres-
sure (blood pressure ≥ 180/120 mm Hg) have no evidence
Correspondence: Mahek Shah (dr.mahekshah@yahoo.co.in).
Initially submitted December 25, 2016; date of first revision February 18,
2017; accepted for publication March 7, 2017; online publication April
20, 2017.
700  American Journal of Hypertension  30(7)  July 2017
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of acute cardiorespiratory failure [adjusted odds ratio (OR), 15.8; 95%
confidence interval (CI), 13.2–18.9], stroke or transient ischemia attack
(TIA) (adjusted OR, 7.9; 95% CI, 6.3–9.9), chest pain (adjusted OR, 5.9;
95% CI, 4.4–7.7), stroke/TIA (adjusted OR, 5.9; 95% CI, 4.5–7.7), and aor-
tic dissection (adjusted OR, 5.9; 95% CI, 2.8–12.4) were most predictive
of higher in-hospital mortality in addition to factors such as age, aortic
dissection, acute myocardial infarction, acute renal failure, and pres-
ence of neurological symptoms.
CONCLUSION
A rising trend in hospitalization for HTNE, with an overall decrease in
in-hospital mortality was observed from 2002 to 2012, possibly related
to changes in coding practices and improved management. Presence
of acute cardiorespiratory failure, stroke/TIA, chest pain, and aortic dis-
section were most predictive of higher hospital mortality.
Keywords: blood pressure; cardio respiratory failure; end-organ dam-
age; hypertensive; hypertensive emergency; hypertension complica-
tions; malignant hypertension; mortality; NIS database.
doi:10.1093/ajh/hpx048
of end-organ damage and do not require immediate work
up and aggressive treatment.4 These patients with severe
asymptomatic hypertension comprise 5% of emergency
department visits and can be managed with oral antihyper-
tensive medications, usually as outpatients.5 Hypertensive
emergency (HTNE) or acute severe hypertension previously
known as malignant hypertension is characterized by an
accelerated increase in blood pressure secondary to increase
in catecholamines, sympathetic nervous system activity,
endothelial dysfunction, renin–angiotensin system activa-
tion, or acute stress and is linked with acute end-organ dam-
age.6 Evidence of cardiac injury or infarction, pulmonary
1Division of Cardiology, Lehigh Valley Hospital Network, Allentown,
Pennsylvania, USA; 2Division of Internal Medicine, UPMC, Pittsburg,
Pennsylvania, USA; 3Department of Medicine, Mount Sinai St Lukefs-
Roosevelt Hospital, New York, New York, USA; 4Department of
Medicine, Saint Peter’s University Hospital, New Brunswick, New Jersey,
USA; 5Division of Cardiology, St. Luke’s University Health Network,
Bethlehem, Pennsylvania, USA; 6Division of Cardiology, University of
Michigan, Ann Arbor, Michigan, USA.
© American Journal of Hypertension, Ltd 2017. All rights reserved.
For Permissions, please email: journals.permissions@oup.com

edema, acute renal failure, stroke, and/or aortic dissection in
the setting of acute rise in blood pressure are considered as
end-organ damage.7 Fortunately, the reported incidence of
HTNE is 1 to 2 cases per million per year.
Approximately 1% of patients with known hyperten-
sion develop HTNE during their lifetime and a majority of
HTNE cases are considered secondary to inadequate treat-
ment.8 In a case series of 100 patients admitted for HTNE,
50% of the patients with pre-existing hypertension had
stopped taking their antihypertensive medications more
than a month prior to admission.9 A  nationwide study in
Italy showed that 8% of visits for HTNE had no prior docu-
mentation of hypertension.10 With the advent of safe and
improved antihypertensive therapies, outcomes among
HTNE have shown improvement in recent years; however,
there is still significant morbidity attached to disease.11
Patients with HTNE remain at a higher short and inter-
mediate term risk for mortality after adjusting for age, sex,
and ethnicity among hypertensives.12 Despite expansion in
available antihypertensive treatment options, HTNE is still
a clinical challenge and the disease remains prevalent.13 In
addition, there are currently no comprehensive evidence-
based guidelines available for HTNE. Thus, there is marked
variability in how it is treated.14
The goal our study was to examine to temporal trends
in incidence of HTNE and in-hospital mortality between
the years of 2002–2012. We also assessed the relationship
between specific acute end-organ damage and in-hospital
mortality.
METHODS
Data source and study population
The Nationwide Inpatient Sample (NIS) is the largest,
publicly available, all-payer inpatient database in the United
States. Annually, the NIS is composed of discharge-level
data from roughly 8 million hospitalizations and approxi-
mates a stratified sample of 20% of community hospitals in
the United States. Each hospitalization within the database
contains clinical and resource-use information. Patients’
diagnoses are documented in parallel, as both International
Classification of Disease-9th edition-Clinical Modification
(ICD-9-CM) and clinically meaningful clusters of ICD-9-
CM’s, termed Clinical Classification Software (CCS) codes.
A comprehensive synopsis on NIS data is available at http://
www.hcup-us.ahrq.gov.
Using the NIS, patients admitted with primary diagnosis
of HTNE between 2002 and 2012 were included. HTNE was
diagnosed using International Classification of Diseases,
Ninth Revision, Clinical Modification coding (ICD-9CM)
including 401.0, 402.0x, 403.0x, 404.0x, and 405.0x. Patients
under the age of 16, missing data, and those transferred out
of hospital were excluded from the study. Death was defined
in the NIS as in-hospital mortality. Different comorbidities
were identified by using ICD-9CM diagnoses and diagnosis-
related group (see Supplementary Appendix). In patients
with HTNE, we assessed the prevalence of demographic
factors, comorbidities (diabetes, coronary artery disease,
Trends in Hospitalization for Hypertensive Emergency
chronic pulmonary disease, peripheral vascular disease, and
secondary hypertension), length of stay, hospital charges, All
Patient Refined Diagnosis Related Groups (APRDRG) sub-
classes for mortality and severity of illness risk score, proce-
dures such as echocardiography, coronary revascularization
[either percutaneous coronary intervention or bypass sur-
gery (CABG)], and acute end-organ complications/symp-
toms associated with HTNE [acute myocardial infarction,
aortic dissection, acute chest pain, acute renal failure, acute
heart failure including acute pulmonary edema, acute neu-
rological symptoms (hypertensive encephalopathy, confu-
sion, altered mental status), and stroke or transient ischemic
attack (TIA)]. We defined severity of comorbid conditions
using Deyo modification of Charlson comorbidity index
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(CCI). This index contains 17 comorbid conditions with
differential weights. The score ranges from 0 to 33, with
higher scores corresponding to greater burden of comorbid
diseases. Our primary outcome was in-hospital mortality
and comparisons were made between those who survived
to those with in-hospital death on the basis of above-men-
tioned variables.
Procedures were in accordance with the ethical standards
of the responsible committee on human experimentation
(institutional or regional) or with the Helsinki Declaration
of 1975 (as revised in 1983). Study was exempt from institu-
tional board review at our institute.
Statistics
Demographics and baseline characteristics were sum-
marized using descriptive statistics. Continuous data was
expressed as mean ± 1 SD and analyzed using the student’s
t-test. Fischer’s exact test or Pearson’s chi-square test was
used for analysis of categorical variables. Trend analysis was
performed using the Mantel–Haenszel test and the analy-
sis of variance test for categorical and continuous variables,
respectively. A multivariable hierarchical mixed effect logis-
tic regression model was created to evaluate the relationship
between baseline demographics (age, African American
race, sex), acute end-organ complications (acute myocar-
dial infarction, acute renal failure, acute cardiorespiratory
failure, stroke or TIA, aortic dissection, acute chest pain,
neurological symptoms), and in-hospital mortality. Results
were considered statistically significant for P values <0.05.
IBM SPSS statistics version 20.0 (Armonk, NY) was used to
perform data analysis.
RESULTS
Trends in admissions and mortality
A total of 129,914 admissions for HTNE were included
from the year 2002 to 2012. There were 630 patient deaths
during hospital stay (Ptrend < 0.05 for both trends). Figure 1
shows the annual trends in admissions and in-hospital for
HTNE. There was a 63% increase in the number of admis-
sions from 2002 to 2012 (9,511 to 15,479 admissions). On
the other hand, the number of in-hospital mortality among
HTNE admissions decreased from 0.8% per year in 2002 to
American Journal of Hypertension  30(7)  July 2017  701
Shah et al.
Figure 1.  Percentage of admissions for hypertensive emergency per year out of the total admissions represented on left vertical axis (n = 122 914).
In-hospital mortality % represented on right vertical axis.
0.3% per year by 2012. By the year 2007, there was a 50%
relative reduction in rate of mortality which was sustained
thereafter. We also compared mortality rates monthly, which
did not show any statistical difference (P = 0.43).
Additionally, we analyzed the annual trends in APRDRG
subclasses for mortality and severity of illness risk score ≥3
in addition to the CCI. We found that there was a statisti-
cally significant uptrend in the proportion of patients with
the higher grades of APRDRG subclasses for mortality risk
≥3 (10.2% vs. 17.2% in 2002 and 2012, respectively), sever-
ity of illness score ≥3 (24.6% vs. 32.3% in 2002 and 2012,
respectively), and the mean CCI (2.95 vs. 3.35 in 2002 and
2012, respectively).
Baseline characteristics
Patients were older (67.9 ± 16.6 years vs. 58.9 ± 17.1 years;
P  <  0.001) within the group that experienced in-hospital
mortality compared to those who were alive at discharge.
Most of the patients were admitted to urban nonteaching
hospitals and regional variations in HTNE admissions were
seen throughout the duration of the study with a consist-
ently larger proportion of admissions being from the South
(52.3%).
Table 1 represents the baseline differences between
patients who experienced in-hospital mortality and those
who survived. Similar to age, the length of stay (11.7 days
vs. 3.8 days; P < 0.001), and hospital charges ($88,899 vs.
$23,701; P < 0.001) were significantly higher within the for-
mer group. Among those who experienced in-hospital mor-
tality, a greater proportion of patients had peripheral arterial
disease (19% vs. 9.8%; P < 0.001), chronic pulmonary disease
(22% vs. 15.1%; P < 0.001), APRDRG mortality risk score,
APRDRG severity score, number of baseline chronic condi-
tions (7.9 ± 2.9 vs. 5.8 ± 2.7; P < 0.001), and CCI (3.6 ± 2.0
vs. 2. 0 ± 1.8; P < 0.001). Both the study groups were similar
when it came to race or gender, weekend admission rate, and
702  American Journal of Hypertension  30(7)  July 2017
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comorbidities such as diabetes, coronary artery disease, and
secondary hypertension.
When we studied baseline socioeconomic status, we
noticed that patients within the lowest income quartile for
ZIP code had highest admission rate. Patients in the lowest
25th percentile for income accounted for nearly 37% of total
admissions, but experienced a similar in-hospital mortality
rate compared to rest of the population (0.47% vs. 0.49%;
P  =  0.53). Forty-nine percent of all admitted patients had
Medicare as primary insurer.
Procedures
The use of echocardiogram was higher in patients who
died than survived (7.0% vs. 3.8%; P < 0.001). There was no
significant difference in the use of coronary angiogram in
the 2 groups (5.9% vs. 5.0%; P  =  0.33); however, a higher
proportion of patients received revascularization within the
group with in-hospital death (2.2% vs. 0.5%; P < 0.001).
Outcomes and association with acute end-organ
complications
The incidence of all studied acute end-organ complica-
tions was consistently higher within the group with in-
hospital mortality (Figure 2). Patients who died were more
than 7 times as likely to suffer from acute cardiorespiratory
failure compared to the patients who survived (66.2 vs. 8.9;
P < 0.001). Single-organ damage was reported in 85.7% of the
patients who died compared to 28.6% in the group that sur-
vived. More than half (56.5%) of the patients within the for-
mer group had 2 or more reported end-organ complications.
Using multivariate logistic regression analysis (Table  2),
end-organ related complications such as acute cardiores-
piratory failure [adjusted odds ratio (OR), 15.8; 95% con-
fidence interval (CI), 13.2–18.9], stroke or TIA (adjusted
OR, 7.9; 95% CI, 6.3–9.9), chest pain (adjusted OR, 5.9; 95%
 Trends in Hospitalization for Hypertensive Emergency

Table 1.  Differences in baseline characteristics, risk assessment scores, and end-organ involvement within the cohort

Died during Alive at

Characteristics hospitalization (n = 630) discharge (n = 129,284) P value

Age in years (mean ± SD) 67.9 ± 16.6 58.9 ± 17.1 <0.001

Admission day is weekend (%) 22.4 21.5 0.577
Sex—female (%) 58.4 58 0.840
Race—Caucasian (%) 38.3 36.9 0.491
Race—African American (%) 30.8 34.1 0.079
Length of stay in days (mean ± SD) 11.7 ± 15.3 3.8 ± 4.1 <0.001
Total cost in US dollars (mean) 88,899 23,071 <0.001
Diabetes (%) 31.6 32.2 0.763

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Coronary artery disease (%) 24 22.3 0.303
Chronic pulmonary disease (%) 22 15.1 <0.001
Peripheral vascular disorder (%) 19 9.8 <0.001
Secondary hypertension (%) 1.4 0.8 0.113
Number of chronic conditions (mean ± SD) 7.9 ± 2.9 5.8 ± 2.7 <0.001
Acute chest pain (%) 11.9 2.0 <0.001
Acute myocardial infarction (%) 16.7 3.5 <0.001
Acute renal failure (%) 41.4 12.6 <0.001
Aortic dissection (%) 1.4 0.3 <0.001
Acute cardiorespiratory failure (%) 66.2 8.9 <0.001
Stroke or TIA (%) 19.2 2.8 <0.001
Neurological symptoms (%) 21.3 4.7 <0.001
APRDRG severity of illness subclass (%) <0.001
 1 1.3 21.2
 2 7.8 45.5
 3 28.2 29.7
 4 62.7 3.6
APRDRG risk of mortality subclass (%) <0.001
 1 3 46.6
 2 9.6 35.1
 3 23.1 15
 4 64.3 3.3
Charlson comorbidity index (mean ± SD) 3.6 ± 2.0 2.0 ± 1.8 <0.001
Median household income quartile for patient ZIP code (%) 0.219
 1 35.4 37.0
 2 24.8 25.7
 3 24.0 20.6
 4 15.8 16.7
Hospital region (%) 0.097
 Northwest 15.9 16.8
 Midwest 15.4 18.5
 South 54.1 52.3
 West 14.6 12.4
Location/teaching status of hospital (%) 0.016

American Journal of Hypertension  30(7)  July 2017  703

Shah et al.
Table 1.  Continued
Characteristics
 Rural
  Urban nonteaching
  Urban teaching
Echocardiogram (%)
Coronary angiography (%)
Percutaneous coronary intervention (%)
Abbreviations: APRDRG, All Patients Refined Diagnosis Related Groups; TIA, transient ischemic attack.
Figure 2.  Incidence of end-organ complications.
CI, 4.4–7.7), aortic dissection (adjusted OR, 5.9; 95% CI,
2.8–12.4) were most predictive of higher in-hospital mortal-
ity. Among other risk factors, acute myocardial infarction,
acute renal failure, presence of neurological symptoms, and
age were also predictive of higher mortality. Sex and African
American race were not predictive of in-hospital mortality
(P > 0.05).
DISCUSSION
The primary finding of this manuscript was that in a large
multi-institutional observational cohort within the United
States, there was a consistent increase in HTNE admissions
with marked reduction of in-hospital mortality from 2002 to
2012. Within the in-hospital mortality group were older, had
longer hospital stays, higher cost of stay, more tests/proce-
dures, and a higher overall prevalence of baseline comorbid-
ities such as peripheral arterial disease, chronic pulmonary
disease, and clinical risk scores. Presence of acute cardi-
orespiratory failure, stroke/TIA, acute chest pain, aortic
dissection, acute myocardial infarction, acute renal failure,
neurological symptoms, and older age were all significantly
704  American Journal of Hypertension  30(7)  July 2017
Died during Alive at
hospitalization (n = 630) discharge (n = 129,284) P value
10.8 14.8
50.2 47.4
39.0 37.8
7 3.8 <0.001
5.9 5.0 0.33
2.2 0.5 <0.001
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predictive of higher in-hospital mortality. Patients who met
the primary endpoint of in-hospital death had a significantly
higher rate of end-organ complications, with almost 86% of
the patients experiencing at least single-organ complications.
A study by Polgreen et al. examined the rising trend for
more severe hypertension-related diagnoses following 2007
within NIS, and hypothesized that there was a substantial
shift in the assigning of more severe diagnoses, less mild
diagnoses, likely upcoding, and changes in billing practices.15
Alterations in coding practices have also been described in
other studies, some of which are influenced by reimburse-
ment practices, and payment policies put forward by the
Centers for Medicare and Medicaid Services.16,17 There was
a trend toward increase in baseline comorbidity and risk
scores during the same period among the HTNE patients in
our study. We propose that finding may be in part secondary
to upcoding of diagnoses, but improvements in care during
this period are also likely to have played significant role in
the decreased mortality.
A recent study on HTNE patients reported a mortal-
ity rate of 4.6%, much higher than reported in our study.18
However, they exclusively analyzed patients admitted to

Table 2.  Multivariate regression analysis assessing association with in-hospital mortality
Variable Odds ratio
Age 1.03
African American race 0.92
Female sex 0.95
Acute myocardial infarction 2.53
Acute renal failure 2.46
Acute cardiorespiratory failure 15.87
Stroke or TIA 7.91
Aortic dissection 5.92
Acute chest pain 5.89
Neurological symptoms 2.47
Abbreviations: CI, confidence intervals; TIA, transient ischemic attack.
the coronary care unit, thus inducing a selection bias and
including patients requiring critical inpatient care and had
a sample size of only 538 HTNE patients. Overall rate of in-
hospital mortality in our study was more comparable to the
mortality rates seen with hypertensive urgency of 0.8% (126
patients) in the same study. A US registry consisting of 1,588
patients admitted with acute severe hypertension requiring
intravenous antihypertensives found patients to have an even
higher hospital mortality of 6.9%.11 When we separately ana-
lyzed in-hospital mortality among our patients who had one
or more of the studied complications, in-hospital mortal-
ity rate was 1.4%. The relatively lower mortality rates (with
reduction in mortality trends) were likely due to the assign-
ment of a diagnosis of HTNE among patients with lesser
degrees of hypertensive disease with relatively benign pres-
entation explained above. This can been seen in the relatively
lower rate of end-organ damage in the group that survived
within our study, with acute renal failure being reported in
half of those. The study by Leiba et al. analyzed 1-year HTNE
mortality rates at a large scale referral center in Israel over
the course of 20 years and found a significant reduction in
mortality rates during this time, which may be attributed to
increased awareness of the worse outcomes associated with
true diagnosis leading to prompt, efficient, and improved
antihypertensive care.19 Interestingly, they reviewed 306
patient files as part of their study and found that only 46% of
the cases had a true diagnosis.
To date, large scale data on specific predictors for mor-
tality in HTNE patients is missing. HTNE has been shown
to have variable presentations when it comes to end-organ
involvement. According to one 1996 study, cerebral infarc-
tion or hemorrhage (28.5%), acute pulmonary edema (23%),
and hypertensive encephalopathy (16%) were the common-
est types of end-organ damage.11 Pacheco et al. found acute
coronary syndrome (59.5%) and acute decompensated heart
failure (25.2%) to be predominant in their assessment of
coronary care unit patients.10 Another study followed 297
HTNE patients for a median of 30 months and found that
diabetes mellitus, acute left ventricular failure, stroke, and
renal impairment were independent predictors of mortal-
ity.20 In our study, we identified age, acute cardiorespiratory
Trends in Hospitalization for Hypertensive Emergency
95% CI lower 95% CI higher P value
1.02 1.03 <0.001
0.77 1.09 0.35
0.79 1.15 0.63
2.00 3.20 <0.001
2.07 2.93 <0.001
13.28 18.96 <0.001
6.32 9.91 <0.001
2.81 12.47 <0.001
4.48 7.75 <0.001
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1.97 3.09 <0.001
failure, acute renal failure, acute myocardial infarction,
acute stroke or TIA, aortic dissection, and the presence of
hypertensive neurologic symptoms or acute chest pain as
independent factors affecting mortality. We did not find any
significant gender-based variation in mortality, though has
been reported in prior published literature. Among patients
who died, 66.2% had acute heart failure, followed by renal
failure (41.4%), neurological symptoms (21.3%), stroke/TIA
(19.2%), and acute myocardial infarction (16.7%). Not all
HTNE is created equal. Patients developing acute cardiores-
piratory failure, stroke or TIA, and aortic dissection suffer-
ing from the worst outcomes.
Additional prognostic information was also obtained by
using risk scores within the NIS database. APRDRG is a clas-
sification system that classifies patients according to their
reason of admission, severity of illness, and risk of mortality
and has been validated when it comes to predicting hospital
outcomes.21 Patients with in-hospital mortality were more
likely to have a greater proportion of patients in the more
severe subclasses for both risk scores. Patient with in-hos-
pital mortality also had a higher CCI, a known prognostic
marker for higher hospital mortality among other factors.22
The incidence and mortality related to several cardio-
vascular emergencies especially myocardial infarction has
a clear tendency to increase during the winter months.23,24
Deshmukh et  al. analyzed the 2000–2007 NIS database
and reported seasonal variations in the incidence of HTNE
admissions, with a spike during the winter months. We ana-
lyzed the trends in seasonal mortality and found no signifi-
cant difference in rates mortality throughout the year.
There are some limitations to this study. The study is based
on administrative data. No charts were available and we did
not study out of hospital deaths. We are heavily dependent
on coders, which may have wide variation and potential for
unrecognized miscoding. There is a possibility of selection
bias and residual measured and unmeasured confounding
factors, as this is a retrospective observational study. We
were unable to assess beyond hospital stay or report upon
treatment strategies used. We hope that the large number of
database studied eliminates these limitations. We propose
incremental improvement in care during the time of the
American Journal of Hypertension  30(7)  July 2017  705
Shah et al.
study but are unable to evaluate the treatment strategies that
may have been responsible. Our findings need validation in
other large registries or observational studies, as it would
enable us to risk stratify patients with HTNE and influence
management. We strongly believe prospectively conducted
studies with stringent criteria for diagnosis of HTNE are
urgently needed to study the impact of end-organ complica-
tions and specific treatment strategies on outcomes.
SUPPLEMENTARY MATERIAL
Supplementary data are available at American Journal of
Hypertension online.
ACKNOWLEDGMENTS
No study specific funding was used to support this work.
The authors are solely responsible for the study design, con-
duct and analyses, drafting and editing of the manuscript,
and its final contents. All authors had access to the data and
a role in writing the manuscript.
DISCLOSURE
The authors declared no conflict of interest.
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