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Association of Hypertension With the Risk and Severity of Epistaxis

Educational Objective
To evaluate the risk of epistaxis for patients with hypertension using a nationwide cohort.
1 Credit CME
Key Points

Question  Is hypertension associated with the risk and severity of epistaxis?

Findings  This nationwide population cohort study of 71 498 individuals found that, compared with patients without hypertension, those with hypertension appeared to have an increased risk of epistaxis, had more emergency department visits, and required more posterior nasal packing procedures.

Meaning  This study suggests that hypertension is associated with an increased risk and severity of epistaxis.

Abstract

Importance  The association between hypertension and epistaxis has long been a subject of debate.

Objectives  To evaluate the risk of epistaxis in patients with hypertension using a nationwide population cohort and to assess the association of hypertension with the methods of managing cases of epistaxis.

Design, Setting, and Participants  In this retrospective cohort study, a hypertension cohort and comparison cohort were built using the Korean National Health Insurance Service–National Sample Cohort that represents the entire population of the Republic of Korea from January 1, 2002, to December 31, 2015. The hypertension cohort comprised 35 749 patients with a record of 3 or more prescriptions of antihypertensive medication and a diagnosis of hypertension (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code I10). Patients with other diseases associated with epistaxis, such as sinonasal tumors, facial trauma, bleeding tendency, and coagulation disorder, as well as those taking anticoagulant medications, were excluded. A comparison cohort comprised 35 749 individuals without hypertension matched sociodemographically in a 1:1 ratio. Statistical analysis was performed from January 1, 2019, to March 31, 2020.

Main Outcomes and Measures  The incidence and recurrence of epistaxis were evaluated in both cohorts. The risk factors for epistaxis and management strategies were also assessed.

Results  Among the 35 749 patients in the hypertension cohort (20 579 men [57.6%]; median age, 52 years [interquartile range, 45-62 years]) the incidence rate (IR) of epistaxis was 32.97 per 10 000 persons (95% CI, 30.57-35.51 per 10 000 persons); among the 35 749 individuals in the comparison cohort (20 910 men [58.5%]; median age, 52 years [interquartile range, 45-62 years]), the IR of epistaxis was 22.76 per 10 000 persons (95% CI, 20.78-24.89 per 10 000 persons) (IR ratio, 1.45; 95% CI, 1.29-1.63; adjusted hazard ratio, 1.47; 95% CI, 1.30-1.66). The IR of recurrent epistaxis was 1.96 per 10 000 persons in the hypertension cohort and 1.59 per 10 000 persons in the nonhypertension cohort (IR ratio, 1.23; 95% CI, 0.77-2.00). Patients with hypertension who experienced epistaxis were more likely to use the emergency department (odds ratio, 2.69; 95% CI, 1.70-4.25; Cohen h effect size, 0.27; 95% CI, 0.16-0.39) and receive posterior nasal packing (odds ratio, 4.58; 95% CI, 1.03-20.38; Cohen h effect size, 0.15; 95% CI, 0.03-0.26) compared with the comparison cohort.

Conclusions and Relevance  This study suggests that patients with hypertension had an increased risk of epistaxis requiring hospital visits. In addition, epistaxis in patients with hypertension appeared to need more emergency department visits and require more posterior nasal packing procedures compared with patients without hypertension. Medical counseling about epistaxis is advisable for individuals with hypertension, and the presence of hypertension should be considered in managing nasal bleedings.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: July 20, 2020.

Published Online: September 10, 2020. doi:10.1001/jamaoto.2020.2906

Correction: This article was corrected on December 10, 2020, to fix an error in the Figure.

Corresponding Author: Jae Ho Chung, MD, PhD, Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Hanyang University, 222-Wangshimni-ro, Seongdong-gu, Seoul, 04763, Korea (jaeho.chung.md@gmail.com).

Author Contributions: Dr Byun and Ms Ryu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Chung, Lee, Kim, Shin.

Acquisition, analysis, or interpretation of data: Byun, Chung, Ryu.

Drafting of the manuscript: Byun, Chung, Lee.

Critical revision of the manuscript for important intellectual content: Byun, Chung, Ryu, Kim, Shin.

Statistical analysis: Chung, Ryu, Shin.

Obtained funding: Chung.

Administrative, technical, or material support: Byun, Chung, Shin.

Supervision: Chung, Lee, Kim.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was supported by the Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education (NRF-2017R1D1A1B03033051).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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