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Reynard C, van den Berg P, Oliver G, Naguib MP, Sammut‐Powell C, McMillan B, Heagerty A, Body R. The prognostic value of emergency department measured hypertension: A systematic review and meta-analysis. Acad Emerg Med 2022; 29:344-353. [PMID: 34553441 DOI: 10.1111/acem.14324] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/07/2021] [Accepted: 06/15/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The objective was to assess the prognostic value of hypertension detected in the emergency department (ED). METHODS The ED presents a unique opportunity to predict long-term cardiovascular disease (CVD) outcomes with its potential for high-footfall, and large-scale routine data collection applied to underserved patient populations. A systematic review and meta-analyses were conducted to assess the prognostic performance and feasibility of ED-measured hypertension as a risk factor for long-term CVD outcomes. We searched MEDLINE and Embase databases and gray literature sources. The target populations were undifferentiated ED patients. The prognostic factor of interest was hypertension. Feasibility outcomes included prevalence, reliability, and follow-up attendance. Meta-analyses were performed for feasibility using a random effect and exact likelihood. RESULTS The searches identified 1072 studies after title and abstract review, 53 studies had their full text assessed for eligibility, and 26 studies were included. Significant heterogeneity was identified, likely due to the international populations and differing study design. The meta-analyses estimate of prevalence for ED-measured hypertension was 0.31 (95% confidence interval 0.25-0.37). ED hypertension was persistent outside the ED (FE estimate of 0.50). The proportion of patients attending follow-up was low with an exact likelihood estimate of 0.41. Three studies examined the prognostic performance of hypertension and demonstrated an increased risk of long-term CVD outcomes. CONCLUSION Hypertension can be measured feasibly in the ED and consequently used in a long-term cardiovascular risk prediction model. There is an opportunity to intervene in targeted individuals, using routinely collected data.
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Affiliation(s)
- Charles Reynard
- Division of Cardiovascular Sciences University of Manchester Manchester UK
- Emergency Department Manchester Royal Infirmary Manchester University NHS Foundation Trust Manchester UK
| | | | - Govind Oliver
- Ysbyty Gwynedd Emergency Department Betsi Cadwaladr University Health Board Bangor UK
| | - Mina Peter Naguib
- Humanitarian and Conflict Response Institute University of Manchester Manchester UK
| | | | - Brian McMillan
- Centre for Primary Care and Health Services Research The University of Manchester Manchester UK
| | - Anthony Heagerty
- Division of Cardiovascular Sciences University of Manchester Manchester UK
| | - Richard Body
- Division of Cardiovascular Sciences University of Manchester Manchester UK
- Emergency Department Manchester Royal Infirmary Manchester University NHS Foundation Trust Manchester UK
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Screening for hypertension in adults during emergency department consultation: a systematic review. Eur J Emerg Med 2019; 27:178-185. [PMID: 31815875 DOI: 10.1097/mej.0000000000000648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A large proportion of patients affected with hypertension go undetected. A systematic review was conducted to assess the performance of a screening strategy in adults using blood pressure measurement at the time of an emergency department consultation. A systematic literature search on Embase, CINHAL and Medline was carried out. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Diagnostic Test Accuracy. Intervention studies with adults including at least one blood pressure measurement for all participants were included. A repeat blood pressure assessment had to have been carried out to assess the validity of the elevated blood pressure value within the next few days after the emergency department initial visit. Out of 1030 articles identified, published between 1985 and 2018, 10 articles met the inclusion criteria. There were no randomized clinical trials. Mean age of participants was 51.6 years. A single study reports that blood pressure screening was measured according to hypertension guidelines referred to in the study. The average follow-up rate was 61.9% (95% confidence interval 45.5-78.3). For diagnostic confirmation, four studies used a blood pressure measurement method based on the reported guidelines. Half of the patients (50.2%) with elevated blood pressure during the emergency department visit had blood pressure corresponding to uncontrolled elevated blood pressure at follow-up measurement. The contribution of emergency department to the screening for hypertension, by recognizing the presence of elevated blood pressure and then making a referral for diagnostic confirmation, could provide an opportunity to detect a large number of people with hypertension.
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Screening for hypertension: an elevated office blood pressure measurement is valuable, adding an automated one is even better. Blood Press Monit 2019; 24:123-129. [PMID: 30998552 DOI: 10.1097/mbp.0000000000000382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Previous studies have examined the relevance of hypertension (HTN) screening in walk-in clinics. So far, no valid algorithm has been proposed on how to integrate HTN screening in this context. The aim of our study was to assess, in a walk-in clinic setting, the HTN screening strategy for performing an automated office blood pressure (AOBP) measurement following an initially high office blood pressure (OBP) measurement. PATIENTS AND METHODS Included participants were adults with nonemergent medical conditions and an initial walk-in clinic OBP between systolic 140 and/or diastolic 90 mmHg and systolic 180 and/or diastolic 110 mmHg. AOBP was performed with patients unattended. The 24-h ambulatory blood pressure measurement (ABPM) was used as the diagnostic threshold. RESULTS Fifty participants were included in the study. The overall HTN prevalence as confirmed by the 24-h ABPM was 46% [95% confidence interval (CI): 32.19-59.81]. After an elevated OBP, AOBP over diagnostic thresholds occurred in 32 patients and were confirmed by ABPM in 20 participants, leading to a 62.5% positive predictive value (95% CI: 51.5-72.3%). Measurements under the AOBP diagnostic threshold occurred in 18 patients and were confirmed by ABPM in 15 participants, leading to a negative predictive value of 83.3% (95% CI: 62.3-93.8%). CONCLUSION In a walk-in clinic, an elevated OBP is a useful screening tool due its ability to recognize nearly one in two patients as actually hypertensive. Adding an AOBP makes it possible to specify what course of action to take. This ultimately results in better targeting of patients for an ABPM referral.
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Galson SW, Stanifer JW, Hertz JT, Temu G, Thielman N, Gafaar T, Staton CA. The burden of hypertension in the emergency department and linkage to care: A prospective cohort study in Tanzania. PLoS One 2019; 14:e0211287. [PMID: 30682173 PMCID: PMC6347227 DOI: 10.1371/journal.pone.0211287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/10/2019] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Globally, hypertension affects one billion people and disproportionately burdens low-and middle-income countries. Despite the high disease burden in sub-Saharan Africa, optimal care models for diagnosing and treating hypertension have not been established. Emergency departments (EDs) are frequently the first biomedical healthcare contact for many people in the region. ED encounters may offer a unique opportunity for identifying high risk patients and linking them to care. METHODS Between July 2017 and March 2018, we conducted a prospective cohort study among patients presenting to a tertiary care ED in northern Tanzania. We recruited adult patients with a triage blood pressure ≥ 140/90 mmHg in order to screen for hypertension. We explored knowledge, attitudes and practices for hypertension using a questionnaire, and assessed factors associated with successful follow-up. Hypertension was defined as a single blood pressure measurement ≥ 160/100 mmHg or a three-time average of ≥ 140/90 mmHg. Uncontrolled hypertension was defined as a three-time average measurement of ≥ 160/100 mmHg. Successful follow-up was defined as seeing an outpatient provider within one month of the ED visit. RESULTS We enrolled 598 adults (mean age 59.6 years), of whom 539 (90.1%) completed the study. The majority (78.6%) of participants were aware of having hypertension. Many (223; 37.2%) had uncontrolled hypertension. Overall, only 236 (43.8%) of participants successfully followed-up within one month. Successful follow-up was associated with a greater understanding that hypertension requires lifelong treatment (RR 1.11; 95% CI 1.03,1.21) and inversely associated with greater anxiety about the future (RR 0.80; 95% CI 0.64,0.99). CONCLUSION In a northern Tanzanian tertiary care ED, the burden of hypertension is high, with few patients receiving optimal outpatient care follow-up. Multi-disciplinary strategies are needed to improve linkage to care for high-risk patients from ED settings.
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Affiliation(s)
- Sophie W. Galson
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- * E-mail:
| | - John W. Stanifer
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Division of Nephrology, Duke University, Durham, North Carolina, United States of America
| | - Julian T. Hertz
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Gloria Temu
- Department of Medicine, Kilimanjaro Christian Medical College Hospital, Kilimanjaro, Tanzania
| | - Nathan Thielman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Temitope Gafaar
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Catherine A. Staton
- Department of Surgery, Division of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Neurosurgery, Division of Global Neurosurgery and Neuroscience, Durham, North Carolina, United States of America
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Galson SW, Staton CA, Karia F, Kilonzo K, Lunyera J, Patel UD, Hertz JT, Stanifer JW. Epidemiology of hypertension in Northern Tanzania: a community-based mixed-methods study. BMJ Open 2017; 7:e018829. [PMID: 29127232 PMCID: PMC5695455 DOI: 10.1136/bmjopen-2017-018829] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Sub-Saharan Africa is particularly vulnerable to the growing global burden of hypertension, but epidemiological studies are limited and barriers to optimal management are poorly understood. Therefore, we undertook a community-based mixed-methods study in Tanzania to investigate the epidemiology of hypertension and barriers to care. METHODS In Northern Tanzania, between December 2013 and June 2015, we conducted a mixed-methods study, including a cross-sectional household epidemiological survey and qualitative sessions of focus groups and in-depth interviews. For the survey, we assessed for hypertension, defined as a single blood pressure ≥160/100 mm Hg, a two-time average of ≥140/90 mm Hg or current use of antihypertensive medications. To investigate relationships with potential risk factors, we used adjusted generalised linear models. Uncontrolled hypertension was defined as a two-time average measurement of ≥160/100 mm Hg irrespective of treatment status. Hypertension awareness was defined as a self-reported disease history in a participant with confirmed hypertension. To explore barriers to care, we identified emerging themes using an inductive approach within the framework method. RESULTS We enrolled 481 adults (median age 45 years) from 346 households, including 123 men (25.6%) and 358 women (74.4%). Overall, the prevalence of hypertension was 28.0% (95% CI 19.4% to 38.7%), which was independently associated with age >60 years (prevalence risk ratio (PRR) 4.68; 95% CI 2.25 to 9.74) and alcohol use (PRR 1.72; 95% CI 1.15 to 2.58). Traditional medicine use was inversely associated with hypertension (PRR 0.37; 95% CI 0.26 to 0.54). Nearly half (48.3%) of the participants were aware of their disease, but almost all (95.3%) had uncontrolled hypertension. In the qualitative sessions, we identified barriers to optimal care, including poor point-of-care communication, poor understanding of hypertension and structural barriers such as long wait times and undertrained providers. CONCLUSIONS In Northern Tanzania, the burden of hypertensive disease is substantial, and optimal hypertension control is rare. Transdisciplinary strategies sensitive to local practices should be explored to facilitate early diagnosis and sustained care delivery.
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Affiliation(s)
- Sophie W Galson
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | - Catherine A Staton
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
- Division of Global Neurosurgery and Neuroscience, Department of Neurosurgery, Duke Global Health Institute, Durham, North Carolina, USA
| | - Francis Karia
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Kajiru Kilonzo
- Department of Medicine, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Joseph Lunyera
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Uptal D Patel
- Department of Medicine, Duke Clinical Research Institute , Duke University, Durham, North Carolina, USA
| | - Julian T Hertz
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Durham, North Carolina, USA
| | - John W Stanifer
- Duke Global Health Institute, Durham, North Carolina, USA
- Division of Nephrology, Department of Medicine, Duke University, Durham, North Carolina, USA
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de Boer AW, de Mutsert R, den Heijer M, Rosendaal FR, Jukema JW, Blom JW, Numans ME. Advantages and disadvantages of unstructured cardiovascular risk factor screening for follow-up in primary care. Eur J Prev Cardiol 2015; 23:1195-201. [PMID: 26603747 DOI: 10.1177/2047487315618794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 11/03/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND In contrast to structured, integrated risk assessment in primary care, unstructured risk factor screening outside primary care and corresponding recommendations to consult a general practitioner (GP) are often based on one abnormal value of a single risk factor. This study investigates the advantages and disadvantages of unstructured screening of blood pressure and cholesterol outside primary care. METHODS After the baseline visit of the Netherlands Epidemiology of Obesity study (population-based prospective cohort study in persons aged 45-65 years, recruited 2008-2012) all participants received a letter with results of blood pressure and cholesterol, and a recommendation to consult a GP if results were abnormal. Four years after the start of the study, participants received a questionnaire about the follow-up of their results. RESULTS The study population consisted of 6343 participants, 48% men, mean age 56 years, mean body mass index 30 kg/m(2). Of all participants 66% had an abnormal result and, of these, 49% had a treatment indication based on the risk estimation system SCORE-NL 2006. Of the 25% of the participants who did not consult a GP, 40% had a treatment indication. Of the participants with an abnormal result 19% were worried, of whom 60% had no treatment indication. CONCLUSIONS In this population 51% of the participants with an abnormal result had unnecessarily received a recommendation to consult a GP, and 10% were unnecessarily worried. GPs should be informed about the complete risk assessment, and only participants at intermediate or high risk should receive a recommendation to consult a GP.
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Affiliation(s)
- Anna W de Boer
- Department of Clinical Epidemiology, Leiden University Medical Centre, The Netherlands Department of Public Health and Primary Care, Leiden University Medical Centre, The Netherlands
| | - Renée de Mutsert
- Department of Clinical Epidemiology, Leiden University Medical Centre, The Netherlands
| | - Martin den Heijer
- Department of Clinical Epidemiology, Leiden University Medical Centre, The Netherlands Department of Internal Medicine, VU Medical Centre, Amsterdam, The Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Centre, The Netherlands Department of Thrombosis and Haemostasis, Leiden University Medical Centre, The Netherlands
| | - Johan W Jukema
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, The Netherlands Department of Cardiology, Leiden University Medical Centre, The Netherlands
| | - Jeanet W Blom
- Department of Public Health and Primary Care, Leiden University Medical Centre, The Netherlands
| | - Mattijs E Numans
- Department of Public Health and Primary Care, Leiden University Medical Centre, The Netherlands
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Zhang DH, Yuan QN, Zabala PM, Zhang F, Ngo L, Darby IB. Diabetic and cardiovascular risk in patients diagnosed with periodontitis. Aust Dent J 2015; 60:455-62. [DOI: 10.1111/adj.12253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2014] [Indexed: 11/28/2022]
Affiliation(s)
- DH Zhang
- Melbourne Dental School; The University of Melbourne; Victoria
| | - QN Yuan
- Melbourne Dental School; The University of Melbourne; Victoria
| | - PM Zabala
- Melbourne Dental School; The University of Melbourne; Victoria
| | - F Zhang
- Melbourne Dental School; The University of Melbourne; Victoria
| | - L Ngo
- Melbourne Dental School; The University of Melbourne; Victoria
| | - IB Darby
- Melbourne Dental School; The University of Melbourne; Victoria
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