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Liberman AL, Razzak J, Lappin RI, Navi BB, Bruce SS, Liao V, Kaiser JH, Ng C, Segal AZ, Kamel H. Risk of Major Adverse Cardiovascular Events After Emergency Department Visits for Hypertensive Urgency. Hypertension 2024; 81:1592-1598. [PMID: 38660784 DOI: 10.1161/hypertensionaha.124.22885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/28/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Chronic hypertension is an established long-term risk factor for major adverse cardiovascular events (MACEs). However, little is known about short-term MACE risk after hypertensive urgency, defined as an episode of acute severe hypertension without evidence of target-organ damage. We sought to evaluate the short-term risk of MACE after an emergency department (ED) visit for hypertensive urgency resulting in discharge to home. METHODS We performed a case-crossover study using deidentified administrative claims data. Our case periods were 1-week intervals from 0 to 12 weeks before hospitalization for MACE. We compared ED visits for hypertensive urgency during these case periods versus equivalent control periods 1 year earlier. Hypertensive urgency and MACE components were all ascertained using previously validated International Classification of Diseases, Tenth Revision Clinical Modification codes. We used McNemar test for matched data to calculate risk ratios. RESULTS Among 2 225 722 patients with MACE, 1 893 401 (85.1%) had a prior diagnosis of hypertension. There were 4644 (0.2%) patients who had at least 1 ED visit for hypertensive urgency during the 12 weeks preceding their MACE hospitalization. An ED visit for hypertensive urgency was significantly more common in the first week before MACE compared with the same chronological week 1 year earlier (risk ratio, 3.5 [95% CI, 2.9-4.2]). The association between hypertensive urgency and MACE decreased in magnitude with increasing temporal distance from MACE and was no longer significant by 11 weeks before MACE (risk ratio, 1.2 [95% CI, 0.99-1.6]). CONCLUSIONS ED visits for hypertensive urgency were associated with a substantially increased short-term risk of subsequent MACE.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | | | | | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Samuel S Bruce
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Vanessa Liao
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Jed H Kaiser
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Catherine Ng
- Information Technologies and Services Department, Weill Cornell Medicine, New York (C.N.)
| | - Alan Z Segal
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
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Liberman AL, Lu J, Wang C, Cheng NT, Moncrieffe K, Lipton RB. Factors associated with hospitalization for ischemic stroke and TIA following an emergency department headache visit. Am J Emerg Med 2020; 46:503-507. [PMID: 33191047 DOI: 10.1016/j.ajem.2020.10.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/06/2020] [Accepted: 10/31/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Misdiagnosis of cerebrovascular disease among Emergency Department (ED) patients with headache has been reported. We hypothesized that markers of substandard diagnostic processes would be associated with subsequent ischemic cerebrovascular events among patients discharged from the ED with a headache diagnosis even after adjusting for demographic variables and medical history. METHODS We conducted a case-control study of adult ED patients diagnosed with a primary headache disorder at Montefiore Medical Center from 9/1/2013-9/1/2018. Cases were defined as patients hospitalized for an ischemic stroke or TIA within 365 days of their index ED visit. Control patients were defined as those who lacked a subsequent hospitalization for cerebrovascular disease. Pre-specified demographic, clinical, and diagnostic process factors were compared between groups; conditional logistic regression was used to assess the separate and joint influence of baseline features on risk of cerebral ischemia. RESULTS A total of 93 consecutive headache patients with a subsequent ischemic stroke/TIA hospitalization were matched to 93 controls (n = 186). Cases were older than controls and more likely to have traditional cerebrovascular risk factors. Neurological consultation was obtained more often for cases (13% vs. 4%; P = 0.03), cases were in the ED for longer (6 vs. 5 h, P = 0.03), and more frequently received neuroimaging (80% vs. 48%; P < 0.0001). Rates of neurological examination, documented differential diagnoses, and clear discharge follow up plans were similar between cases and controls. In our conditional logistic regression model, only history of prior stroke/TIA was associated with increased odds of subsequent cerebral ischemia. CONCLUSION Factors associated with diagnostic process failures did not increase the odds of subsequent ischemic stroke/TIA hospitalization following ED headache visit in our study.
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Affiliation(s)
- Ava L Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Jenny Lu
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States of America.
| | - Cuiling Wang
- Department of Biostatistics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Natalie T Cheng
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Khadean Moncrieffe
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Richard B Lipton
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
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Chen LH, Li FJ, Zhang HT, Chen WJ, Sun K, Xu RX. The microsurgical treatment for primary hypertensive brainstem hemorrhage: Experience with 52 patients. Asian J Surg 2020; 44:123-130. [PMID: 32600922 DOI: 10.1016/j.asjsur.2020.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/31/2019] [Accepted: 04/05/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study aims to investigate the effect of minimal invasive microsurgery in treating primary hypertensive brainstem hemorrhage (PHBH). METHODS 52 patients of PHBH (≥3.5 ml) who have taken the minimal invasive microsurgery with neuronavigation guidance were included between Jan. 2011 and Dec. 2018. The volume/location/type of hematoma, preoperative Glasgow Coma Scale (GCS), postoperative Glasgow Outcome Scale (GOS) and hemorrhagic dilatation of the fourth ventricle were analyzed during the follow-up period ranged from 3 to 57 months. RESULTS Among all the patients, 18 achieved complete hematoma evacuation (≥95%), 31 achieved subtotal evacuation (≥90%), 3 achieved premodinantly evacuation (>75%). No rebleeding during or after surgery within 24 h were found. 45 patients survived after 3 months, the mean preoperative hematoma volume decreased from 7.1 ± 2.6 ml-0.9 ml (p < 0.05), 19 patients got GOS Grade V/Ⅳ. It is shown the volume less than 10 ml always led to better outcome while massive and bilateral hematoma were related with poor prognosis. CONCLUSION The microsurgical hematoma evacuation under neuronavigation assistance is a rapid, effective, and safe technique for the removal of PHBH, especially for the volume less than 10 ml.
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Affiliation(s)
- Li-Hua Chen
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Fang-Jia Li
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Hong-Tian Zhang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Wen-Jin Chen
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Kai Sun
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Ru-Xiang Xu
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
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Cho Y, Kang H, Oh J, Lim TH, Ryu J, Ko BS. Risk of Venous Thromboembolism After Carbon Monoxide Poisoning: A Nationwide Population-Based Study. Ann Emerg Med 2019; 75:587-596. [PMID: 31759754 DOI: 10.1016/j.annemergmed.2019.08.454] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/19/2019] [Accepted: 08/26/2019] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE Few studies have investigated the association between carbon monoxide (CO) poisoning and risk of venous thromboembolism. We aim to identify the risk of pulmonary embolism and deep venous thrombosis after CO poisoning. METHODS We conducted a nationwide cohort-crossover study using administrative claims data in Korea. We compared the risk of venous thromboembolism (pulmonary embolism or deep venous thrombosis) in the cohort period after CO poisoning to that of the same period 1 year later (crossover period), using conditional logistic regression analysis. RESULTS We included 22,699 patients with a diagnosis of CO poisoning during the study period between 2004 and 2015. The risk of venous thromboembolism was significantly elevated during days 0 to 90 after CO poisoning (odds ratio 3.96; 95% confidence interval 2.50 to 6.25). However, this risk was not significantly elevated during subsequent postexposure periods through 360 days. During days 0 to 30 after CO poisoning, the risks of pulmonary embolism (odds ratio 22.00; 95% confidence interval 5.33 to 90.75) and deep venous thrombosis (odds ratio 10.33; 95% confidence interval 3.16 to 33.80) were significantly elevated. CONCLUSION We found that the risk of venous thromboembolism persisted for up to 90 days after CO poisoning. The risk was increased 22-fold for pulmonary embolism and 10-fold for deep venous thrombosis, especially in the first month after CO poisoning. Patients should be monitored for venous thromboembolism risk after CO poisoning.
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Affiliation(s)
- Yongil Cho
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Hyunggoo Kang
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Jaehoon Oh
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Jiin Ryu
- Biostatistical Consulting and Research Laboratory, Medical Research Collaborating Center, Hanyang University, Seoul, Republic of Korea
| | - Byuk Sung Ko
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea.
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Abstract
BACKGROUND Prognostic significance of serum calcium level in patients with intracerebral hemorrhage is not well studied. The aim of the study was to identify if a relationship between admission serum calcium level and prognosis exists in patients with intracerebral hemorrhage. METHODS A total of 1262 confirmed intracerebral hemorrhage patients were included. Demographic data, medical history, medicine history, laboratory data, imaging data, clinical score, and progress note were collected from their medical records. All images of head computed tomography were reanalyzed. Ninety-day prognosis was recorded, and poor outcome was defined as death or major disability caused by intracerebral hemorrhage. RESULTS During the 90-day follow-up period, 504 patients died and 226 patients suffered from major disability. Death and major disability were combined as poor prognosis. The remaining 532 patients showed good prognosis. Admission serum calcium level was lower in the patients with poor prognosis than in the patients with good prognosis (2.41 ± 0.23 mmol/l, 2.55 ± 0.26 mmol/l, P < 0.001). Admission INR and hematoma volume were higher in the patients with poor prognosis than in the patients with good prognosis (INR: 1.74 ± 0.29, 1.70 ± 0.29, P = 0.029; hematoma volume: 11.6 ± 4.4 ml, 10.7 ± 4.1 ml, P < 0.001). There was no difference in admission APTT level between the two prognosis groups (28.4 ± 5.6 s, 27.8 ± 5.4 s, P = 0.056). A multivariate COX regression analysis reported that admission serum calcium level ≤ 2.41 mmol/l was associated with the increased risk of poor prognosis (death or major disability) in the patients (HR 1.45, 95% CI 1.32-1.60). In addition, there was a significant linear association of serum calcium level with coagulation function markers and hematoma volume on admission (APTT: r = - 0.091, P = 0.001; INR: r = - 0.063, P = 0.025; hematoma volume: r = -0.108, P < 0.001). CONCLUSIONS Admission serum calcium level might be a prognostic marker for intracerebral hemorrhage. Potential mechanism involved calcium-induced coagulation function abnormality.
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Lee S, You CY, Kim J, Jo YH, Ro YS, Kang SH, Lee H. Long-term cardiovascular risk of hypertensive events in emergency department: A population-based 10-year follow-up study. PLoS One 2018; 13:e0191738. [PMID: 29447174 PMCID: PMC5813929 DOI: 10.1371/journal.pone.0191738] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/10/2018] [Indexed: 12/18/2022] Open
Abstract
Background Hypertension-related visits to the emergency department (ED) are increasing every year. Thus, ED could play a significant role in detecting hypertension and providing necessary interventions. However, it is not known whether a hypertensive event observed in the ED is an independent risk factor for future major adverse cardiovascular events (MACE). Methods A population-based observational study was conducted using a nationally representative cohort that contained the claim data of 1 million individuals from 2002 to 2013. We included non-critical ED visits without any history of MACE, and compared the new occurrences of MACE according to the presence of hypertensive events using extended Cox regression model. The disease-modifying effect of a follow-up visit was assessed by analyzing the interaction between hypertensive event and follow-up visit. Results Among 262,927 first non-critical ED visits during the study period (from 2004 to 2013), 6,243 (2.4%) visits were accompanied by a hypertensive event. The hypertensive event group had a higher risk of having a first MACE at 3 pre-specified intervals: 0–3 years (HR, 4.25; 95% CI, 3.83–4.71; P<0.001), 4–6 years (HR, 3.65; 95% CI, 3.14–4.24; P<0.001), and 7–10 years (HR, 3.20; 95% CI, 2.50–4.11; P<0.001). Follow-up visits showed significant disease-modifying effect at 2 intervals: 0–3 years (HR 0.65, 95% CI, 0.50–0.83) and 4–7 years (HR 0.68, 95% CI, 0.48–0.95). Conclusions A hypertensive event in the ED is an independent risk factor for MACE, and follow-up visits after the event can significantly modify the risk.
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Affiliation(s)
- Sihyoung Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Chang-youn You
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
- * E-mail:
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Jongno-gu, Seoul, Republic of Korea
| | - Si-Hyuck Kang
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Heeyoung Lee
- Department of Preventive Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
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