Subclinical hypertensive heart disease in black patients with elevated blood pressure in an inner-city emergency department

Recruitment of emergency department patients to a prospective observational study

BACKGROUND

The dynamic environment of the emergency department (ED) poses unique challenges to the execution of well-designed research. There is limited investigation into the viability of studies conducted in the ED. This paper offers a systematic evaluation of our recruitment of emergency patients for a prospective observational research study, shedding light on the intricate landscape of research feasibility within the ED setting.

RESULTS

Research coordinators dedicated 2816.83 h to screening, recruiting, and enrolling patients between June 2018 and September 2023, having to stop recruitment twice due to financial constraints and the COVID-19 pandemic. 485 patients were approached and 84 of them were enrolled, resulting in a 31.94% enrollment rate, with approximately 2.8 participants recruited per month. Of those enrolled, 77 completed all study endpoints. Most participants were Hispanic (n = 44; 52.3%) and/or Black (n = 37; 44%), middle-aged (µ = 51.7 years), and female (n = 48; 57.1%). Participant recruitment was challenged by competing mindsets, the COVID-19 pandemic, and high staff turnover.

CONCLUSIONS

Recruiting emergency patients for a prospective observational study is feasible given adequate staffing and financial resources. Standardizing feasibility assessments for the recruitment of patients in the emergency department is important to the success of future study.

Brief Risk Communication for Emergency Department Patients With Sustained Asymptomatic Hypertension

INTRODUCTION

Sustained asymptomatic hypertension in ED patients is a powerful predictor of chronic uncontrolled hypertension. In this study, we assess the feasibility of using a storyboard video and communicating real-time cardiovascular imaging results on blood pressure control and primary care engagement.

METHODS

This was a prospective observational exploratory sub-study. Following Institutional Review Board approval (#18-00197), 20 English-speaking adults in an urban emergency department with an initial blood pressure ≥160/100 mm Hg and a second blood pressure ≥140/90 mm Hg were enrolled. Patients watched a 60-second storyboard video about uncontrolled hypertension in the ED setting, featuring racially and ethnically diverse avatars. They then received a real-time bedside echocardiogram. Emergency nurses communicated the echocardiogram results using a standard script and advised follow-up within 2 weeks after discharge. Patient characteristics, blood pressure control, primary care engagement, and acceptability of the intervention were assessed at baseline, 12 weeks, and 24 weeks post-discharge.

RESULTS

All 20 enrolled patients (mean age 55, 70% female, and 95% from underrepresented groups [30% Black, 50% Hispanic, and 15% Black and Hispanic]) exhibited subclinical heart disease on echocardiograms. Blood pressure control improved from baseline (systolic 166 mm Hg, diastolic 97 mm Hg) to 24 weeks (systolic 137 mm Hg, diastolic 78 mm Hg). Seventy percent of patients engaged with primary care post-discharge, and the intervention had high acceptability (94.8% approval).

DISCUSSION

The Brief Risk Communication for ED patientswith sustained asymptomatic hypertension study demonstrates the feasibility and acceptability of using a brief video and real-time cardiovascular imaging for risk communication in the emergency department. Future research will build on these findings with a larger, more comprehensive study.

Prevalence of undiagnosed stage B heart failure among emergency department patients

INTRODUCTION

Heart failure (HF) is associated with significant morbidity, mortality, and health care costs. Stage B HF is defined as structural heart disease prior to developing symptomatic HF. If identified early in the disease process, preventative measures may be implemented to slow disease progression to Stage C (symptomatic) or Stage D (refractory) HF. Previous research has focused on outpatient screening for HF in the primary care setting; however, there are limited data on Stage B HF screening in the Emergency Department (ED) setting. The objective of this study was to determine the prevalence of undiagnosed Stage B HF among those with cardiovascular risk factors in the ED setting and identify which risk factors were associated with a greater risk of having Stage B HF.

METHODS

A prospective, observational study was performed in a single, urban academic ED from 07/2023 to 05/2024. Inclusion criteria were age ≥ 45 years with hypertension, diabetes, obesity, coronary heart disease, previous cardiotoxic chemotherapy, or family history of HF. Exclusion criteria included signs or symptoms of HF, known history of HF, valvular disease, current atrial fibrillation, or primary language other than English. A focused cardiac ultrasound was performed and interpreted by ultrasound-fellowship trained emergency physicians. Sonographers assessed systolic function as ejection fraction <50 % using visual assessment in at least two different views. Sonographers assessed diastolic dysfunction as an E/A ratio < 0.8, or if ≥2 of the following were present: septal e' < 7 cm/s or lateral e' < 10 cm/s, E/e' ratio > 14, or left atrial volume > 34 mL/m2. Descriptive statistics were performed, followed by comparative analyses and regression modeling.

RESULTS

209 participants were included in the study, with a mean age of 60 years and 51.7 % women. Of these, 125 (59.8 %) had undiagnosed Stage B HF, with 13 (10.4 %) having systolic dysfunction and 112 (89.6 %) having isolated diastolic dysfunction. Among those with isolated diastolic dysfunction, 44 (39.3 %) were grade I, 66 (58.9 %) were grade II, and 2 (1.8 %) were grade III. Predictors of undiagnosed Stage B HF included age (odds ratio 1.06; 95 % CI 1.02 to 1.10) and BMI (odds ratio 1.06; 95 % CI 1.01 to 1.10).

CONCLUSION

A large majority of ED patients with cardiovascular risk factors had undiagnosed Stage B HF. Age and obesity were associated with a higher risk of Stage B HF. This provides an opportunity for early identification and intervention for patients with undiagnosed Stage B HF to reduce progression to more severe HF.

Evaluation of myocardial strain in patients with subclinical hypertrophic cardiomyopathy and subclinical Hypertensive Heart Disease using Cardiac magnetic resonance feature tracking

The evaluation of cardiac magnetic resonance feature tracking may have great diagnostic value in hypertrophic cardiomyopathy and hypertensive heart disease. Exploring the diagnostic and clinical research value of cardiac magnetic resonance feature tracks in evaluation of myocardium deformation in patients with subclinical hypertrophic cardiomyopathy(SHCM)and subclinical hypertensive heart disease(SHHD). Cardiovascular Magnetic Resonance (CMR) scans were performed on a 1.5 T MR scanner in 33 patients with SHCM, 31 patients with SHHD, and 27 controls(NS). The CMR image post-processing software was used to analyze the characteristics of routine cardiac function, different global and regional myocardial strain in each group. Analysis of variance (ANOVA) was used to compare age, blood pressure, heart rate, routine cardiac function, body mass index (BMI), as well as the strain between different segments within each of the three groups. Once a significant difference was detected, a least significant difference (LSD) comparison would be performed. The diagnostic efficacy of different parameters in differentiating SHHD from SHCM was evaluated through receiver operating characteristic (ROC) curve analysis, and the best cut-off value was determined. There was no statistical difference among three groups (P>0.05) in routine cardiac function while significant statistical differences were found in the global myocardial strain parameters and the peak strain parameters of some segments (especially basal segments) (P < 0.05). The global radial peak strain (GRPS) was most effective (AUC = 0.885, 95% CI: 0.085-0.971, P<0.001) with a sensitivity and specificity of 84% and 88% at a cut-off value of 40.105, contributing to distinguishing SHCM from SHHD group. Cardiac magnetic resonance feature tracking could detect left ventricular deformation in patients with SHCM and SHHD group. The abnormality of strain has important research value for subclinical diagnosis and clinical evaluation.

Clinical utility of routine investigations and risk factors of end-organ damage in asymptomatic severe hypertension

Asymptomatic severe hypertension is defined as systolic blood pressure of ≥ 180 mmHg or diastolic blood pressure of ≥ 120 mmHg without signs and symptoms of end-organ damage or dysfunction. Literature shows that around 5% of the patients with severe asymptomatic hypertension had acute hypertension-related end-organ damage. This study aimed to determine the clinical utility of routine investigations and risk factors of end-organ damage in patients presented to the emergency department with  asymptomatic severe hypertension. This single-center, cross-sectional study was conducted at the emergency department of the Aga Khan University Hospital, Karachi, Pakistan, from January 2018 to December 2020. All adult patients (age ≥ 18 years) presented to the emergency department with a systolic blood pressure of ≥ 180 or diastolic blood pressure of ≥ 120 mmHg without any signs and symptoms of end-organ damage (e.g., chest pain, unilateral limb or facial weakness, or hemiplegia, altered mental status, shortness of breath, decreased urine output, and sudden-onset of severe headache) were included. Routine investigations were analyzed to detect end-organ damage, including complete blood count, basic metabolic panel, urine detailed report, electrocardiogram, and troponin-I. Multivariable binary logistic regression was applied to identify the risk factors of end-organ damage considering the significant p value of ≤ 0.05. A total of 180 patients were presented to the emergency department with asymptomatic severe hypertension during the study period. Among the total patients, 60 patients (33.3%) had abnormal investigation findings; out of them, new-onset end-organ damage was diagnosed in 15 patients (8.3%). The most common end-organ damage was the kidney (73.3%) followed by the heart (26.6%). The multivariable binary logistic regression showed that age of more than 60 years, past medical history of diabetes, ischemic heart disease, and cerebrovascular accident were significantly associated with a higher risk of end-organ damage (p < 0.05). The study identified a higher prevalence of abnormal routine investigations and acute end-organ damage in emergency department patients with asymptomatic severe hypertension compared to high-income countries and suggested a lower threshold for end-organ damage screening in these patients. The current recommendations of foregoing further workup in patients with asymptomatic severe hypertension may need modification for emergency departments in low-middle-income countries if similar associations are replicated in other settings.

Does Vitamin D Provide Added Benefit to Antihypertensive Therapy in Reducing Left Ventricular Hypertrophy Determined by Cardiac Magnetic Resonance?

BACKGROUND

Left ventricular hypertrophy (LVH) and vitamin D deficiency have been linked to hypertension (HTN) and cardiovascular disease, particularly in African Americans (AAs). Our objective was to determine if the addition of vitamin D to antihypertensive therapy would lead to greater regression of LV mass index (LVMI) as determined by cardiac magnetic resonance (CMR) after 1 year in vitamin D deficient AA patients with uncontrolled HTN and LVH.

METHODS

This study was a randomized, double-blind, placebo-controlled, single-center study. AA patients with HTN (systolic blood pressure [BP] >160 mm Hg), increased LVMI, and vitamin D deficiency (<20 ng/ml) were randomized. All patients received antihypertensive therapy combined with biweekly 50,000 IU vitamin D3 (vitamin D group, n = 55) or placebo (placebo group, n = 58).

RESULTS

At 1 year, there were no statistical differences between the vitamin D and placebo groups in LVMI (-14.1 ± 14.6 vs. -16.9 ± 13.1 g/m2; P = 0.34) or systolic BP (-25.6 ± 32.1 vs. -25.7 ± 25.6 mm Hg; P = 0.99) reduction, respectively. Serum vitamin D levels increased significantly in the vitamin D group compared with placebo (12.7 ± 2.0 vs. 1.8 ± 8.2 ng/ml; P < 0.001).

CONCLUSIONS

In this high-risk cohort of AAs we did not find an association between vitamin D supplementation and differential regression of LVMI or reduction in systolic BP. However, our study suffered from a small sample size with low statistical power precluding a definitive conclusion on the therapeutic benefit of vitamin D in such patients.

CLINICAL TRIALS REGISTRATION

Trial Number NCT01360476. Full trial protocol is available from corresponding author.

Effect of Lower Blood Pressure Goals on Left Ventricular Structure and Function in Patients With Subclinical Hypertensive Heart Disease

BACKGROUND

Subclinical hypertensive heart disease (SHHD) is a precursor to heart failure. Blood pressure (BP) reduction is an important component of secondary disease prevention in patients with SHHD. Treating patients with SHHD utilizing a more intensive BP target (120/80 mm Hg), may lead to improved cardiac function but there has been limited study of this, particularly in African Americans (AAs).

METHODS

We conducted a single center, randomized controlled trial where subjects with uncontrolled, asymptomatic hypertension, and SHHD not managed by a primary care physician were randomized to standard (<140/90 mm Hg) or intensive (<120/80 mm Hg) BP therapy groups with quarterly follow-up for 12 months. The primary outcome was the differences of BP reduction between these 2 groups and the secondary outcome was the improvement in echocardiographic measures at 12 months.

RESULTS

Patients (95% AAs, 65% male, mean age 49.4) were randomized to the standard (n = 65) or the intensive (n = 58) BP therapy groups. Despite significant reductions in systolic BP (sBP) from baseline (-10.9 vs. -19.1 mm Hg, respectively) (P < 0.05), no significant differences were noted between intention-to-treat groups (P = 0.33) or the proportion with resolution of SHHD (P = 0.31). However, on post hoc analysis, achievement of a sBP <130 mm Hg was associated with significant reduction in indexed left ventricular mass (-6.91 gm/m2.7; P = 0.008) which remained significant on mixed effect modeling (P = 0.031).

CONCLUSIONS

In post hoc analysis, sBP <130 mm Hg in predominantly AA patients with SHHD was associated with improved cardiac function and reverse remodeling and may help to explain preventative effects of lower BP goals.

CLINICAL TRIALS REGISTRATION

Trial Number NCT00689819.

Efficacy of enhanced emergency department discharge for chronic hypertension management - Results of a randomized controlled trial

Introduction

AchieveBP is a randomized controlled trial (RCT) of an education intervention for patients with chronic hypertension who have uncontrolled blood pressure (BP) at discharge from an urban emergency department (ED). The study examined efficacy and moderators of an educational intervention in an RCT on BP control at 180-day post-intervention.

Methods

Participants were recruited from a single, urban ED and randomized to receive or not to receive hypertension education. To minimize potential bias, participants were all started on an evidence-based anti-hypertensive regimen and medications were dispensed directly to participants by the study team. Bivariate analysis was performed to examine differences in sociodemographic characteristics between patients achieving BP control and those who did not. Paired t-test was used to compare the difference of systolic and diastolic BP between baseline and 180 days post-discharge. Multiple logistic regression analysis examined interaction of covariates and intervention on achieving BP control.

Results

One hundred and thirty-nine participants were randomized into the study. All were African-American with a mean age of 47.6 (SD = 10.8) years; 51% were male, 63% had smoked cigarettes and 15% had diabetes. A total of 66 patients completed the study (47.4%), 44 of whom (67%) achieved BP control. However, there was no difference in BP reduction or control between the two groups. Age and smoking status showed moderation effects on intervention efficacy.

Conclusion

Despite a neutral effect of our intervention, a high level of BP control was achieved overall, suggesting that the ED may be a viable location for efforts aimed at reducing the impact of chronic hypertension in predominantly African American communities.

Institutional Pathways to Improve Care of Patients with Elevated Blood Pressure in the Emergency Department

PURPOSE OF REVIEW

Hypertension (HTN) is the most prevalent cardiovascular disease and poses a major population level risk to long-term health outcomes. Despite this critical importance, and the widespread availability of effective and affordable medications, blood pressure (BP) remains uncontrolled in up to 50% of the diagnosed patients. This problem is exacerbated in communities with limited access to primary care, who often utilize hospital emergency departments (EDs) as their primary healthcare resource. Despite the ubiquity of patients presenting to EDs with severely elevated BP, a unified, evidence-based approach is not yet widely implemented, and both under- and overtreatment are common. The purpose of this review is to describe an approach towards institutional policy regarding asymptomatic HTN, in which we will translate the accepted principles of appropriate outpatient BP management to ED and inpatient settings.

RECENT FINDINGS

Results from the recent SPRINT trial, and the subsequent publication of the American Heart Association updated guidelines for the treatment of HTN, significantly lower both the diagnostic threshold and the treatment goals for hypertensive patients. This change will drastically increase the proportion of patients presenting to EDs with newly diagnosed and uncontrolled HTN. Several recent studies emphasize the safety in outpatient management of patients with severely elevated BP in the absence of acute end-organ damage and, conversely, the long- and intermediate-term risk associated with these patients. System-based approaches, particularly those led by non-physicians, have shown the greatest promise in reducing population level uncontrolled HTN. Evidence-based approaches, such as those described in emergency medicine and cardiology society guidelines, can guide appropriate management of ED and inpatient BP elevations. Translating these patient oriented guidelines into institutional policy, and maintaining provider adherence, is a challenge across healthcare institutions. We present here several examples of successful policies developed and implemented by the authors. While brief inpatient and ED encounters cannot replace long-term outpatient care, they have the potential to serve as a crucial inlet to health care and an opportunity to optimize care.

Recognition of Asymptomatic Hypertension in an Urban Emergency Department: Where Are We Now?

Persistently elevated blood pressure ([BP]; hypertension [HTN]) occurs at higher rates in the emergency department ([ED]; 44%) than in the general population (27%) and disproportionately affects black patients and older adults. The American College of Emergency Physicians recommends referral to primary care for HTN confirmation and management when patients are asymptomatic and their BP is persistently elevated (). However, adherence to this clinical policy is suboptimal. The purpose of this study was to examine the prevalence of asymptomatic HTN, rates of BP reassessment and referral, and factors associated with it among adult patients who visit the ED and who were discharged a decade after this policy was disseminated. A retrospective chart analysis of adults with an initial BP of 140/90 mmHg or greater and who were discharged was included in the sampling frame. Appropriate bivariate analysis, followed by multivariate regression, was conducted. There were 2,367 patients who met inclusion criteria, of which 1,184 patients had asymptomatic HTN. A greater proportion of the sample was male (51.3%), Black (43.2%; p < 0.000), middle aged (μ = 50.2 ± 16), and covered by Medicaid (39.8%). Mean initial BP was 170/88 mmHg. A large proportion of patients with asymptomatic HTN (94.2%) had no previously diagnosed cardiovascular disease (CVD). The BP reassessment rate was 49% (μ = 158/88), and these patients were more likely to have no previously diagnosed CVDs (p = 0.02). Only 4.6% (n = 28) of patients with asymptomatic HTN were referred, and these patients were more likely to have no previously diagnosed CVDs (p = 0.000) and be middle-aged (p = 0.008). Adherence to follow-up was 100%.

Screening and Treatment for Subclinical Hypertensive Heart Disease in Emergency Department Patients With Uncontrolled Blood Pressure: A Cost-effectiveness Analysis

OBJECTIVES

Poorly controlled hypertension (HTN) is extremely prevalent and, if left unchecked, subclinical hypertensive heart disease (SHHD) may ensue leading to conditions such as heart failure. To address this, we designed a multidisciplinary program to detect and treat SHHD in a high-risk, predominantly African American community. The primary objective of this study was to determine the cost-effectiveness of our program.

METHODS

Study costs associated with identifying and treating patients with SHHD were calculated and a sensitivity analysis was performed comparing the effect of four parameters on cost estimates. These included prevalence of disease, effectiveness of treatment (regression of SHHD, reversal of left ventricular hypertrophy [LVH], or blood pressure [BP] control as separate measures), echocardiogram costs, and participant time/travel costs. The parent study for this analysis was a single-center, randomized controlled trial comparing cardiac effects of standard and intense (<120/80 mm Hg) BP goals at 1 year in patients with uncontrolled HTN and SHHD. A total of 149 patients (94% African American) were enrolled, 133 (89%) had SHHD, 123 (93%) of whom were randomized, with 88 (72%) completing the study. Patients were clinically evaluated and medically managed over the course of 1 year with repeated echocardiograms. Costs of these interventions were analyzed and, following standard practices, a cost per quality-adjusted life-year (QALY) less than $50,000 was defined as cost-effective.

RESULTS

Total costs estimates for the program ranged from $117,044 to $119,319. Cost per QALY was dependent on SHHD prevalence and the measure of effectiveness but not input costs. Cost-effectiveness (cost per QALY less than $50,000) was achieved when SHHD prevalence exceeded 11.1% for regression of SHHD, 4.7% for reversal of LVH, and 2.9% for achievement of BP control.

CONCLUSIONS

In this cohort of predominantly African American patients with uncontrolled HTN, SHHD prevalence was high and screening with treatment was cost-effective across a range of assumptions. These data suggest that multidisciplinary programs such as this can be a cost-effective mechanism to mitigate the cardiovascular consequences of HTN in emergency department patients with uncontrolled BP.

Total antihypertensive therapeutic intensity score and its relationship to blood pressure reduction

Predicting blood pressure (BP) response to antihypertensive therapy is challenging. The therapeutic intensity score (TIS) is a summary measure that accounts for the number of medications and the relative doses a patient received, but its relationship to BP change and its utility as a method to project dosing equivalence has not been reported. We conducted a prospective, single center, randomized controlled trial to compare the effects of Joint National Committee (JNC) 7 compliant treatment with more intensive (<120/80 mm Hg) BP goals on left ventricular structure and function in hypertensive patients with echocardiographically determined subclinical heart disease who were treated over a 12-month period. For this preplanned subanalysis, we sought to compare changes in BP over time with changes in TIS. Antihypertensive therapy was open label. TIS and BP were determined at 3-month intervals with titration of medication doses as needed to achieve targeted BP. Mixed linear models defined antihypertensive medication TIS as an independent variable and change in systolic BP as an outcome measure, while controlling for gender, age, baseline BP, and treatment group. A total of 123 patients (mean age 49.4 ± 8.2 years; 66% female; 95.1% African-American) were enrolled and 88 completed the protocol. For each single point increase in total antihypertensive TIS, a 14.5 (95% confidence interval: 11.5, 17.4) mm Hg decrease in systolic BP was noted (15.5 [95% confidence interval: 13.0, 18.0] mm Hg for those who completed the trial). Total TIS is a viable indicator of the anticipated BP-lowering effect associated with antihypertensive therapy.

The Inter-rater Reliability of Echocardiographic Diastolic Function Evaluation Among Emergency Physician Sonographers

STUDY OBJECTIVES

In a patient with dyspnea and suspected CHF, the evaluation of diastolic function involves: tissue Doppler of the mitral annulus and 2) pulsed wave Doppler of the mitral inflow. We aimed to 1) determine the inter-rater reliability for overall diastolic function and 2) evaluate the reliability of the individual Doppler measurements.

METHODS

A convenience sample of adult emergency department patients was prospectively enrolled by 8 EPs who had participated in a 1-hour didactic session. Patients were selected if they had a history of CHF or suspected abnormal diastolic function due to chronic hypertension. Diastolic function was considered to be abnormal if Tissue Doppler of the septal e' was <8 cm/s and if the lateral e' was <10 cm/s. In cases of discordance, the E/e' ratio was calculated with ≤8 considered normal and >8 considered abnormal. A Kappa coefficient. Bland-Altman plot and a fixed effect regression model were used in the analysis.

RESULTS

Thirty-two patients were enrolled, and 3 (9.4%) were excluded due to technical inadequacy. The inter-rater reliability among sonographers for overall interpretation was very good: κ = 0.86 (95% CL [0.67, 1.0]). Based on the Bland-Altman plot, was no consistent bias between readers. There was no evidence to conclude that the readings differed among sonographers: septal e' (p = 0.77), lateral e' (p = 0.89) and E (p = 0.15).

CONCLUSION

EP sonographers obtained similar Doppler measurements for diastolic function evaluation with very good inter-rater reliability for the assessment of overall diastolic function.

Clinical and Research Considerations for Patients With Hypertensive Acute Heart Failure: A Consensus Statement from the Society for Academic Emergency Medicine and the Heart Failure Society of America Acute Heart Failure Working Group

Management approaches for patients in the emergency department (ED) who present with acute heart failure (AHF) have largely focused on intravenous diuretics. Yet, the primary pathophysiologic derangement underlying AHF in many patients is not solely volume overload. Patients with hypertensive AHF (H-AHF) represent a clinical phenotype with distinct pathophysiologic mechanisms that result in elevated ventricular filling pressures. To optimize treatment response and minimize adverse events in this subgroup, we propose that clinical management be tailored to a conceptual model of disease that is based on these mechanisms. This consensus statement reviews the relevant pathophysiology, clinical characteristics, approach to therapy, and considerations for clinical trials in ED patients with H-AHF.

Hypertension in the Emergency Department

Hypertension is the leading risk factor for the global burden of disease, yet more than 20% of adults with hypertension are unaware of their condition. Underlying hypertension affects over 25% emergency department attendees, and the condition is more commonly encountered in emergency departments than in primary care settings. Emergency departments are strategically well placed to fulfill the important public health goal of screening for hypertension, yet less than 30% of patients with mild to severe hypertension are referred for follow up. In predominantly African American populations, subclinical hypertensive disease is highly prevalent in ED attendees with asymptomatic elevated blood pressure. Although medical intervention is not usually required, in select patient populations, it may be beneficial for antihypertensive medications to be started or adjusted in the emergency department, aiming for optimizing blood pressure control earlier while waiting for continuing care.

Patient education and follow-up as an intervention for hypertensive patients discharged from an emergency department: a randomized control trial study protocol

Background

Persistently elevated blood pressure (BP) is a leading risk factor for cardiovascular disease development, making effective hypertension management an issue of considerable public health importance. Hypertension is particularly prominent among African Americans, who have higher disease prevalence and consistently lower BP control than Whites and Hispanics. Emergency departments (ED) have limited resources for chronic disease management, especially for under-served patients dependent upon the ED for primary care, and are not equipped to conduct follow-up. Kiosk-based patient education has been found to be effective in primary care settings, but little research has been done on the effectiveness of interactive patient education modules as ED enhanced discharge for an under-served urban minority population.

Methods/Design

Achieving Blood Pressure Control Through Enhanced Discharge (AchieveBP) is a behavioral RCT patient education intervention for patients with a history of hypertension who have uncontrolled BP at ED discharge. The project will recruit up to 200 eligible participants at the ED, primarily African-American, who will be asked to return to a nearby clinical research center for seven, thirty and ninety day visits, with a 180 day follow-up. Consenting participants will be randomized to either an attention-control or kiosk-based interactive patient education intervention. To control for potential medication effects, all participants will be prescribed similar, evidenced-based anti-hypertensive regimens and have their prescription filled onsite at the ED and during visits to the clinic. The primary target endpoint will be success in achieving BP control assessed at 180 days follow-up post-ED discharge. The secondary aim will be to assess the relationship between patient activation and self-care management.

Discussion

The AchieveBP trial will determine whether using interactive patient education delivered through health information technology as ED enhanced discharge with subsequent education sessions at a clinic is an effective strategy for achieving short-term patient management of BP. The project is innovative in that it uses the ED as an initial point of service for kiosk-based health education designed to increase BP self-management. It is anticipated findings from this translational research could also be used as a resource for patient education and follow-up with hypertensive patients in primary care settings.

Trial registration

ClinicalTrials.gov Registration Number: NCT02069015. Registered February 19, 2014.

Correlation between Subclinical Heart Disease and Cardiovascular Risk Profiles in an Urban Emergency Department Population with Elevated Blood Pressures: A Pilot Study

BACKGROUND

Uncontrolled hypertension is a primary risk factor for development of cardiovascular complications.

OBJECTIVE

Determine the point prevalence of left ventricular hypertrophy (LVH) and diastolic dysfunction in an urban emergency department (ED) population with elevated blood pressures (BP) and examine correlations between subclinical disease and patient cardiovascular risk profiles.

METHODS

A convenience sample of patients with EBP (>140/90 on two measurements) had limited bedside echocardiograms (LBE). Subclinical hypertensive heart disease was classified as the presence of: LVH, abnormal ejection fraction (EF), or diastolic dysfunction.

RESULTS

Thirty-nine patients with EBP were enrolled. The mean age was 46 years (SD = 10.9), 59% were women, 21% were smokers, and 92% had a history of hypertension. The average body mass index was 30.7 (SD = 8.7). Patients were 67% African American, 23% Latino, 5% Caucasian, 3% Asian, and 3% Native American. Subclinical disease was found in 39%: 31% had LVH, 15% had diastolic dysfunction, and 8% had abnormal EF. On bivariate analysis, elevated BP (p = 0.039) and blood urea nitrogen (p = 0.016) were correlated with subclinical heart disease. After adjusting for other covariates, receiving oral/intravenous antihypertensive medications in the ED (p = 0.005) was associated with subclinical heart disease.

CONCLUSIONS

We found a point prevalence of subclinical heart disease of 39% in this urban ED population, using LBE. Real-time identification of subclinical heart disease at early stages in the ED in conjunction with abnormal renal function can help emergency physicians identify those patients in need of more aggressive therapy and urgent follow-up.

Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

Test characteristics of electrocardiography for detection of left ventricular hypertrophy in asymptomatic emergency department patients with hypertension

OBJECTIVES

The objective was to evaluate the diagnostic test characteristics of three validated electrocardiographic (ECG) criteria for the diagnosis of left ventricular hypertrophy (LVH) in undifferentiated, asymptomatic emergency department (ED) patients with hypertension (HTN).

METHODS

This was a prospective cohort study of ED patients with asymptomatic HTN at a single tertiary care facility. Patients 35 years of age or older with systolic blood pressure (sBP) ≥ 140 mm Hg or diastolic blood pressure (dBP) ≥ 90 mm Hg on two separate readings (at least 1 hour apart) were eligible for inclusion. At enrollment, ECGs were obtained for all patients. Presence of LVH on ECG was defined using Cornell voltage, Cornell product, and Minnesota Code 3.1/3.2 criteria. Echocardiography was then performed, with LVH defined by the presence of one or more of the following validated criteria: interventricular septal or posterior wall thickness ≥ 1.3 cm, LV mass ≥ 225 g (male) or ≥ 163 g (female), or LV mass indexed to height raised to the power of 2.7 ≥ 48 g/m(2.7) (male) or ≥ 45 g/m(2.7) (female). Descriptive statistics and diagnostic characteristics (i.e., sensitivity and specificity) with corresponding 95% confidence intervals (CIs) for each of the three ECG criteria were derived for both the composite and the individual echocardiographic determinants of LVH. Logistic regression was also used to model LVH before and after subsequent inclusion of clinically relevant variables.

RESULTS

A total of 161 patients (93.8% African American; mean [±SD] age = 49.8 [±8.3] years) were enrolled, and LVH was present in 89 patients (55.2%, 95% CI = 47.6% to 62.8%). On ECG analysis, mean Cornell voltage (21.5 mV vs. 28.7 mV; difference = -7.2 mV, 95% CI = -3.8 to -10.7 mV) and Cornell product (1868.4 msec × mV vs. 2616.4 msec × mV; difference = -748.0 msec × mV, 95% CI = -401.2 to -1094.8 msec × mV) were significantly lower among those without LVH on echocardiography. Subjects without LVH on echocardiography were less likely to meet Cornell voltage (30.5% vs. 48.3%; difference = -17.8%, 95% CI = -2.5% to -31.7%) or Cornell product (26.4% vs. 49.4%; difference = -23.0%, 95% CI = -8.0% to -36.5%) criteria for LVH. The diagnosis of LVH by Minnesota Code was less common (18.1% vs. 25.8%; difference = -7.7%, 95% CI = -20.1% to 5.3%) with no difference by group. Sensitivity and specificity were as follows: for the Cornell voltage, sensitivity 25.4% (95% CI = 15.3% to 37.9%), specificity 50.0% (95% CI = 67.6% to 93.2%); for the Cornell product, sensitivity 25.4% (95% CI = 15.3% to 37.9%), specificity 75.0% (95% CI = 19.4% to 99.4%); and for the Minnesota code, sensitivity 26.9% (95% CI = 16.6% to 39.7%), specificity 75.0% (95% CI = 19.4% to 99.4%). On logistic regression, the c-statistics for Cornell voltage and Cornell product were equivalent (0.67), with only marginal improvement after the addition of body mass index (BMI; 0.69 and 0.70, respectively), B-type natriuretic peptide (BNP; 0.68 and 0.69, respectively), or both (0.71 and 0.72, respectively) to the models.

CONCLUSIONS

In this cohort of predominately African American ED patients with asymptomatic HTN, sensitivity and specificity of standard ECG criteria were relatively poor for the diagnosis of LVH on echocardiography. Thus, ECG is of limited use for LVH risk stratification in asymptomatic ED patients with elevated blood pressure, with additional clinical information only modestly strengthening its predictive value.

Primary care in the emergency department -- an untapped resource for public health research and innovation

With rising patient volumes and increasingly complex cases, the specialty of emergency medicine faces a growing array of challenges. Efforts have been made to improve patient throughput, yet little attention has been directed to the increasing amount of primary care delivered in emergency departments (EDs) for chronic disease states such as hypertension and diabetes. Management of chronic medical conditions is traditionally seen as beyond the purview of the ED and emergency physicians tend to defer critical aspects of related patient care to other components of the healthcare continuum. As a result, vulnerable patients are often forced to navigate exceedingly complex and fragmented systems of care with little guidance, which often leads to inadequate treatment and exposure to increased risk for development of potentially avoidable complications. As evidenced by our experience with hypertension in an under resourced community, there is a crucial need for emergency physicians to espouse their role as providers of healthcare across the acuity spectrum and lead the way in defining regionally relevant solutions to better manage patients with chronic medical problems.

Blood pressure control and perceived health status in African Americans with subclinical hypertensive heart disease

The role of antihypertensive therapy in reducing the risk of cardiovascular complications such as heart failure is well established, but the effects of different blood pressure goals on patient-perceived health status has not been well defined. We sought to determine if adverse effects on perceived health status will occur with lower blood pressure goals or more intensive antihypertensive therapy. Data were prospectively collected as a part of a single center, randomized controlled trial designed to evaluate standard (Seventh Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure-compliant) versus intense (<120/80 mm Hg) blood pressure goals for patients with uncontrolled hypertension and subclinical hypertensive heart disease. Blood pressure management was open label, and health status was measured at 3-month intervals over 1 year of follow-up using the short-form (SF)-36. Mixed linear models were constructed for each of the SF-36 summary scores. One hundred twenty-three (mean age 49.4 ± 8.2; 65% female; 95.1% African American) patients were randomized, 88 of whom completed the protocol. With the exception of a decrease in perceived health transition, health status did not change significantly on repeat measurement. Lower blood pressure goals and more intensive antihypertensive therapy appear to be well tolerated with limited effects on patients' perception of health status.