Gaps between guidelines and practice in hypertensive urgencies and emergencies: data from a multinational European registry in ESH excellence centres

OBJECTIVE: Hypertensive urgencies (HU) and hypertensive emergencies (HE) have significant clinical and public health implications, yet standardized management strategies are lacking. To address this gap, the European Society of Hypertension (ESH) initiated the ESH-URGEM registry to assess the epidemiology, clinical characteristics, and management of HU and HE across Europe over 12 months. METHODS: ESH conducted a prospective, observational study in emergency departments (EDs) of ESH-affiliated hospitals (ESH Excellence Centers). Adult patients (≥18 years) presenting with HU or HE were enrolled during ≥12-h shifts, once weekly, over 1 year. RESULTS: Among 115 169 ED visits, 998 cases (0.87%) were identified as hypertensive crises (HC): 77.3% HU and 22.7% HE. HE patients were older (mean age 70 vs. 66 years; P = 0.004) and had more comorbidities, including coronary artery disease, heart failure, and chronic kidney disease. The most frequent triggers were emotional stress (44.8%), acute pain (33.7%), and medication nonadherence (15.5%). HE commonly manifested as acute coronary syndromes (39.6%), pulmonary edema (33.8%), or neurological complications (14.1%). HE treatment most often included intravenous nitrates (60.5%) and diuretics (45.8%). Also, 35.1% of HU cases also received intravenous therapy. Only 18.9% of HE patients were admitted to coronary or intensive care units, while 16.1% of HU patients were hospitalized, frequently for nonhypertension-related conditions. Guideline-recommended assessments for target organ damage and cardiovascular risk estimation such as fundoscopy and albuminuria testing were rarely performed. CONCLUSIONS: This registry highlights critical issues in the ED management of HC and hypertension, including: underdiagnosis of chronic hypertension, insufficient admission of HE patients to intensive or coronary care units, overly aggressive treatment of HU, and underuse of fundoscopy and albuminuria screening. Addressing these deficiencies through guideline implementation, structured care pathways, and improved follow-up could enhance outcomes for this high-risk population.