Nosebleeds – epistaxis – and hypertension are common conditions in the adult population, but establishing a link between blood pressure level and the incidence of epistaxis in a patient with hypertension is a real issue facing physicians in their clinical practice.
Epistaxis occurs in 60% of people at least once in their lifetime. Most episodes are mild and short-lived, but around 6% of people with epistaxis require medical intervention, reports Medscape.
We know that epistaxis has many causes, including dry air, infection, allergy, trauma, alcohol abuse and anticoagulant use.
Of the many risk factors for developing epistaxis, hypertension is considered one of the most important; a hypothesis postulated on the basis of clinical impression.
In recent years, several studies have examined the link between hypertension and epistaxis, with heterogeneous results emerging from systematic reviews and meta-analyses. The association between these two conditions remains controversial.
High BP
The link between blood pressure and epistaxis in a hypertensive patient is certainly a commonly discussed matter in clinical practice.
A systematic review has analysed the correlation of a patient’s arterial pressure at presentation with nasal bleeding and the repercussions of episodes of epistaxis in hypertensive patients. Overall, nine studies that fulfilled the inclusion criteria were identified.
Six of nine studies agreed that arterial pressure is higher at the time of epistaxis compared with the control group or the general population.
Seven of nine studies concluded that there is cross-correlation between arterial pressure and the actual incident of epistaxis, in the sense that the epistaxis may lead to initial diagnosis of already established arterial hypertension.
Epistaxis severity
Epistaxis severity in relation to hypertension was investigated in a retrospective study carried out in a hospital setting in patients admitted for an episode of severe spontaneous epistaxis.
Epistaxis was classified into two groups, severe and life-threatening, on the basis of the severity criteria for the event (need for transfusion, surgical approach, medication required, etc.).
No significant differences were observed between the two groups in terms of age, sex, history of epistaxis and blood pressure characteristics, including history of hypertension.
Patients with more severe epistaxis had a similar exposure to anticoagulant and platelet anti-aggregant medications, compared with patients with less severe epistaxis.
As a result, the authors assert that the pathophysiology of serious spontaneous epistaxis remains unclear.
The study involved older adults (age > 60-70 years) with a history of hypertension in about 50% of cases. Serious spontaneous epistaxis may also be the presenting sign of underlying true hypertension in about 43% of patients, in whom there is no history of hypertension at the time of the first nosebleed.
However, hypertension per se does not appear to be a statistically significant cause of or a factor in the severity of serious spontaneous epistaxis.
More recent findings from a retrospective cohort study suggest that hypertension is associated with an increased risk for and severity of epistaxis.
In a cohort of more than 35 000 hypertensive persons, the incidence rate of epistaxis was 32.97 per 10 000 people, compared with 22.76 per 10 000 in the control group. The incidence rate of recurrent epistaxis was 1.96 per 10 000 people in the hypertension cohort and 1.59 per 10 000 in the non-hypertension cohort.
Patients with hypertension who experienced epistaxis were more likely to use the emergency department (odds ratio, 2.69) and receive posterior nasal packing (odds ratio, 4.58) compared with the comparison cohort.
The study confirms that patients with hypertension have more episodes of epistaxis requiring a greater number of emergency department visits compared with patients without hypertension. The former have a greater incidence and severity of epistaxis, but the number of recurrent episodes between the two groups is not significantly different.
Nosebleeds requiring emergency department access and more advanced management methods (such as posterior nasal packing) were more common in patients with hypertension.
However, these results and the mutual relationship between the two conditions require confirmation from further studies to determine whether effective management of hypertension is sufficient to reduce the incidence and severity of epistaxis.
Medscape article – Epistaxis and Hypertension: Reviewing a Complex Relationship (Open access)
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