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Yip R, Swainson J, Khullar A, McIntyre RS, Skoblenick K. Intravenous ketamine for depression: A clinical discussion reconsidering best practices in acute hypertension management. Front Psychiatry 2022; 13:1017504. [PMID: 36245888 PMCID: PMC9556663 DOI: 10.3389/fpsyt.2022.1017504] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Ketamine is a versatile medication with an emerging role for the treatment of numerous psychiatric conditions, including treatment resistant depression. Current psychiatry guidelines for its intravenous administration to treat depression recommend regular blood pressure monitoring and an aggressive approach to potential transient hypertensive episodes induced by ketamine infusions. While this approach is aimed at ensuring patient safety, it should be updated to align with best practice guidelines in the management of hypertension. This review defines and summarizes the currently recommended approach to the hypertensive emergency, the asymptomatic hypertensive urgency, and discusses their relevance to intravenous ketamine therapy. With an updated protocol informed by these best practice guidelines, ketamine treatment for depression may be more accessible to facilitate psychiatric treatment.
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Affiliation(s)
- Ryan Yip
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Swainson
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada.,Misericordia Community Hospital, Edmonton, AB, Canada
| | - Atul Khullar
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada.,Northern Alberta Sleep Clinic, Edmonton, AB, Canada.,Grey Nuns Community Hospital, Edmonton, AB, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Pharmacology, University of Toronto, Toronto, ON, Canada.,Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Kevin Skoblenick
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada.,Royal Alexandra Hospital, Edmonton, AB, Canada.,Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
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Park SH, Hsu CJ, Lin JT, Dee W, Roth EJ, Rymer WZ, Wu M. Increased motor variability facilitates motor learning in weight shift toward the paretic side during walking in individuals post-stroke. Eur J Neurosci 2021; 53:3490-3506. [PMID: 33783888 DOI: 10.1111/ejn.15212] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 02/01/2023]
Abstract
The purpose of this study was to determine whether applying "varied" versus constant pelvis assistance force mediolaterally toward the paretic side of stroke survivors during walking would result in short-term improvement in weight shift toward the paretic side. Twelve individuals post-stroke (60.4 ± 6.2 years; gait speed: 0.53 ± 0.19 m/s) were tested under two conditions (varied vs. constant). Each condition was conducted in a single separate session, which consisted of (a) treadmill walking with no assistance force for 1 min (baseline), pelvis assistance toward the paretic side for 9 min (adaptation), and then no force for additional 1 min (post-adaptation), and (b) overground walking. In the "varied" condition, the magnitude of force was randomly changed across steps between 30% and 100% of the predetermined amount. In the abrupt condition, the magnitude of force was kept constant at 100% of the predetermined amount. Participants exhibited greater improvements in weight shift toward the paretic side (p < 0.01) and in muscle activity of plantar flexors and hip adductors of the paretic leg (p = 0.02) from baseline to late post-adaptation period for the varied condition than for the constant condition. Motor variability of the peak pelvis displacement at baseline was correlated with improvement in weight shift toward the paretic side after training for the varied (R2 = 0.64, p = 0.01) and the constant condition (R2 = 0.39, p = 0.03). These findings suggest that increased motor variability, induced by applying the varied pelvis assistance, may facilitate motor learning in weight shift and gait symmetry during walking in individuals post-stroke.
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Affiliation(s)
- Seoung Hoon Park
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - Chao-Jung Hsu
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA
| | - Jui-Te Lin
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA
| | - Weena Dee
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA
| | - Elliot J Roth
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - William Z Rymer
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - Ming Wu
- Legs and Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA.,Department of Bioengineering, University of Illinois at Chicago, Chicago, IL, USA
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Pieragostini R, Perrin G, Nevoret C, Amar L, Jannot AS, Sabatier P, Korb-Savoldelli V, Sabatier B. Conditional prescriptions of oral antihypertensive drugs for the management of hypertension urgencies in the inpatient setting: An observational study. J Clin Pharm Ther 2019; 45:282-289. [PMID: 31562777 DOI: 10.1111/jcpt.13059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 09/03/2019] [Accepted: 09/09/2019] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES The management of hypertension urgencies during hospitalization may generally not necessitate urgent care. However, physicians frequently prescribe 'as needed' antihypertensive drugs for which administration is triggered by blood pressure thresholds. The lack of rationale for this hospital practice led us to study oral conditional antihypertensive (OCA) prescriptions. We aimed to estimate the prevalence of OCA prescriptions and to establish their characteristics. METHODS In our institution, prescriptions are computerized. The study was retrospectively performed using a hospital clinical data warehouse over a 5-year period. RESULTS AND DISCUSSION The prevalence of OCA prescriptions was 6.9% among subjects treated with an antihypertensive drug. The median duration of these prescriptions was 4 days, until the day of the patient discharge in 78.8% stays. The calcium channel inhibitors were the main (79.9%) pharmacological class prescribed, with mostly prescriptions of nicardipine. OCA prescriptions were associated with another antihypertensive medication in 58.8% of the prescriptions; for 19.3%, it was a medication belonging to the same pharmacological class than the OCA drug prescribed. Regarding the computerized drafting, 39.6% of the conditional prescriptions were considered uninterpretable. At least one administration by nurses concerned 65.1% of the OCA prescriptions. The mean SBP and DBP before the initiation of an OCA drug was 142.9 ± 28.2 and 75.8 ± 24.5 mm Hg, respectively, relative to 143.0 ± 24.9 and 77.6 ± 19.9 mm Hg after the initiation (P = .8 for SBP and P = .06 for DBP). WHAT IS NEW AND CONCLUSION The originality of this study lies in the use of a clinical data warehouse to evaluate OCA prescriptions in hospital. These prescriptions are current, often uninterpretable and mostly ordered until patient discharge. Such drug orders could be associated with an increased risk of iatrogenic events and/or administration errors. This underlies the need for developing decision support tools and computerized protocols to manage hypertension urgencies.
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Affiliation(s)
- Rémi Pieragostini
- Pharmacy Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Germain Perrin
- Pharmacy Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France.,Equipe 22, Centre de Recherche des Cordeliers, UMR 1138, INSERM, Paris, France
| | - Camille Nevoret
- Biomedical Informatics and Public Health department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laurence Amar
- Hypertension Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Anne-Sophie Jannot
- Biomedical Informatics and Public Health department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France.,Université Paris Sorbonne, UPMC, Paris VI, UMR_S 1138, Centre de Recherche des Cordeliers, Paris, France
| | - Pierre Sabatier
- Pharmacy Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France.,Equipe 22, Centre de Recherche des Cordeliers, UMR 1138, INSERM, Paris, France
| | - Virginie Korb-Savoldelli
- Pharmacy Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France.,Faculté de pharmacie, Université Paris Sud, Châtenay-Malabry, France
| | - Brigitte Sabatier
- Pharmacy Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France.,Equipe 22, Centre de Recherche des Cordeliers, UMR 1138, INSERM, Paris, France
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Miller JB, Calo S, Reed B, Thompson R, Nahab B, Wu E, Chaudhry K, Levy P. Cerebrovascular risks with rapid blood pressure lowering in the absence of hypertensive emergency. Am J Emerg Med 2018; 37:1073-1077. [PMID: 30172599 DOI: 10.1016/j.ajem.2018.08.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 08/20/2018] [Accepted: 08/20/2018] [Indexed: 11/27/2022] Open
Abstract
STUDY OBJECTIVE In the Emergency Department (ED) setting, clinicians commonly treat severely elevated blood pressure (BP) despite the absence of evidence supporting this practice. We sought to determine if this rapid reduction of severely elevated BP in the ED has negative cerebrovascular effects. METHODS This was a prospective quasi-experimental study occurring in an academic emergency department. The study was inclusive of patients with a systolic BP (SBP) > 180 mm Hg for whom the treating clinicians ordered intensive BP lowering with intravenous or short-acting oral agents. We excluded patients with clinical evidence of hypertensive emergency. We assessed cerebrovascular effects with measurements of middle cerebral artery flow velocities and any clinical neurological deterioration. RESULTS There were 39 patients, predominantly African American (90%) and male (67%) and with a mean age of 50 years. The mean pre-treatment SBP was 210 ± 26 mm Hg. The mean change in SBP was -38 mm Hg (95% CI -49 to -27) mm Hg. The average change in cerebral mean flow velocity was -5 (95% CI -7 to -2) cm/s, representing a -9% (95% CI -14% to -4%) change. Two patients (5.1%, 95% CI 0.52-16.9%) had an adverse neurological event. CONCLUSION While this small cohort did not find an overall substantial change in cerebral blood flow, it demonstrated adverse cerebrovascular effects from rapid BP reduction in the emergency setting.
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Affiliation(s)
- Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, United States of America; Department of Internal Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, United States of America.
| | - Sean Calo
- Central Michigan University School of Medicine, Mount Pleasant, MI, United States of America
| | - Brian Reed
- Department of Emergency Medicine, Wayne State University, Detroit, MI, United States of America
| | - Richard Thompson
- Wayne State University School of Medicine, Detroit, MI, United States of America
| | - Bashar Nahab
- Department of Radiology, Wayne State University, Detroit, MI, United States of America
| | - Evan Wu
- Department of Emergency Medicine, University of California Davis, Davis, CA, United States of America
| | - Kaleem Chaudhry
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States of America
| | - Phillip Levy
- Department of Emergency Medicine, Cardiovascular Research Institute, Wayne State University, Detroit, MI, United States of America; Department of Physiology, Wayne State University, Detroit, MI, United States of America
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Gaynor MF, Wright GC, Vondracek S. Retrospective review of the use of as-needed hydralazine and labetalol for the treatment of acute hypertension in hospitalized medicine patients. Ther Adv Cardiovasc Dis 2018; 12:7-15. [PMID: 29265003 DOI: 10.1177/1753944717746613] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the use of as-needed (PRN) labetalol and hydralazine [intravenous (IV) or oral] in hospitalized medicine patients for the treatment of severe asymptomatic hypertension and to examine the potential negative outcomes associated with their use. METHODS The electronic health record of 250 medicine patients hospitalized at the University of Colorado Hospital between November 2014 and April 2016 who received at least one dose of PRN IV or oral hydralazine or labetalol were retrospectively reviewed. The primary outcome was to describe the use of PRN antihypertensive medications in this population. RESULTS A total of 573 PRN doses of antihypertensive medication were administered. Oral hydralazine was the most common (521 doses, 90.9%). A total of 36% of PRN administrations were given for a systolic blood pressure (SBP) <180 mmHg and diastolic blood pressure (DBP) <110 mmHg (cut-point for acute severe hypertension). No serious adverse events were related to PRN antihypertensive administration. Despite receiving at least one PRN antihypertensive medication during hospitalization, 40.8% of patients were not continued on their home antihypertensive medication(s) while hospitalized, and 62.4% of patients did not have their home regimens intensified at discharge. CONCLUSION As-needed oral hydralazine is frequently prescribed for acute blood pressure lowering with administration thresholds often less than what are used to define acute severe hypertension. Many patients are prescribed PRN antihypertensive medication instead of being continued on their home regimens, and most patients do not have the intensity of their home regimens increased. Providers need to be educated about the use of PRN antihypertensive medication for the management of severe asymptomatic hypertension in the hospital setting.
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Affiliation(s)
| | - Garth C Wright
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Sheryl Vondracek
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 East Montview Boulevard, C238, Aurora, CO 80045, USA
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Brody AM, Miller J, Polevoy R, Nakhle A, Levy PD. Institutional Pathways to Improve Care of Patients with Elevated Blood Pressure in the Emergency Department. Curr Hypertens Rep 2018; 20:30. [PMID: 29637311 DOI: 10.1007/s11906-018-0831-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Aaron M Brody
- Department of Emergency Medicine, Wayne State University School of Medicine, 6135 Woodward Ave., Detroit, MI, 48202, USA.
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, 48202, USA
- Department of Internal Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, 48202, USA
| | - Rimma Polevoy
- Department of Internal Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, 48202, USA
| | - Asaad Nakhle
- Department of Internal Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, 48202, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University School of Medicine, 6135 Woodward Ave., Detroit, MI, 48202, USA
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7
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An Emergency Medicine–Primary Care Partnership to Improve Rural Population Health: Expanding the Role of Emergency Medicine. Ann Emerg Med 2017; 70:640-647. [DOI: 10.1016/j.annemergmed.2017.06.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 06/14/2017] [Accepted: 06/16/2017] [Indexed: 01/17/2023]
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Miller JB, Arter A, Wilson SS, Janke AT, Brody A, Reed BP, Levy PD. Appropriateness of Bolus Antihypertensive Therapy for Elevated Blood Pressure in the Emergency Department. West J Emerg Med 2017; 18:957-962. [PMID: 28874950 PMCID: PMC5576634 DOI: 10.5811/westjem.2017.5.33410] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/18/2017] [Accepted: 05/08/2017] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION While moderate to severely elevated blood pressure (BP) is present in nearly half of all emergency department (ED) patients, the incidence of true hypertensive emergencies in ED patients is low. Administration of bolus intravenous (IV) antihypertensive treatment to lower BP in patients without a true hypertensive emergency is a wasteful practice that is discouraged by hypertension experts; however, anecdotal evidence suggests this occurs with relatively high frequency. Accordingly, we sought to assess the frequency of inappropriate IV antihypertensive treatment in ED patients with elevated BP absent a hypertensive emergency. METHODS We performed a retrospective cohort study from a single, urban, teaching hospital. Using pharmacy records, we identified patients age 18-89 who received IV antihypertensive treatment in the ED. We defined treatment as inappropriate if documented suspicion for an indicated cardiovascular condition or acute end-organ injury was lacking. Data abstraction included adverse events and 30-day readmission rates, and analysis was primarily descriptive. RESULTS We included a total of 357 patients over an 18-month period. The mean age was 55; 51% were male and 93% black, and 127 (36.4%) were considered inappropriately treated. Overall, labetalol (61%) was the most commonly used medication, followed by enalaprilat (18%), hydralazine (18%), and metoprolol (3%). There were no significant differences between appropriate and inappropriate BP treatment groups in terms of clinical characteristics or adverse events. Hypotension or bradycardia occurred in three (2%) patients in the inappropriate treatment cohort and in two (1%) patients in the appropriately treated cohort. Survival to discharge and 30-day ED revisit rates were equivalent. CONCLUSION More than one in three patients who were given IV bolus antihypertensive treatment in the ED received such therapy inappropriately by our definition, suggesting that significant resources could perhaps be saved through education of providers and development of clearly defined BP treatment protocols.
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Affiliation(s)
- Joseph B Miller
- Henry Ford Hospital, Department of Emergency Medicine, Detroit, Michigan
| | - Andrew Arter
- Detroit Medical Center, Detroit Receiving Hospital, Detroit, Michigan
| | - Suprat S Wilson
- Detroit Medical Center, Detroit Receiving Hospital, Detroit, Michigan
| | - Alexander T Janke
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Aaron Brody
- Wayne State University, Department of Emergency Medicine, Detroit, Michigan
| | - Brian P Reed
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut.,Wayne State University, Department of Emergency Medicine, Detroit, Michigan
| | - Phillip D Levy
- Wayne State University, Department of Emergency Medicine, Detroit, Michigan.,Wayne State University, Cardiovascular Research Institute, Detroit, Michigan
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Janke AT, McNaughton CD, Brody AM, Welch RD, Levy PD. Trends in the Incidence of Hypertensive Emergencies in US Emergency Departments From 2006 to 2013. J Am Heart Assoc 2016; 5:JAHA.116.004511. [PMID: 27919932 PMCID: PMC5210448 DOI: 10.1161/jaha.116.004511] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background The incidence of hypertensive emergency in US emergency departments (ED) is not well established. Methods and Results This study is a descriptive epidemiological analysis of nationally representative ED visit‐level data from the Nationwide Emergency Department Sample for 2006–2013. Nationwide Emergency Department Sample is a publicly available database maintained by the Healthcare Cost and Utilization Project. An ED visit was considered to be a hypertensive emergency if it met all the following criteria: diagnosis of acute hypertension, at least 1 diagnosis indicating acute target organ damage, and qualifying disposition (admission to the hospital, death, or transfer to another facility). The incidence of adult ED visits for acute hypertension increased monotonically in the period from 2006 through 2013, from 170 340 (1820 per million adult ED visits overall) to 496 894 (4610 per million). Hypertensive emergency was rare overall, accounting for 63 406 visits (677 per million adult ED visits overall) in 2006 to 176 769 visits (1670 per million) in 2013. Among adult ED visits that had any diagnosis of hypertension, hypertensive emergency accounted for 3309 per million in 2006 and 6178 per million in 2013. Conclusions The estimated number of visits for hypertensive emergency and the rate per million adult ED visits has more than doubled from 2006 to 2013. However, hypertensive emergencies are rare overall, occurring in about 2 in 1000 adult ED visits overall, and 6 in 1000 adult ED visits carrying any diagnosis of hypertension in 2013. This figure is far lower than what has been sometimes cited in previous literature.
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Affiliation(s)
| | - Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Aaron M Brody
- Wayne State University School of Medicine, Detroit, MI.,Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Robert D Welch
- Wayne State University School of Medicine, Detroit, MI.,Department of Emergency Medicine, Wayne State University, Detroit, MI.,Cardiovascular Research Institute, Wayne State University, Detroit, MI
| | - Phillip D Levy
- Wayne State University School of Medicine, Detroit, MI.,Department of Emergency Medicine, Wayne State University, Detroit, MI.,Cardiovascular Research Institute, Wayne State University, Detroit, MI
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10
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Vondracek S, Scoular S, Patel T. Management of severe asymptomatic hypertension in the hospitalized patient. ACTA ACUST UNITED AC 2016; 10:974-984. [DOI: 10.1016/j.jash.2016.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 10/06/2016] [Accepted: 10/30/2016] [Indexed: 11/30/2022]
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11
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Asymptomatic Elevated BP and the Hypertensive Insurgency. Curr Hypertens Rep 2016; 18:88. [PMID: 27878563 DOI: 10.1007/s11906-016-0695-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
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.
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Affiliation(s)
- Stewart Siu-Wa Chan
- A&E Department, Prince of Wales Hospital, Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong.
| | - Colin A Graham
- A&E Department, Prince of Wales Hospital, Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong
| | - T H Rainer
- A&E Department, Prince of Wales Hospital, Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong.,Emergency Medicine, Cardiff University, Cardiff and Vale UHB. NHS Wales, Cardiff, UK
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13
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Lipari M, Moser LR, Petrovitch EA, Farber M, Flack JM. As-needed intravenous antihypertensive therapy and blood pressure control. J Hosp Med 2016; 11:193-8. [PMID: 26560085 DOI: 10.1002/jhm.2510] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 10/09/2015] [Accepted: 10/13/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND Hospitalized patients with elevated blood pressure (BP) in most cases should be treated with intensification of oral regimens, but are often given intravenous (IV) antihypertensives. OBJECTIVE To determine frequency of prescribing and administering episodic IV antihypertensives and outcomes. DESIGN Retrospective review. SETTING Urban academic hospital. PATIENTS Non-critically ill, hospitalized patients with an IV antihypertensive order for enalaprilat, labetalol, hydralazine, or metoprolol. MEASUREMENTS We analyzed BP thresholds for ordering and administering IV antihypertensives, the types and frequencies of IV antihypertensives administered, and the effect of IV antihypertensive use on short-term BP and adverse outcomes. The BP change during hospitalization was contrasted in those receiving IV antihypertensives between those who did and did not receive subsequent intensification of chronic oral antihypertensive regimens. RESULTS Two hundred forty-six patients had an episodic IV antihypertensive order. One hundred seventy-two patients received 458 doses, with 48% receiving a single dose. Over 98% of episodic IV antihypertensive doses were administered for systolic blood pressure (SBP) <200 mm Hg and 84.5% for SBP <180 mm Hg. Within 6 hours of administration, there was a statistically significant decline in average SBP and diastolic BP in patients receiving IV hydralazine and labetolol. After administration of IV antihypertensives, the oral inpatient medication regimen was adjusted in 52% of patients; these patients had a greater reduction in SBP from admission to discharge than patients with no change to their oral regimens. A total of 32.6% of patients receiving treatment experienced a BP reduction of more than 25% within 6 hours. CONCLUSIONS IV antihypertensive drugs are ordered and administered in patients with asymptomatic, uncontrolled BP for levels unassociated with substantive immediate cardiovascular risk, which may cause adverse effects.
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Affiliation(s)
- Melissa Lipari
- Department of Pharmacy, Harper University Hospital, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, and Department of Pharmacy, St. John Hospital and Medical Center, Detroit, Michigan
| | - Lynette R Moser
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, and Department of Pharmacy, Harper University Hospital, Detroit, Michigan
| | | | - Margo Farber
- Department of Pharmacy, University of Michigan Hospital, Ann Arbor, Michigan
| | - John M Flack
- Division of General Internal Medicine, Hypertension Section, Department of Medicine, Southern Illinois University, Springfield, Illinois
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14
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Cooper CM, Fenves AZ. Hypertensive Urgencies and Emergencies in the Hospital Setting. Hosp Pract (1995) 2016; 44:21-27. [PMID: 26781933 DOI: 10.1080/21548331.2016.1141657] [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] [Indexed: 06/05/2023]
Abstract
The prevalence of hypertension in the general population has steadily climbed over the past several decades and hypertension is a primary or secondary diagnosis in nearly a fourth of hospitalized adults. Hospitalization is often a time of pertubation in a patient's usual blood pressure control, with pain, anxiety and missed medications all risk factors for severe hypertension. Hospitalists are often faced with severe hypertension in a patient not previously known to them and this presents a challenge of how best to assess the clinical importance of blood pressure elevation. An additional challenge is the lack of literature to guide the optimal management of hypertension in inpatients. This review aims to describe the scope of the problem, to describe the near and long-term risks of overzealous blood pressure management, and to identify areas for future study.
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Affiliation(s)
- Cynthia M Cooper
- a Harvard Medical School , Massachusetts General Hospital , Boston , MA , USA
| | - Andrew Z Fenves
- a Harvard Medical School , Massachusetts General Hospital , Boston , MA , USA
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Leiba A, Cohen-Arazi O, Mendel L, Holtzman EJ, Grossman E. Incidence, aetiology and mortality secondary to hypertensive emergencies in a large-scale referral centre in Israel (1991-2010). J Hum Hypertens 2015; 30:498-502. [PMID: 26674757 DOI: 10.1038/jhh.2015.115] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/27/2015] [Accepted: 11/03/2015] [Indexed: 02/07/2023]
Abstract
Hypertensive emergency (HE) is a life-threatening condition that requires immediate blood pressure (BP) reduction. Although it has been on the decline, the incidence of HE has recently increased in a few countries. The aim of the present retrospective study was to evaluate the incidence, aetiology and 1-year mortality of HE in a large medical centre over a 20-year period (1991-2010). The electronic medical records of all patient files who were hospitalized in the Chaim Sheba Medical Center in Israel from 1991 to 2010 with a primary diagnosis (at admission or discharge) of Malignant Hypertension, Hypertensive Emergency or Accelerated Hypertension were retrieved and analysed. The study interval was divided into four periods of 5 years each. Among 306 files reviewed, only 142 patients had a true HE. Average age at presentation was 63.3±16.5 years. Men were younger than women (59±16 vs 68±16 years; P<0.001). At presentation, most patients (80.3%) had been diagnosed with essential hypertension previously and were undertreated. Average maximum mean arterial pressure (MAP) was higher in men (169±22 mm Hg) than in women (161±17 mm Hg; P=0.026). The rate of HE decreased over the course of the study, from 12.7/100 000 admissions during 1991-1995 to 6.2/100 000 admissions (2006-2010). Similarly, 1-year mortality decreased from 16.7 to 3.6%. The rate of HE has decreased and the prognosis has improved over the last two decades. Appropriate BP control of patients with essential hypertension may further decrease the risk of HE.
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Affiliation(s)
- A Leiba
- Nephrology and Hypertension Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine and Medical Education, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, USA
| | - O Cohen-Arazi
- Internal Medicine D and Hypertension Unit, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - L Mendel
- Omnistat Statistical Consulting, Tel Aviv, Israel
| | - E J Holtzman
- Nephrology and Hypertension Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Grossman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Internal Medicine D and Hypertension Unit, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Levy PD, Mahn JJ, Miller J, Shelby A, Brody A, Davidson R, Burla MJ, Marinica A, Carroll J, Purakal J, Flack JM, Welch RD. Blood pressure treatment and outcomes in hypertensive patients without acute target organ damage: a retrospective cohort. Am J Emerg Med 2015; 33:1219-24. [PMID: 26087706 DOI: 10.1016/j.ajem.2015.05.036] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 05/21/2015] [Accepted: 05/22/2015] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES The objective is of the study to evaluate the effect of antihypertensive therapy in emergency department (ED) patients with markedly elevated blood pressure (BP) but no signs/symptoms of acute target organ damage (TOD). METHODS This is a retrospective cohort study of ED patients age 18 years and older with an initial BP greater than or equal to 180/100 mm Hg and no acute TOD, who were discharged with a primary diagnosis of hypertension. Patients were divided based on receipt of antihypertensive therapy and outcomes (ED revisits and mortality) and were compared. RESULTS Of 1016 patients, 435 (42.8%) received antihypertensive therapy, primarily (88.5%) oral clonidine. Average age was 49.2 years, and 94.5% were African American. Treated patients more often had a history of hypertension (93.1% vs 84.3%; difference = -8.8; 95% confidence interval [CI], -12.5 to -4.9) and had higher mean initial systolic (202 vs 185 mm Hg; difference = 16.9; 95% CI, -19.7 to -14.1) and diastolic (115 vs 106 mm Hg; difference = -8.6; 95% CI, -10.3 to -6.9) BP. Emergency department revisits at 24 hours (4.4% vs 2.4%; difference = -2.0; 95% CI, -4.5 to 0.3) and 30 days (18.9% vs 15.2%; difference = -3.7; 95% CI, -8.5 to 0.9) and mortality at 30 days (0.2% vs 0.2%; difference = 0; 95% CI, -1.1 to 0.8) and 1 year (2.1% vs 1.6%; difference = -0.5; 95% CI, -2.5 to 1.2) were similar. CONCLUSIONS Revisits and mortality were similar for ED patients with markedly elevated BP but no acute TOD, whether they were treated with antihypertensive therapy, suggesting relative safety with either approach.
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Affiliation(s)
- Phillip D Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI; Cardiovascular Research Institute, Wayne State University, Detroit, MI.
| | - James J Mahn
- Internal Medicine, St Joseph Mercy Ann Arbor, Ann Arbor, MI
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
| | - Alicia Shelby
- Department of Emergency Medicine, Akron General Medical Center, Akron, OH
| | - Aaron Brody
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Russell Davidson
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
| | - Michael J Burla
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Alexander Marinica
- Michigan State University College of Osteopathic Medicine, East Lansing, MI
| | - Justin Carroll
- Department of Emergency Medicine, Wayne State University, Detroit, MI; Wayne State University School of Medicine, Detroit, MI; Department of Emergency Medicine, University of Illinois Medical Center, Chicago, IL
| | - John Purakal
- Department of Emergency Medicine, Wayne State University, Detroit, MI; Internal Medicine, St Joseph Mercy Ann Arbor, Ann Arbor, MI
| | - John M Flack
- Cardiovascular Research Institute, Wayne State University, Detroit, MI; Department of Internal Medicine, Wayne State University, Detroit, MI
| | - Robert D Welch
- Department of Emergency Medicine, Wayne State University, Detroit, MI
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Scheuermeyer FX, Pourvali R, Rowe BH, Grafstein E, Heslop C, MacPhee J, McGrath L, Ward J, Heilbron B, Christenson J. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm. Ann Emerg Med 2015; 65:511-522.e2. [DOI: 10.1016/j.annemergmed.2014.09.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/27/2014] [Accepted: 09/15/2014] [Indexed: 11/25/2022]
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Abstract
Elevated blood pressure (BP) is a common problem in patients hospitalized for reasons other than hypertension. Unexpected elevations commonly result in calls to physicians who too often prescribe medication to reduce the numbers without evaluating the patient or determining the cause of the elevation. This may result in unnecessary and sometimes harmful treatment. Such BP elevation has many potential causes. These include anxiety, post-operative salt and volume overload, failure to administer the patient's known antihypertensive medication, inability to give oral antihypertensive medication to patients who cannot take pills by mouth, incipient heart failure, previously unrecognized renal failure, obstructive uropathy and other causes. These must be identified and treated prior to addressing only the elevated BP numbers. We present an algorithm for evaluating hospitalized patients with elevated BP in order to assist physicians in identifying the true cause of the elevation, treating the identified cause, and giving appropriate drug treatment. We also note that this is a golden opportunity for communication with the outpatient providers who will follow the patient.
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Affiliation(s)
- Win Myint Aung
- Department of Medicine, Division of Hospital Medicine, Miller School of Medicine, University of Miami , Miami, FL , USA
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Peacock F, Beckley P, Clark C, Disch M, Hewins K, Hunn D, Kontos MC, Levy P, Mace S, Melching KS, Ordonez E, Osborne A, Suri P, Sun B, Wheatley M. Recommendations for the evaluation and management of observation services: a consensus white paper: the Society of Cardiovascular Patient Care. Crit Pathw Cardiol 2014; 13:163-198. [PMID: 25396295 DOI: 10.1097/hpc.0000000000000033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Observation Services (OS) was founded by emergency physicians in an attempt to manage "boarding" issues faced by emergency departments throughout the United States. As a result, OS have proven to be an effective strategy in reducing costs and decreasing lengths of stay while improving patient outcomes. When OS are appropriately leveraged for maximum efficiency, patients presenting to emergency departments with common disease processes can be effectively treated in a timely manner. A well-structured observation program will help hospitals reduce the number of inappropriate, costly inpatient admissions while avoiding the potential of inappropriate discharges. Observation medicine is a complicated multidimensional issue that has generated much confusion. This service is designed to provide the best possible patient care in a value-based purchasing environment where quality, cost, and patient satisfaction must continually be addressed. Observation medicine is a service not a status. Therefore, patients are admitted to the service as outpatients no matter whether they are placed in a virtual or dedicated observation unit. The key to a successful observation program is to determine how to maximize efficiencies. This white paper provides the reader with the foundational guidance for observational services. It defines how to set up an observational service program, which diagnoses are most appropriate for admission, and what the future holds. The goal is to help care providers from any hospital deliver the most appropriate level of treatment, to the most appropriate patient, in the most appropriate location while controlling costs.
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Affiliation(s)
- Frank Peacock
- From the *Baylor College of Medicine, Ben Taub Hospital, Houston, TX; †Society of Cardiovascular Patient Care, Dublin, OH; ‡Beaumont Health System, Royal Oaks, MI; §Virginia Commonwealth University Medical Center, Richmond, VA; ¶Wayne State University School of Medicine, Detroit, MI; ‖Cleveland Clinic, Cleveland, OH; **Emory University School of Medicine, Atlanta, GA; and ††Oregon Health & Science University, Portland, OR
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Mahn JJ, Dubey E, Brody A, Welch R, Zalenski R, Flack JM, Ference B, Levy PD. Test characteristics of electrocardiography for detection of left ventricular hypertrophy in asymptomatic emergency department patients with hypertension. Acad Emerg Med 2014; 21:996-1002. [PMID: 25269580 DOI: 10.1111/acem.12462] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 04/19/2014] [Accepted: 04/20/2014] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- James J. Mahn
- The Wayne State University School of Medicine; Wayne State University; Detroit MI
- The Department of Emergency Medicine; Wayne State University; Detroit MI
| | - Elizabeth Dubey
- The Department of Emergency Medicine; Wayne State University; Detroit MI
| | - Aaron Brody
- The Department of Emergency Medicine; Wayne State University; Detroit MI
| | - Robert Welch
- The Department of Emergency Medicine; Wayne State University; Detroit MI
| | - Robert Zalenski
- The Department of Emergency Medicine; Wayne State University; Detroit MI
| | - John M. Flack
- The Department of Internal Medicine; Wayne State University; Detroit MI
- The Cardiovascular Research Institute; Wayne State University; Detroit MI
| | - Brian Ference
- The Department of Internal Medicine; Wayne State University; Detroit MI
- The Division of Cardiology; Wayne State University; Detroit MI
| | - Phillip D. Levy
- The Department of Emergency Medicine; Wayne State University; Detroit MI
- The Cardiovascular Research Institute; Wayne State University; Detroit MI
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Lackland DT, Roccella EJ, Deutsch AF, Fornage M, George MG, Howard G, Kissela BM, Kittner SJ, Lichtman JH, Lisabeth LD, Schwamm LH, Smith EE, Towfighi A. Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association. Stroke 2014; 45:315-53. [PMID: 24309587 PMCID: PMC5995123 DOI: 10.1161/01.str.0000437068.30550.cf] [Citation(s) in RCA: 555] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden. METHODS Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. RESULTS The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions. CONCLUSIONS The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.
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Scheuermeyer FX, Innes G, Pourvali R, Dewitt C, Grafstein E, Heslop C, MacPhee J, Ward J, Heilbron B, McGrath L, Christenson J. Missed Opportunities for Appropriate Anticoagulation Among Emergency Department Patients With Uncomplicated Atrial Fibrillation or Flutter. Ann Emerg Med 2013; 62:557-565.e2. [DOI: 10.1016/j.annemergmed.2013.04.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/16/2013] [Accepted: 04/04/2013] [Indexed: 11/25/2022]
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Multimodality imaging findings of pheochromocytoma with associated clinical and biochemical features in 53 patients with histologically confirmed tumors. AJR Am J Roentgenol 2013; 201:825-33. [PMID: 24059371 DOI: 10.2214/ajr.12.9576] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the spectrum of imaging appearances of pheochromocytoma and the associated clinical and biochemical features. MATERIALS AND METHODS In this retrospective study, a citywide pathology database (2000-2011) was searched to identify the records of patients with pheochromocytoma. The search yielded the cases of 53 patients (28 men, 25 women; mean age, 50 years). The institutional PACS and radiology information system records, hospital charts, and the provincial electronic health records of these patients were reviewed. Imaging appearances and clinical and biochemical features related to pheochromocytomas were recorded. RESULTS One chart was not available for review. In the 52 cases analyzed, 40 of the patients had symptoms: 31 patients had hypertension; 10 had the triad of palpitations, diaphoresis, and headaches; and all had elevated urinary metanephrine concentrations. Seven patients had a familial syndrome, and five had bilateral pheochromocytomas. One patient had an extraadrenal pheochromocytoma, and five had malignant tumors. The mean size of pheochromocytomas was 4.0 cm. Most pheochromocytomas were heterogeneous (CT, 56%; MRI, 65%; ultrasound, 45%) and were MIBG positive (90%). Eleven of 34 (32%) pheochromocytomas had T2 signal intensity greater than that of the spleen. Most pheochromocytomas were less enhancing than the spleen (CT, 85%; MRI, 71%). Contrast-enhanced CT was performed on 33 tumors, of which 20 enhanced less than the spleen and 8 showed similar enhancement to the spleen; contrast-enhanced MRI was performed on 24 tumors, of which 12 enhanced less than the spleen and 5 showed similar enhancement to the spleen. Predominant cystic change was found in 4 of 20 (20%) ultrasound, 9 of 41 (22%) CT, and 11 of 34 (32%) MRI examinations. Eight of 34 (24%) pheochromocytomas were hemorrhagic, two (5%) had calcifications, and three of six were PET positive. Two cystic pheochromocytomas and one lipid-containing pheochromocytoma were misdiagnosed as adrenal adenomas. CONCLUSION Most pheochromocytomas were heterogeneous at imaging, were MIBG positive, accompanied elevated urinary metanephrine concentrations, and were symptomatic. High T2 signal intensity was found in approximately one third of solid tumors. Atypical imaging features included homogeneity, cystic change, hemorrhage, intense enhancement, calcifications, intracellular lipid, bilaterality, and malignancy.
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McNaughton CD, Self WH, Levy PD, Barrett TW. High-Risk Patients with Hypertension: Clinical Management Options. CLINICAL MEDICINE REVIEWS IN VASCULAR HEALTH 2013; 2012:65-71. [PMID: 23888121 DOI: 10.4137/cmrvh.s8109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Hypertension, one of the most common human diseases worldwide, affects nearly 1 billion individuals. Complaints related to hypertension are commonly evaluated and treated in the acute care settings such as emergency departments and acute care medical clinics. The evaluation, treatment, and disposition of these patients require thorough knowledge of potential complications and treatment options. This manuscript details a structured approach to evaluating high-risk patients with acute hypertension-related complaints and provides recommendations for treatment and disposition.
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Affiliation(s)
- Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure. Ann Emerg Med 2013; 62:59-68. [PMID: 23842053 DOI: 10.1016/j.annemergmed.2013.05.012] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Scheuermeyer FX, Grafstein E, Stenstrom R, Innes G, Heslop C, MacPhee J, Pourvali R, Heilbron B, McGrath L, Christenson J. Thirty-Day and 1-Year Outcomes of Emergency Department Patients With Atrial Fibrillation and No Acute Underlying Medical Cause. Ann Emerg Med 2012; 60:755-765.e2. [DOI: 10.1016/j.annemergmed.2012.05.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 05/02/2012] [Accepted: 05/08/2012] [Indexed: 10/28/2022]
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Baumann BM, Cline DM, Pimenta E. Treatment of hypertension in the emergency department. ACTA ACUST UNITED AC 2011; 5:366-77. [DOI: 10.1016/j.jash.2011.05.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 04/22/2011] [Accepted: 05/06/2011] [Indexed: 12/18/2022]
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Zangfu zheng (patterns) are associated with clinical manifestations of zang shang (target-organ damage) in arterial hypertension. Chin Med 2011; 6:23. [PMID: 21682890 PMCID: PMC3155491 DOI: 10.1186/1749-8546-6-23] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 06/17/2011] [Indexed: 12/22/2022] Open
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Severely elevated blood pressure: when is it an emergency? J Cardiovasc Nurs 2011; 26:519-23. [PMID: 21372732 DOI: 10.1097/jcn.0b013e31820db112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
High blood pressure is one of the most common chronic medical conditions in this country, occurring in about 1 of every 3 adults. It is not uncommon for nurses to see individuals in the emergency room, hospital, home, or other settings who have severely elevated blood pressure readings. Extremely elevated readings generally evoke considerable concern among healthcare staff. They are faced with deciding whether the individual requires immediate treatment and a higher level of care, such as transport to an emergency department. Severely elevated blood pressure can be a true medical emergency, may require urgent care, or may in fact be a nonemergency. The purpose of this article is to assist nurses in recognizing those situations in which severely elevated blood pressure requires immediate intervention. Current research and best evidence regarding severely elevated blood pressure are presented.
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Magadza C, Radloff SE, Srinivas SC. The effect of an educational intervention on patients' knowledge about hypertension, beliefs about medicines, and adherence. Res Social Adm Pharm 2010; 5:363-75. [PMID: 19962679 DOI: 10.1016/j.sapharm.2009.01.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 01/30/2009] [Accepted: 01/30/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND The burden of chronic noncommunicable diseases continues to rise in South Africa, leading to high rates of morbidity and mortality. The control of hypertension is far from optimal because of factors such as inadequate patient understanding of the condition and its therapy, as well as poor adherence to prescribed regimens. OBJECTIVE This study investigated the effect of an educational intervention on selected hypertensive participants' levels of knowledge about hypertension, their beliefs about medicines, and adherence to antihypertensive therapy. METHOD Participants took part in an educational intervention that provided them with information about hypertension and its therapy through presentations, monthly meetings, and a summary information leaflet. The participants' levels of knowledge about hypertension and its therapy as well as their beliefs about medicines were measured using interviews and/or self-administered questionnaires. Levels of adherence were assessed using pill counts, self-reports, and punctuality in collecting medication refills. Paired t tests for dependent samples were performed to compare the participants' levels of knowledge about hypertension and its therapy, beliefs about medicines, and levels of adherence to antihypertensive therapy before and after the educational intervention. RESULTS There were significant increases in the participants' levels of knowledge about hypertension and its therapy (P<.0001). Most of the parameters used to indicate beliefs about medicines were significantly modified in a positive manner (P<.01 for concerns about medicines, P<.01 for beliefs about the harmful nature of medicines, and P<.01 for the necessity-concerns differential). CONCLUSION Results of this study show that the educational intervention led to an increase in the participants' levels of knowledge about hypertension and a positive influence on their beliefs about medicines. Despite these positive changes, adequate time is required before anticipated behavioral changes, such as increased adherence, can be observed.
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Affiliation(s)
- C Magadza
- Faculty of Pharmacy, Rhodes University, Grahamstown, 6140, Eastern Cape, South Africa
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Abstract
BACKGROUND Hypertension is the major risk factor for cardiovascular (CV) disease such as myocardial infarction (MI) and stroke. This risk is well known to extend into the perioperative period. Although most perioperative hypertension can be managed with the patient's outpatient regimen, there are situations in which oral medications cannot be administered and parenteral medications become necessary. They include postoperative nil per os status, severe pancreatitis, and mechanical ventilation. This article reviews the management of perioperative hypertensive urgency with parenteral medications. METHODS A PubMed search was conducted by cross-referencing the terms "perioperative hypertension," "hypertensive urgency," "hypertensive emergency," "parenteral anti-hypertensive," and "medication." The search was limited to English-language articles published between 1970 and 2008. Subsequent PubMed searches were performed to clarify data from the initial search. RESULTS As patients with hypertensive urgency are not at great risk for target-organ damage (TOD), continuous infusions that require intensive care unit (ICU) monitoring and intraarterial catheters seem to be unnecessary and a possible misuse of resources. CONCLUSIONS When oral therapy cannot be administered, patients with hypertensive urgency can have their blood pressure (BP) reduced with hydralazine, enalaprilat, metoprolol, or labetalol. Due to the scarcity of comparative trials looking at clinically significant outcomes, the medication should be chosen based on comorbidity, efficacy, toxicity, and cost.
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Affiliation(s)
- Kartikya Ahuja
- Division of Cardiology, Albert Einstein College of Medicine, Bronx, New York 10461, USA.
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Souza LM, Riera R, Saconato H, Demathé A, Atallah AN. Oral drugs for hypertensive urgencies: systematic review and meta-analysis. SAO PAULO MED J 2009; 127:366-72. [PMID: 20512292 DOI: 10.1590/s1516-31802009000600009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 12/10/2009] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE Hypertensive urgencies are defined as severe elevations in blood pressure without evidence of acute or progressive target-organ damage. The need for treatment is considered urgent but allows for slow control using oral or sublingual drugs. If the increase in blood pressure is not associated with risk to life or acute target-organ damage, blood pressure control must be implemented slowly over 24 hours. For hypertensive urgencies, it is not known which class of antihypertensive drug provides the best results and there is controversy regarding when to use antihypertensive drugs and which ones to use in these situations. The aim of this review was to assess the effectiveness and safety of oral drugs for hypertensive urgencies. METHODS This systematic review of the literature was developed at the Brazilian Cochrane Center, and in the Discipline of Emergency Medicine and Evidence-Based Medicine at the Universidade Federal de São Paulo - Escola Paulista de Medicina (Unifesp-EPM), in accordance with the methodology of the Cochrane Collaboration. RESULTS Sixteen randomized clinical trials including 769 participants were selected. They showed that angiotensin-converting enzyme inhibitors had a superior effect in treating hypertensive urgencies, evaluated among 223 participants. The commonest adverse event for calcium channel blockers were headache (35/206), flushing (17/172) and palpitations (14/189). For angiotensin-converting enzyme inhibitors, the principal side effect was bad taste (25/38). CONCLUSIONS There is important evidence in favor of the use of angiotensin-converting enzyme inhibitors for treating hypertensive urgencies, compared with calcium channel blockers, considering the better effectiveness and the lower frequency of adverse effects (like headache and flushing).
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Affiliation(s)
- Luciana Mendes Souza
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
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Levy PD, Cline D. Asymptomatic hypertension in the emergency department: a matter of critical public health importance. Acad Emerg Med 2009; 16:1251-7. [PMID: 19845553 DOI: 10.1111/j.1553-2712.2009.00512.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Asymptomatic hypertension (HTN) is commonly encountered in the emergency department (ED), but in most circumstances little is done about it. While many factors may contribute to this, the failure to recognize asymptomatic HTN as a public health problem is particularly important. Given the established long-term consequences of elevated blood pressure (BP), a reconsideration of methods that could enhance surveillance and intervention in the ED is needed. In this article, we discuss the relevant epidemiology of asymptomatic HTN and present a novel approach using a modified version of the Haddon's matrix to systematically address the challenges that contribute to ineffective screening and suboptimal outcomes.
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Affiliation(s)
- Phillip D Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA.
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Sobrino Martínez J, Hernández del Rey R. Situaciones urgentes en hipertensión arterial. HIPERTENSION Y RIESGO VASCULAR 2009. [DOI: 10.1016/s1889-1837(09)70509-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Carlos Mario Jiménez-Yepes
- From the School of Medicine (C.M.J.-Y.), Universidad de Antioquia, Hospital Universitario San Vicente de Paúl, Medellín, Colombia; and the National School of Public Health (J.L.L.-F.), Universidad de Antioquia, Medellín, Colombia
| | - Juan Luis Londoño-Fernández
- From the School of Medicine (C.M.J.-Y.), Universidad de Antioquia, Hospital Universitario San Vicente de Paúl, Medellín, Colombia; and the National School of Public Health (J.L.L.-F.), Universidad de Antioquia, Medellín, Colombia
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Karras DJ, Kruus LK, Cienki JJ, Wald MM, Ufberg JW, Shayne P, Wald DA, Heilpern KL. Utility of Routine Testing for Patients With Asymptomatic Severe Blood Pressure Elevation in the Emergency Department. Ann Emerg Med 2008; 51:231-9. [PMID: 17499391 DOI: 10.1016/j.annemergmed.2007.03.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Revised: 03/15/2007] [Accepted: 03/26/2007] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE Recommendations for the treatment of emergency department (ED) patients with asymptomatic severely elevated blood pressure advise assessment for occult, acute hypertensive target-organ damage. This study determines the prevalence of unanticipated, clinically meaningful test abnormalities in ED patients with asymptomatic severely elevated blood pressure. METHODS This was a prospective observational study at 3 urban academic EDs. Consecutive patients with systolic blood pressure greater than or equal to 180 mm Hg or diastolic blood pressure greater than or equal to 110 mm Hg on 2 measurements were enrolled if they denied symptoms of hypertensive emergency. A basic metabolic panel, urinalysis, ECG, CBC count, and chest radiograph were obtained. Treating physicians were interviewed about the indication for each test and whether an abnormal result was anticipated according to clinical findings. When test results were available, physicians were asked whether abnormal findings were clinically meaningful, defined as leading to unanticipated hospitalization, medication modification, or further immediate evaluation. The primary outcome was the prevalence of unanticipated clinically meaningful test abnormalities. RESULTS One hundred nine patients with asymptomatic severely elevated blood pressure were enrolled. Unanticipated abnormal test results were noted in 57 (52%) patients. Clinically meaningful unanticipated test abnormalities were found in 7 (6%) patients: basic metabolic panel in 2 (2%), CBC count in 3 (3%), urinalysis in 3 (4%), ECG in 2 (2%), and chest radiograph in 1 (1%). Five patients (5%) had abnormalities assessed as possible manifestations of acute hypertensive target-organ injury; none had abnormalities clearly related to severely elevated blood pressure. CONCLUSION Screening tests of urban ED patients with asymptomatic severely elevated blood pressure infrequently detect unanticipated hypertension-related abnormalities that alter ED management.
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Affiliation(s)
- David J Karras
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA 19140, USA.
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40
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Baumann BM, Abate NL, Cowan RM, Chansky ME, Rosa K, Boudreaux ED. Characteristics and Referral of Emergency Department Patients with Elevated Blood Pressure. Acad Emerg Med 2007. [DOI: 10.1111/j.1553-2712.2007.tb02351.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rogers RL, Anderson RS. Severe Hypertension in the Geriatric Patient—Is it an Emergency or Not? Clin Geriatr Med 2007; 23:363-70, vii. [PMID: 17462522 DOI: 10.1016/j.cger.2007.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Hypertension is a medical condition commonly seen in the outpatient setting. Primary care providers should be aware that asymptomatic hypertension, despite the degree of elevation, is rarely an emergency. Based on consensus guidelines from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the lack of any evidence showing harm, extreme blood pressure elevations do not need acute treatment. This article provides evidence for the argument that hypertension is rarely an emergency at all; even patients who have exceedingly high blood pressure can be treated as outpatients.
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Affiliation(s)
- Robert L Rogers
- Department of Emergency Medicine, The University of Maryland School of Medicine, 110 South Paca Street, Suite 200, 6th floor, Baltimore, MD 21201, USA.
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Rehman SU, Basile JN, Vidt DG. Hypertensive Emergencies and Urgencies. Hypertension 2007. [DOI: 10.1016/b978-1-4160-3053-9.50051-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Hypertension management is a common reason for visits to primary care physicians. One third of patients with hypertension do not have controlled blood pressure, and may present to the physician's office with hypertensive urgencies or emergencies. How to define severely elevated blood pressure, appropriate triage, and the clinical evaluation of those with hypertensive urgencies or emergencies is reviewed. Suggestions for pharmacologic therapy and follow-up are offered.
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Affiliation(s)
- David L Stewart
- Department of Family Medicine, University of Maryland School of Medicine, 29 South Paca Street, Baltimore, MD 21201, USA
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Woisetschläger C, Bur A, Vlcek M, Derhaschnig U, Laggner AN, Hirschl MM. Comparison of intravenous urapidil and oral captopril in patients with hypertensive urgencies. J Hum Hypertens 2006; 20:707-9. [PMID: 16826189 DOI: 10.1038/sj.jhh.1002063] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Decker WW, Godwin SA, Hess EP, Lenamond CC, Jagoda AS. Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department. Ann Emerg Med 2006; 47:237-49. [PMID: 16492490 DOI: 10.1016/j.annemergmed.2005.10.003] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Karras DJ, Kruus LK, Cienki JJ, Wald MM, Chiang WK, Shayne P, Ufberg JW, Harrigan RA, Wald DA, Heilpern KL. Evaluation and Treatment of Patients With Severely Elevated Blood Pressure in Academic Emergency Departments: A Multicenter Study. Ann Emerg Med 2006; 47:230-6. [PMID: 16492489 DOI: 10.1016/j.annemergmed.2005.11.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2005] [Revised: 10/26/2005] [Accepted: 11/02/2005] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE Current guidelines advise that emergency department (ED) patients with severely elevated blood pressure be evaluated for acute target organ damage, have their medical regimen adjusted, and be instructed to follow up promptly for reassessment. We examine factors associated with performance of recommended treatment of patients with severely elevated blood pressure. METHODS Observational study performed during 1 week at 4 urban, academic EDs. Severely elevated blood pressure was defined as systolic blood pressure greater than or equal to 180 mm Hg or diastolic blood pressure greater than or equal to 110 mm Hg on at least 1 measurement. ED staff were blinded to the study purpose. Demographics, presenting complaints, vital signs, tests ordered, medications administered, disposition, and discharge instructions were recorded, and associations were tested in bivariate analyses. RESULTS Severely elevated blood pressure was noted in 423 patients. Serum chemistry was obtained in 73% of patients, ECG in 53% of patients, chest radiograph in 46% of patients, urinalysis in 43% of patients, and funduscopy documented in 36% of patients. All studies were performed in 6% of patients and were associated with complaints of dyspnea (odds ratio [OR] 3.1; 95% confidence interval [CI] 1.1 to 8.7) and chest pain (OR 3.0; 95% CI 1.2 to 7.6). Oral antihypertensives were administered to 36% of patients and were associated with blood pressure-related complaints (OR 2.0 [1.2 to 3.3]), patient-suspected severely elevated blood pressure (OR 5.6, 95% CI 2.0 to 15.3), and being uninsured (OR 2.0; 95% CI 1.2 to 3.3). Intravenous antihypertensives were given to 4% of patients, associated only with chest pain (OR 3.2; 95% CI 1.1 to 9.5). Modification of antihypertensive regimen was documented in 19% of discharged patients and associated with patient-suspected severely elevated blood pressure (OR 5.5; 95% CI 2.5 to 12.2) and being uninsured (OR 1.8; 95% CI 1.1 to 2.9). CONCLUSION The majority of ED patients with severely elevated blood pressure do not receive the evaluation, medical regimen modification, and discharge instructions advised by current guidelines. Further study is necessary to determine whether these recommendations are appropriate in this setting.
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Affiliation(s)
- David J Karras
- Temple University School of Medicine, Philadelphia, PA 19140, USA.
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Abstract
A hypertensive emergency is a clinical diagnosis that is appropriate when marked hypertension is associated with acute target-organ damage; in this setting, lowering of blood pressure (BP) is typically begun within hours of diagnosis. For hypertensive urgency with no acute target-organ damage, BP lowering may occur over hours to days. A hypertensive emergency may present with cardiac, renal, neurologic, hemorrhagic, or obstetric manifestations, but prompt recognition of the condition and institution of rapidly acting parenteral therapy to lower BP (typically in an intensive care unit) are widely recommended. For aortic dissection, the systolic BP target is lower than 120 mm Hg, to be achieved during the first 20 minutes using a beta-blocker (typically esmolol) and a vasodilator to reduce both shear stress on the aortic tear and the BP, respectively. Otherwise, sodium nitroprusside is the agent with the lowest acquisition cost and longest record of successful use in hypertensive emergencies; however, it is metabolized to toxic thiocyanate and cyanide. Other attractive agents include fenoldopam mesylate, nicardipine, and labetalol; in pregnant women, magnesium and nifedipine are used commonly. Most authors suggest a reduction in mean arterial pressure of approximately 10% during the first hour and a further 10% to 15% during the next 2 to 4 hours; hypoperfusion can result if the BP is lowered too suddenly or too far (eg, into the range of <140/90 mm Hg). Oral antihypertensive therapy can usually be instituted after 6 to 12 hours of parenteral therapy, and the patient moved out of the intensive care unit, when consideration should be given to screening for secondary causes of hypertension. Long-term follow-up to ensure adequate control of hypertension is necessary to prevent further target-organ damage and recurrence of another hypertensive emergency.
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Affiliation(s)
- William J Elliott
- Department of Preventive Medicine, RUSH Medical College, RUSH University, RUSH University Medical Center, Chicago, IL 60612, USA.
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Gilmore RM, Miller SJ, Stead LG. Severe Hypertension in the Emergency Department Patient. Emerg Med Clin North Am 2005; 23:1141-58. [PMID: 16199342 DOI: 10.1016/j.emc.2005.07.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Severely elevated blood pressure is a common clinical problem en-countered in the Emergency Department. It is often difficult for physicians to differentiate between patients who need emergent blood pressure reduction, requiring the use of intravenous agents and in-tensive monitoring, and those for whom careful, slow reduction in BP is more appropriate. The optimal assessment and management of these patients is reviewed here, with an emphasis on clinical strategies that will most efficiently identify those at greatest risk.
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Affiliation(s)
- Rachel M Gilmore
- Department of Emergency Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Escalante CP, Weiser MA, Lam T, Ho V, Yeung SCJ. Hypertension in cancer patients seeking acute care: an opportunity to intervene. Am J Med Sci 2005; 330:120-7. [PMID: 16174995 DOI: 10.1097/00000441-200509000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The objectives were to describe clinical factors associated with hypertension or increased blood pressure in cancer patients seeking acute care, to describe the outcomes of these patients related to hypertension or increased blood pressure, and to determine whether these patients receive appropriate treatment and follow-up instructions. METHODS We retrospectively reviewed the records of patients admitted to the emergency center at The University of Texas M. D. Anderson Cancer Center from May 1, 2001 through August 5, 2001. Patients were included in our analysis if their emergency center triage blood pressure was 140 mm Hg or greater, systolic, or 90 mm Hg or greater, diastolic and remained in this range at emergency center discharge or if they were treated with an antihypertensive medication in the emergency center. Descriptive statistics, chi and Student t tests were utilized in the analysis. RESULTS Records of 143 patients were analyzed. The mean baseline, emergency center triage, and emergency center discharge blood pressure were 140/78 mm Hg, 159/84 mm Hg, and 153/81 mm Hg, respectively. Of 77 patients (54%) with controlled neoplastic disease, 54 (38%) were not receiving cancer treatment. Forty-one (30%) were admitted to the hospital and 27 (19%) returned to the emergency center with hypertension or possible hypertension-related events within 6 months. Discharge instructions regarding hypertension follow-up were documented in 9% of records. CONCLUSIONS Most patients (54%) had controlled cancer; more than one third were not receiving cancer treatment and had good performance status. Such patients would be likely to benefit from management of hypertension. In addition, only 9% of hypertensive patients were given hypertensive specific discharge instructions. The emergency center may provide another opportunity to alert patients of abnormal blood pressures and assist in arranging follow-up.
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Affiliation(s)
- Carmen P Escalante
- Department of General Internal Medicine, Ambulatory Treatment and Emergency Care, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77230-1402, USA.
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Karras DJ, Ufberg JW, Harrigan RA, Wald DA, Botros MS, McNamara RM. Lack of relationship between hypertension-associated symptoms and blood pressure in hypertensive ED patients. Am J Emerg Med 2005; 23:106-10. [PMID: 15765324 DOI: 10.1016/j.ajem.2004.02.043] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A number of cardiopulmonary and neurological symptoms are presumed to be associated with hypertension. We examined the prevalence of these symptoms in ED patients with elevated blood pressure (BP) and studied the relationship between symptom prevalence and BP value. We enrolled consecutive adult ED patients with sustained BP elevation (systolic BP>or=140 mm Hg, diastolic BP>or=90 mm Hg). BP values were categorized according to Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure, 6th Report criteria. Elevated BP was noted in 551 (29%) of 1908 patients. Unprompted complaints of hypertension-associated symptoms were noted in 26%, and there was no association between BP category and complaints other than dyspnea. Symptom interviews were conducted in 294 (56%) patients; 68% of this subset noted >or=1 current hypertension-associated symptom with no relationship between symptom prevalence and BP category. We conclude that symptoms putatively associated with hypertension are common among ED patients with elevated BP, and their prevalence appears unrelated to BP value.
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Affiliation(s)
- David J Karras
- Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, PA 19140, USA.
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