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Manolis AJ, Kallistratos MS, Koutsaki M, Doumas M, Poulimenos LE, Parissis J, Polyzogopoulou E, Pittaras A, Muiesan ML, Mancia G. The diagnostic approach and management of hypertension in the emergency department. Eur J Intern Med 2024; 121:17-24. [PMID: 38087668 DOI: 10.1016/j.ejim.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 03/08/2024]
Abstract
Hypertension urgency and emergency represents a challenging condition in which clinicians should determine the assessment and/or treatment of these patients. Whether the elevation of blood pressure (BP) levels is temporary, in need of treatment, or reflects a chronic hypertensive state is not always easy to unravel. Unfortunately, current guidelines provide few recommendations concerning the diagnostic approach and treatment of emergency department patients presenting with severe hypertension. Target organ damage determines: the timeframe in which BP should be lowered, target BP levels as well as the drug of choice to use. It's important to distinguish hypertensive emergency from hypertensive urgency, usually a benign condition that requires more likely an outpatient visit and treatment.
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Affiliation(s)
- A J Manolis
- Metropolitan Hospital, 2nd Department of Cardiology, Ethnarchou Makariou 9, Praeus, Greece
| | - M S Kallistratos
- Metropolitan Hospital, 2nd Department of Cardiology, Ethnarchou Makariou 9, Praeus, Greece.
| | - M Koutsaki
- Asklepeion General Hospital, Cardiology Department, Vasileos Pavlou 1 street, Voula Greece
| | - M Doumas
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - L E Poulimenos
- Asklepeion General Hospital, Cardiology Department, Vasileos Pavlou 1 street, Voula Greece
| | - J Parissis
- Second Department of Cardiology, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece
| | - E Polyzogopoulou
- Second Department of Cardiology, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece
| | - A Pittaras
- Metropolitan Hospital, 2nd Department of Cardiology, Ethnarchou Makariou 9, Praeus, Greece
| | - M L Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia & 2a Medicina ASST Spedali Civili di Brescia, 25121 Brescia, Italy
| | - G Mancia
- University of Milano-Bicocca (Emeritus Professor), Milan, Italy
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2
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Papadopoulou A, Fragkou PC, Maratou E, Dimopoulou D, Kominakis A, Kokkinopoulou I, Kroupis C, Nikolaidou A, Antonakos G, Papaevangelou V, Armaganidis A, Tsantes A, Polyzogopoulou E, Tsiodras S, Antoniadou A, Moutsatsou P. Angiotensin-converting-enzyme insertion/deletion polymorphism, ACE activity, and COVID-19: A rather controversial hypothesis. A case-control study. J Med Virol 2021; 94:1050-1059. [PMID: 34708878 PMCID: PMC8661574 DOI: 10.1002/jmv.27417] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/04/2021] [Accepted: 10/20/2021] [Indexed: 01/19/2023]
Abstract
Accumulating data has shown a contribution of the renin‐angiotensin system in COVID‐19 pathogenesis. The role of angiotensin‐converting enzyme (ACE) insertion (I)/deletion (D) polymorphism as a risk factor in developing COVID‐19 disease comes from epidemiological data and is controversially discussed. We conducted a retrospective case‐control study and assessed the impact of ACE I/D genotype in COVID‐19 disease prevalence and severity. In 81 COVID‐19 patients explicitly characterized and 316 controls, recruited during the first wave of COVID‐19 pandemic, ACE I/D genotype, and ACE activity were determined. A generalized linear model was used and Poisson regression analysis estimated the risk ratios (RRs) of alleles and genotypes for disease severity. DD patients had almost 2.0‐fold increased risk (RR: 1.886, confidence limit [CL] 95%: 1.266–2.810, p = 0.0018) of developing a more severe disease when contrasted to ID and II individuals, as did D allele carriers compared to I carriers (RR: 1.372; CL 95%: 1.051–1.791; p = 0.0201). ACE activity (expressed as arbitrary units, AU/L) was lower in patients (3.62 ± 0.26) than in controls (4.65 ± 0.13) (p < 0.0001), and this reduction was observed mainly among DD patients compared to DD controls (3.97 ± 0.29 vs. 5.38 ± 0.21; p = 0.0014). Our results demonstrate that ACE DD genotype may predispose to COVID‐19 increased disease severity via a mechanism associated, at least in part, with the significant fall in their ACE activity. Our findings suggest a more complex pattern of synergy between this polymorphism and ACE activity in COVID‐19 patients compared to healthy individuals and set the grounds for large‐scale studies assessing ACE genotype‐based optimized therapies with ACE inhibitors and angiotensin receptor blockers.
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Affiliation(s)
- Anna Papadopoulou
- Department of Clinical Biochemistry, University General Hospital "ATTIKO," National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Paraskevi C Fragkou
- Fourth Department of Internal Medicine, University General Hospital "ATTIKO," National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Eirini Maratou
- Department of Clinical Biochemistry, University General Hospital "ATTIKO," National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Dimitra Dimopoulou
- Third Department of Pediatrics, University General Hospital "ATTIKO," National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Antonis Kominakis
- Department of Animal Science and Aquaculture, Agricultural University of Athens, Athens, Greece
| | - Ioanna Kokkinopoulou
- Department of Clinical Biochemistry, University General Hospital "ATTIKO," National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Christos Kroupis
- Department of Clinical Biochemistry, University General Hospital "ATTIKO," National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Athina Nikolaidou
- Department of Clinical Biochemistry, University General Hospital "ATTIKO," National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Georgios Antonakos
- Department of Clinical Biochemistry, University General Hospital "ATTIKO," National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Vasiliki Papaevangelou
- Third Department of Pediatrics, University General Hospital "ATTIKO," National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Apostolos Armaganidis
- Second Department of Critical Care, "Attikon" University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Argirios Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Eftychia Polyzogopoulou
- Department of Emergency Medicine, "Attiko" Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, University General Hospital "ATTIKO," National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Anastasia Antoniadou
- Fourth Department of Internal Medicine, University General Hospital "ATTIKO," National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Paraskevi Moutsatsou
- Department of Clinical Biochemistry, University General Hospital "ATTIKO," National and Kapodistrian University of Athens, Medical School, Athens, Greece
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Apostolou E, Rafouli-Stergiou P, Liori S, Bistola V, Polyzogopoulou E, Doumanis G, Cholevas N, Frogoudaki A, Ikonomidis I, Parissis J. In-hospital prognosis of patients with primary and secondary acute heart failure diagnosis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Secondary acute heart failure (AHF) during hospitalization for another primary diagnosis is a frequent in-hospital complication.
Purpose
This analysis aims to describe differences in prognosis of these patients in comparison with patients admitted for AHF (primary AHF diagnosis) and also identify factors associated with in-hospital mortality.
Methods
This is a sub-analysis of the Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF), which enrolled 4953 patients from 9 countries. All parameters univariately associated with in-hospital mortality in the primary and secondary AHF groups were included in the multivariate logistic regression model.
Results
Secondary AHF diagnosis was observed in 24.1% (N=1196) of the total study cohort. These patients demonstrated almost double all-cause in-hospital mortality rates compared to patients with primary AHF (16.9% versus 8.9%, p<0.001).
In patients with primary AHF, negative prognostic factors included older age (>75 years) (OR 2.01, 95% CI 1.24–3.26, p=0.004), acute coronary syndromes (ACS) (OR 2.71, 95% CI 1.57–4.69, p<0.001), chronic renal disease (OR 2.02, 95% CI 1.13–3.61, p=0.017), presence of cold extremities (OR 2.04, 95% CI 1.23–3.40, p=0.006), in-hospital treatment with CPAP (OR 2.55, 95% CI 1.20–5.41, p=0.014), dobutamine (OR 2.55, 95% CI 1.52–4.28, p<0.001), dopamine (OR 3.03, 95% CI 1.74–5.27, p<0.001) and noradrenaline (OR 4.76, 95% CI 2.32–9.76, p<0.001). Favorable predictors were systolic blood pressure ≥100 mmHg on admission (OR 0.54, 95% CI 0.31–0.94, p=0.031), in-hospital treatment with ACEIs (OR 0.07, 95% CI 0.03–0.16, p<0.001), ARBs (OR 0.30, 95% CI 0.13–0.70, p=0.005) and vitamin-K antagonists (OR 0.06, 95% CI 0.007–0.44, p=0.006).
In secondary AHF, independent predictors of in-hospital mortality included left ventricular ejection fraction (LVEF) <40% (OR 2.36, 95% CI 1.17–4.75, p=0.016), age >75 years (OR 2.23, 95% CI 1.09–4.54, p=0.026), ACS (OR 3.55, 95% CI 1.50–8.39, p=0.004), diabetes (OR 2.26, 95% CI 1.23–4.16, p=0.008), pre-admission treatment with digoxin (OR 7.27, 95% CI 1.83–28.87, p=0.005), in-hospital medication with dobutamine (OR 2.43, 95% CI 1.28–4.61, p=0.006), dopamine (OR 2.29, 95% CI 1.12–4.67, p=0.022) and noradrenaline (OR 4.14, 95% CI 1.76–9.76, p=0.001). Covariates independently associated with survival benefit in secondary AHF were pre-admission treatment with diuretics (OR 0.29, 95% CI 0.09–0.88, p=0.030) and in-hospital treatment with ACEIs (OR 0.17, 95% CI 0.07–0.39, p<0.001) and aspirin (OR 0.27, 95% CI 0.11–0.69, p=0.006).
Conclusion
Patients with secondary AHF experienced a more complicated in-hospital course with worse prognosis, compared to primary AHF. LVEF <40%, age >75 years, ACS, diabetes, pre-admission treatment with digitalis, in-hospital medication with dobutamine, dopamine and noradrenaline were identified as independent negative prognostic factors of in-hospital mortality in secondary AHF patients.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- E Apostolou
- Attikon University Hospital - 2nd Department of Cardiology - Heart Failure Unit, Athens, Greece
| | - P Rafouli-Stergiou
- Attikon University Hospital - 2nd Department of Cardiology - Heart Failure Unit, Athens, Greece
| | - S Liori
- Attikon University Hospital - 2nd Department of Cardiology - Heart Failure Unit, Athens, Greece
| | - V Bistola
- Attikon University Hospital - 2nd Department of Cardiology - Heart Failure Unit, Athens, Greece
| | - E Polyzogopoulou
- Attikon University Hospital - 2nd Department of Cardiology - Heart Failure Unit, Athens, Greece
| | - G Doumanis
- Attikon University Hospital - 2nd Department of Cardiology - Heart Failure Unit, Athens, Greece
| | - N Cholevas
- Attikon University Hospital - 2nd Department of Cardiology - Heart Failure Unit, Athens, Greece
| | - A Frogoudaki
- Attikon University Hospital - 2nd Department of Cardiology - Heart Failure Unit, Athens, Greece
| | - I Ikonomidis
- Attikon University Hospital - 2nd Department of Cardiology - Heart Failure Unit, Athens, Greece
| | - J Parissis
- Attikon University Hospital - 2nd Department of Cardiology - Heart Failure Unit, Athens, Greece
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Fountoulaki K, Tsiodras S, Polyzogopoulou E, Olympios C, Parissis J. Beneficial Effects of Vaccination on Cardiovascular Events: Myocardial Infarction, Stroke, Heart Failure. Cardiology 2018; 141:98-106. [DOI: 10.1159/000493572] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 09/07/2018] [Indexed: 12/28/2022]
Abstract
Influenza and pneumococcal infections have been suggested to be potential risk factors for causing adverse cardiovascular events, especially in high-risk patients. Vaccination against respiratory infections in patients with established cardiovascular disease (CVD) could serve as a potential cost-effective intervention to improve their clinical outcomes and cardiac societies have encouraged it. Previous studies have shown that influenza vaccination reduce mortality, acute coronary syndromes and hospitalization in patients with coronary heart disease (CHD) and/or heart failure (HF). However, there is a paucity of randomized prospective clinical trials in the field of the pneumococcal vaccination, and additional higher-quality evidence is needed. Furthermore, questions around the role of vaccination in the primary prevention of CVD, the optimal dose and timing are largely unanswered. The pathophysiologic mechanism in which vaccination provides cardiovascular protection may be related to the modification of the immune-inflammatory model of atherogenesis. The present review summarizes the current evidence and understanding for vaccination against influenza and streptococcus pneumoniae in CHD, HF and stroke and highlights its beneficial effect in the reduction of adverse cardiovascular events.
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