AHA Guidelines Research Articles

92 aetiologic factors for heart failure: prevalence, co-occurrence, prognosis and potential for prevention in 170,885 incident HF cases

Abstract Background ESC and AHA guidelines identify 92 putative aetiological factors for heart failure, but primary prevention strategies for heart failure (HF) have had limited success. There are no previous studies systematically evaluating the potential for prevention among such a wide range of clinically manifest aetiologic factors. Objective To estimate for 92 (putative) aetiologic factors their prevalence, co-occurrence, preventability and impact on HF prognosis in incident HF. Methods We identified 170885 individuals aged ≥30 years with incident HF from 1997–2017 using linked primary and secondary care electronic health records (EHR) in the UK (CALIBER). For each of the 92 factors we developed EHR phenotypes using ICD-10 diagnosis, Read, procedure and medication codes (total = 5961 codes). We conducted a literature review of trials of primary HF prevention across 92 factors. Results 35.6% of individuals with HF had ≥4 aetiologic factors recorded in the preceding 5 years. Of all new HF cases 71.5% had ≥1 of the 7 aetiologic factors with trial evidence of effective preventive therapy for HF; 12.9% had ≥1 aetiologic factor with effective preventive therapy for CVD and 15.6% had either no aetiological factor, or an aetiological factor with no evidence of preventive potential. 88/91 factors were represented. The commonest factors in the 5 years prior to HF diagnosis were hypertension (48.7%), smoking (46.6%), reduced physical activity (39.6%), stable angina (35.6%), obesity (29.4%), atrial arrhythmias (17.3%), unstable angina (16.9%), cancer (16.6%), myocardial infarction (15.9%), diabetes (15.2%), alcohol (14.9%) and severe anaemia (14.3%). Mortality at 1 year varied across all 91 factors (lowest: pregnancy-related hormonal disorder – 4.2%; highest: phaeochromocytoma – 73.7%). Conclusion We provide a systematic map of primary preventive opportunities for heart failure, demonstrate the high burden of co-occurring aetiologic factors and highlight need for trials tackling multiple aetiological factors. Aetiologic factors of heart failure Funding Acknowledgement Type of funding source: Public grant(s) – EU funding. Main funding source(s): Innovative Medicines Initiative-2 Joint Undertaking

10-year trend analysis of in-hospital cardiac arrest: 2008–2017 United State hospitalizations

Abstract Introduction In-hospital cardiac arrest (IHCA) survival trends have not been well reported in recent years. Whether the implementation of the new 2015 AHA guideline affects the survival of IHCA is largely unknown. Our study aims to provide an updated analysis of the trends of IHCA among the hospitals in the United States Method Using United States National Inpatient Sample Database 2008–2017, the cohort was generated with patients age above 18 who received Cardiopulmonary resuscitation during Hospitalization. Hospitalization with a principle diagnosis of cardiac arrest or ventricular fibrillation/ventricular tachycardia were excluded as outside hospital cardiac arrest. Demographic features, baseline characteristic as well as hospital outcomes were described. Trend analysis was performed using a multivariate model adjusted for age, sex, and comorbidities score. Results From 2008 to 2017, the cases of In-hospital cardiac arrest (IHCA) has steadily increased from 96,771 to 106,320. This trend was accompanied by a decline in age from (67.48±0.30 to 65.78±0.13, Ptrend <0.001) but increase in comorbidity score (from 2.44±0.27 to 3.47±0.21, Ptrend <0.001). It is noted that the mortality rate has been steadily declining since 2008 (from 74.01% to 68.68%, Ptrend <0.001)), although no significant changes before or after 2015 were noted (from 68.90 to 68.68, P>0.05). Length of stay has decreased from an average of 9.06± days to 8.76±0.13 days at the cost of increased health care costs (from 30.78 to 37.40 thousand dollar P<0.001 adjusted for inflation rate). Conclusion The survival rate of In-hospital cardiac arrest has increased from 2008 to 2017 despite increased comorbidity burden. The length of stays has decreased at the cost of an increase in health costs. Funding Acknowledgement Type of funding source: None

<p>Acute Ischemic Stroke Management: A Clinical Audit in Accordance with the 2019 AHA Guidelines</p>

<p>Acute Ischemic Stroke Management: A Clinical Audit in Accordance with the 2019 AHA Guidelines</p>

Abstract P156: Improvement In Blood Pressure Using Remote Patient Monitoring During COVID19

Introduction: The coronavirus disease 2019 (COVID19) pandemic required strict social distancing to curb transmission. Unfortunately, these measures severely limited healthcare access and chronic disease management. In response, many health organizations rapidly developed or expanded telemedicine to provide care directly to patients at home. Little has been reported about the impact of such interventions on clinical outcomes during COVID19. We examined whether enrollment in a remote patient monitoring (RPM) program for hypertension (HTN) prior to COVID19 was associated with improved blood pressure during the pandemic. Methods: We developed an RPM program that tracked vital signs, medication side effects, and treatment adherence patterns outside of the clinic. Patients were referred by their primary care doctor for uncontrolled HTN or suspected white coat HTN. Patients received a two-way tablet, blood pressure cuff, and virtual nursing support via scheduled video visits. Those referred for uncontrolled HTN who had at least two weeks of data both before and after the onset of COVID19 (defined as the first two weeks of March 2020) were included in the study. A mixed-models analysis that adjusted for serial autocorrelation was used to compare mean systolic blood pressure (SBP) and mean diastolic blood pressure (DBP) in the pre-/post-COVID19 periods. Results: Of 94 patients enrolled in the RPM program to date, 46 had at least two weeks of data both pre-COVID19 and post-COVID19. Mean age was 69.0 ± 10.9 years, 69.6% (32 of 46) were women, 78.3% (36 of 46) were Hispanic, and 63.0% (29 of 46) were Spanish-speaking. Pre-COVID, mean SBP was 132.31 ± 13.99 mmHg, mean DBP was 77.10 ± 9.87 mmHg, and 70% (32 of 46) of patients had uncontrolled BP (>130/80 mmHg per AHA guidelines). Post-COVID, mean SBP was 129.57 ± 13.29 mmHg, mean DBP was 76.00 ± 9.16 mmHg, and 57% (26 of 46) of patients had uncontrolled BP. There was a significant reduction in both mean SBP (β = –2.74, 95% CI –5.21, –0.26, p = 0.03) and mean DBP (β = –1.10, 95% CI –2.22, 0.02, p = 0.05) post-COVID vs. pre-COVID. Discussion: Despite the stress and social isolation associated with COVID19, participation in an RPM program that combines home BP monitoring with virtual nursing support can help maintain and even mildly decrease BP.

Abstract P180: Effect Of Sunitinib Treatment On Skin Sodium Accumulation In Patients With Metastatic Renal Cancer: A Pilot Study

Angiogenesis is required for invasive tumor growth and metastasis which is controlled mainly by vascular endothelial growth factors (VEGF). Novel strategies for cancer treatment target VEGF signaling. These agents are featured by adverse events including hypertension. New concepts suggest that besides the kidneys, the skin also plays a role in body sodium homeostasis and blood pressure regulation by a VEGF-C–dependent buffering mechanism. Here, we tested the hypothesis that changes in blood pressure correspond to tissue sodium accumulation during sunitinib treatment of metastatic renal cell carcinoma patients (https://clinicaltrials.gov/identifier: NCT04368546; Charité ethical approval EA1/044/15).Male patients (n=4) took sunitinib according to the standard treatment protocol, 50 mg once daily, taken for 4 weeks followed by a 2-weeks off treatment period. Measurements were performed at baseline (before sunitinib treatment), and over a complete on-off-on period. Tissue sodium content was measured using non-invasive 23Na-MRI; skin sodium was measured in a group (n=5) of age-matched healthy subjects, as well. Blood pressure was measured according to AHA guidelines. Blood withdrawal followed after ca. 45 minutes of sitting to measure VEGF-A, VEGF-C, endothelin-1, renin and aldosterone levels.Elevated systolic blood pressure under sunitinib treatment decreased to the baseline level in the off-treatment phase (130.5 mmHg vs 117.5 mmHg, respectively, p<0.05). Plasma endothelin-1 levels mirrored directly and VEGF-A levels inversely the blood pressure changes. Baseline skin sodium content was similar to the skin sodium level of healthy controls. Skin sodium content was elevated after the first on-treatment phase and stayed high in all the following measurements in comparison to control subjects. Patients had high baseline VEGF-C levels that decreased after the first treatment with sunitinib and stayed low independently of further treatment phase.In conclusion, sunitinib treatment suppresses VEGF-C levels permanently which is associated with sustained elevated skin sodium levels. Furthermore, we confirmed the association between plasma endothelin-1 levels and blood pressure changes during sunitinib treatment protocol.

Abstract P174: Value Of Six Minute Walk Test In The Evaluation Of Children With Elevated Blood Pressures

Lifestyle modifications, a mainstay of hypertension (HTN) therapy, include recommendations for regular physical activity. However, fitness is not typically assessed. In the HTN clinic at Seattle Children’s, we conduct the 6-minute walk test (6MWT) in children > 6 yrs referred for HTN. We sought to assess whether children referred for HTN underperform on the 6MWT. Methods: We performed a retrospective chart review of patients seen from 9/1/18 - 9/30/19 who completed an ambulatory blood pressure monitor (ABPM) and 6MWT. Chart review included ABPM results, age, sex, BMI z-score, self-reported physical activity (RepPA) levels, rating of perceived exertion (RPE) and comorbid conditions. Exclusion criteria included lack of ABPM, 6MWT or compromised exercise capacity. ABPM was classified according to the 2014 AHA guidelines and 6MWT was compared to normative datasets. Fisher’s Exact test was used to compare the distributions of distance from mean values for the 6MWT and ANOVA was used to compare mean BMI z-score and RPE among groups. Linear regression assessed 6MWT with HTN status, adjusted for age, sex, and BMI z-score. Results: Demographics and clinical measures are summarized in Table 1. RepPA, 6MWT and RPE did not differ significantly. Most children underachieved regardless of group; the distance walked was > 2 SD below mean in 31 of 52 (60%). BMI z-score was significantly higher in the abnormal ABPM group. Linear regression showed no effect of HTN status. Conclusion: Most children underperformed on the 6MWT and results did not differ based on HTN status. This study suggests the 6MWT is useful to assess fitness in this population and serves as baseline for comparison.

Abstract 5: White Coat Hypertension Stability In Children And Adolescents: Pediatric Nephrology Research Consortium Study

There is no pediatric data on whether white coat hypertension (WCH) is a precursor of sustained HTN. The objective of this study was to determine diagnosis changes on follow-up ambulatory blood pressure monitoring (ABPM) in children and adolescents diagnosed with WCH on their initial ABPM and to assess for predictive factors of progression to HTN. Retrospective review was conducted at 11 centers to identify patients with WCH diagnosed by ABPM and had repeat ABPM at least 6 months after the first study. Subjects with secondary HTN, on antihypertensive medication, and diabetes mellitus were excluded. Patients with ADHD were included in the study if medications were stable. Chart review included associated risk factors such as BMI, obstructive sleep apnea, and family history of HTN. ABPM phenotype was determined using the 2014 AHA guidelines. The association between abnormal ABPM diagnosis on follow-up and ABPM index and blood pressure load variables was assessed using univariable generalized linear mixed effect models. Significant ABPM index and load variables (based on p < 0.15) were subsequently added to a multivariable model with the following pre-specified covariates: gender, family history of HTN, age, BMI z-score, ADHD, and interval time between ABPMs. One hundred and one patients met criteria for inclusion with a median age of 14 years (80% males) and median interval time of 14 months (range: 6 – 55 months). On follow-up ABPM, 18% and 32% of patients demonstrated HTN and prehypertension respectively (18 and 32 of 101, respectively). In univariable modeling, awake and nocturnal systolic BP index ≥ 0.9 on the first ABPM were found to be significantly associated with progression to abnormal ABPM [unadjusted OR (95% CI) awake: 4.3 (1.2 – 14.6); nocturnal: 3.2 (1.0 – 10.1)]; however, these associations were not significant after adjusting for pre-specified covariates [adjusted OR (95% CI) awake: 2.7 (0.7-10.4); nocturnal: 2.6 (0.7 – 9.2)]. Approximately half of children and adolescents first diagnosed with WCH progressed to an abnormal ABPM phenotype on follow-up, suggesting that longitudinal follow-up with ABPM is indicated in pediatric WCH patients. We were unable to identify ABPM findings that might predict a higher risk for progression.

Effectiveness of basic life support training in improving the knowledge and skills among medical and dental students

Background and Aim: The knowledge and skills about Basic Life Support (BLS) is the most important determining factor of cardiopulmonary resuscitation (CPR) success rates. This study was conducted on BLS skills to assess the effects of pre training evaluation followed by post training evaluation and retention of knowledge after six months among medical and dental students. Materials and Methods: Cross sectional study was conducted by assessing the responses of 20 basic questions regarding Basic Life Support prepared from BLS 2015 AHA Guideline. Total number of 300 respondents were selected for the survey which included 200 medical and 100 dental students. The assessment of the knowledge of the students was done in three phases in the form of (pre test) performance in pre training evaluation, immediately after training (post test) and at follow up after six months (retention test). The data was analysed and expressed as mean, standard deviation and percentage. T test were used for statistical analysis and P values Results: Among Medical students the average score in pre test was 56.92+18.90%, in post test the score was 80.87+17.97%, and in retention test the score was 72.45+17.85%. Among Dental students the average score in pre test was 50.40+16.34%, in post test the score was 67.70+15.75%, and in retention test the score was 59.45+15.96%. P values Conclusion: The knowledge of BLS before training was inadequate. The present BLS training programme was effective in enhancing the knowledge of resuscitation among the students. To enhance the retention power time to time retraining by working on mannequins to practice and perfect their skills is highly recommended for the students. Keywords: Basic life support, Cardiac arrest, Medical students, Dental students, Training.

Evaluating the utility of fasting lipid panel in addition to random lipid panel in determining lipid-lowering therapy in acute ischemic stroke or TIA patients

BackgroundHyperlipidemia is one of the major risk factors for cerebrovascular disease and it is common practice to obtain fasting lipid profile prior to starting lipid lowering therapy (LLT). Recent AHA Guidelines published in 2018 allow for a non-fasting value to be used. ObjectiveTo determine if obtaining fasting lipid levels in addition to random lipid levels prompts changes in hyperlipidemia management of acute stroke patients. Methods206 patients met the study criteria which included a diagnosis of acute ischemic stroke or transient ischemic attack on admission and availability of both random and fasting LDL levels collected within 72 h of each other. Patients were divided into three groups based on random LDL at admission: Group A: LDL < 70, Group B: LDL 70−99, and Group C: LDL ≥ 100 mg/dL. The dataset was analyzed to conform to the 2018 AHA/ACC guidelines using an LDL cutoff of 70 mg/dL. ResultsIn 206 patients, statin management would change based on the fasting LDL level in 12 patients, 11 of whom were in Group B. Our data suggests that lipid management is more likely to change if the initial random LDL falls between 70−99 mg/dL as compared to a value outside of this range (P < 0.001). We present a decision algorithm to guide lipid management in acute stroke patients. ConclusionsForegoing a fasting lipid panel to guide LLT in patients with ischemic stroke is appropriate in most cases but for select patients with random LDL levels between 70 and 99, fasting lipid profile should be obtained prior to deciding upon LLT.

Dental Management of Medically Compromised Patients- A Questionnaire among Dental Practitioner

Introduction : An increase in the number of medically compromised patients in dental clinics may cause serious problems for practicing dentists all over the world. When a dentist does not understand well the relationship between oral and systemic diseases, dental care may become a quite complicated issue. Management of the medically compromised patients require acquisition of complete health history as well as dental history of the patient. This should include documentation via questionnaire as well as a verbal history. Preferably an oral history should also be obtained as a review of systems. The dental history should also include questions related to current oral conditions such as periodontal disease or oral ulceration and past dental treatment and potential complications from prior intervention including treatment failure and the delivery of anesthesia or post-treatment medication. The first step in managing the patients with medical problems is acquiring thorough health history of the patients. Aim: The aim of this study is to analyse the knowledge about dental management of medically compromised patients among dental practitioners. Materials and Method: A cross sectional survey was initiated from a randomly chosen population of 100 dental practitioners. Informed consent was obtained from the participants. the survey was conducted online using online survey planet online survey tool. the survey instrument used was a pretested questionnaire comprising of 10 questions eliciting responses pertaining to the dental management of medically compromised patients among dental practitioners. Results: Among 100 dental practitioners 100% of them enquire medical history including medication and allergy, 68% of them obtain vital signs of the patient commencing dental treatment, 50% of them are confident in handling emergency conditions. 82% of them have emergency kit in dental office, 98% of them get consent from the physician before treating medically compromised patients, 62% of them have knowledge about prescribing AHA guidelines of antibiotics for cardiovascular patients, 42% of them said they can efficiently manage patients on 1st, 2nd and 3rd trimester and 88% of them are aware of diagnosing oral signs of anemia and management. Conclusion: Dental practitioners have adequate knowledge about managing medically compromised patients in a dental unit. The handling of a medical emergency in a dental office is a skill. One must have hands

Abstract 391: Telemetry Talk: A Quality Improvement Initiative To Decrease Inappropriate Telemetry Use

Objectives: The purpose of this study was to identify the percentage of inappropriate telemetry and reduce inappropriate use via a multidisciplinary interventional approach. Background: Nationally studies have demonstrated that up to 43% of telemetry orders are inappropriate and do not change patient outcomes or clinical decision making. Overuse may also lead to unnecessary diagnostic workup, hospital costs, clinical duties, and even hospital divert status. Methods: Using the AHA guidelines and the TUH official policy, we created an updated table of appropriate telemetry indications (Table 1). We used the Epic telemetry column to identify active orders. Then, each patient’s chart was reviewed to determine whether the order was appropriate."We reviewed all active telemetry orders on our medicine services over four days. Results: Teaching services had 72/140 (51%) inappropriate orders while direct-care services had 4/19 (21%) inappropriate orders (Table 2). "Subspecialty teaching services had 10/15 (67%) inappropriate orders. Discussion: Inappropriate telemetry use is a systems-based, multidisciplinary problem requiring interventions at multiple levels Our goal was to reduce overall inappropriate telemetry use from 49% to 35% At our center, interventions underway include: Posting the indications on workstations, Encouraging “Time out for Tele!” review on rounds, Educating hospital teams, Additional Epic modifications. Conclusions: Inappropriate telemetry use on medicine services at our institution is higher than national averages. We increased physician awareness of orders and performed education on appropriate use. We plan to re-assess telemetry use at interval periods to assess for improvement.

Abstract 376: Adverse Pregnancy Outcomes and Cardiovascular Risks Multi-disciplinary Awareness Project

Background: Cardiovascular disease (CVD) remains the number one cause of death amongst women. There has been much effort put forth over the past decade in reducing both the incidence and prevalence of this disease burden through screening and treating the traditional risk factors. Recent guidelines have shown that adverse pregnancy outcomes (APOs), including pre-eclampsia (PEC), gestational diabetes mellitus (GDM) and pre-term birth (PTB) have been associated with future maternal CVD risk. Much of the current literature focuses almost exclusively on PEC. Our investigation is more comprehensive, covering not only these other APOs but assessing whether providers of multiple specialties in our community are aware of the APO to CVD risk association. The primary objective of this study was to investigate if there exist any knowledge gaps regarding the progression from APO to CVD and if this knowledge varies by specialty. Methods: An anonymous voluntary survey through REDCap© was sent to providers in the fields of Internal medicine (IM, 21%), Family medicine (FM, 26%), Obstetrics-Gynecology (Ob-Gyn, 23%) and Cardiology (30%) who have been in practice for greater than five years in our local Gainesville community. This project was registered as a QI project and descriptive analysis was used to examine the responses. Results: A total of 53 providers responded to the survey. Despite having the majority of patients being women, Ob-Gyn was the least likely amongst all specialties to routinely screen for CV risk factors. However, when addressed, they were the most likely to ask about APOs. Cardiologists, despite declaring to be aware of the association between APOs and CV risk, were least likely to ask about APOs. All specialties recognized PEC and GDM as APOs linked to long-term maternal CV risk but failed to associate PTB as an APO. The majority of providers amongst IM, FM, and Cardiology did not ask about APOs and lacked the knowledge of how often to appropriately screen for secondary risk factors associated with APOs. Additionally, these providers outright admitted that they are not familiar with the current AHA and/or ACOG guidelines for screening and follow-up. Conclusion: Descriptive statistical analysis of our data suggests that there exists a notable knowledge gap between all four specialties investigated in our survey. Education concerning the link between APOs and future maternal CV risk is needed amongst all specialties, especially amongst the providers in Cardiology, IM, and FM. Targeted efforts at our institution to improve awareness of all APOs, their associated secondary risk factors, and appropriate screening is required in all specialties to help reduce CVD morbidity and mortality.

Effect of Chest Compression Position Depending on the Rescuer’s Hip Joint Angle During Basic CPR

This study aims to investigate the improvement in basic CPR quality on the basis of the hip joint angle of the rescuer among students in the Department of Emergency Medical Technology who completed a basic CPR curriculum. In this study, we carried out a comparative analysis using SimPad SkillReporter and Resusci Anne® QCPR® to measure the quality of CPR (depth of chest compressions, full relaxation, compression speed, and more) on the basis of the rescuer’s hip joint angle in accordance with the 2015 AHA Guidelines and conducted chest compressions and CPR 5 times in a 30:2 ratio. It was found that maintenance of the rescuer’s hip joint angle at 90 degrees while compressing and relaxing the chest made a statistically significant difference in both the experimental and control groups. Moreover, this indicated that the closer the hip joint angle was to 90 degrees, the better was the quality of basic CPR. However, there was no significant difference in the hip joint angle, degree of CPR, depth of chest compressions, chest compression speed, chest compression and relaxation percentages (%), accuracy of chest compressions, hands-off time during CPR, and percentage of chest compression time (p &gt; 0.05). Maintaining the hip joint angle at 90 degrees for basic CPR was not significantly different from not maintaining this angle. Nonetheless, good results have been obtained at moderate depth and 100% recoil. Therefore, good outcome and high-quality CPR are expected.

Concordance between the 2010 and 2015 Resuscitation Guidelines of International Liaison Committee of Resuscitation Councils (ILCOR) members and the ILCOR Consensus of Science and Treatment Recommendations (CoSTRs)

BackgroundCardiac arrests are associated with poor outcomes. The International Liaison Committee on Resuscitation (ILCOR) evaluates resuscitation science and produced, until 2015, five-yearly consensus on science and treatment recommendations (CoSTRs), informing global resuscitation guidelines.We aimed to identify similarities/differences in resuscitation guidelines from ILCOR members, noting concurrence over time, and CoSTRs influence on these guidelines. MethodsWe considered the component elements of paediatric and adult, basic and advanced resuscitation guidelines, published in 2010 and 2015, along with matching ILCOR CoSTRs to examine their influence. We contacted the responsible councils when guidelines were unavailable online. ResultsComplete resuscitation guidelines were found for six of the seven ILCOR council members. The Resuscitation Council of Asia only had adult basic life support (BLS) guidelines in English. Three members used the AHA guidelines. Therefore, five rather than seven sets of resuscitation guidelines were compared to the CoSTRs.Concurrence between CoSTRs recommendations and ILCOR council member's resuscitation guidelines has improved over time. Minor variations were identified in both basic and advanced life support, with most variance in paediatric guidelines, but these narrowed over time. ConclusionThe improved concurrence across the resuscitation guidelines with the CoSTRs suggests that ILCOR members accept and hence incorporate CoSTRs recommendations to inform their own resuscitation guidelines. This is one step towards the development of international universal guidelines for adult and paediatric resuscitation.

Comparison of Tmax values between full- and half-dose gadolinium perfusion studies

AHA guidelines recommend use of perfusion imaging for patient selection in the 6–24 h window. Recently, the safety of gadolinium-based contrast agents for MR perfusion imaging has been questioned based on findings that gadolinium accumulates in brain tissue. Regulatory bodies have recommended to limit the use of gadolinium-based contrast agents where possible. Focusing specifically on the time to maximum of the tissue residue function (Tmax) parameter, used in DAWN and DEFUSE 3, we hypothesized that half-dose scans would yield a similar Tmax delay pattern to full-dose scans. We prospectively recruited 10 acute ischemic stroke patients imaged with two perfusion scans at their follow-up visit, one with a standard dose gadolinium followed by a half-dose injection a median of 7 min apart. The brain was parcellated into a grid of 3 × 3 regions and the mean of the difference in Tmax between the 3 × 3 regions on the half- and full-dose Tmax maps was 0.1 s (iqr 0.38 s). The fraction of brain tissue that differed by no more than ±1 s was 93.7%. In patients with normal or modest Tmax delays, half-dose gadolinium appears to provide comparable Tmax measurements to those of full-dose scans.

Abstract P303: Use of Community Health Workers for Community-based Hypertension Screening in Urban Haiti

Background: Cardiovascular disease is the leading cause of mortality among Haitian adults, and hypertension (HTN) is the most important CVD risk factor, as in other resource-poor countries. The majority of Haitians have never been screened for hypertension and access to clinic-based services is limited. Methods: Twenty-eight Haitian community health workers (CHW) conducted household-based HTN screening within a population-based longitudinal cohort study of 3,000 adults in metropolitan Port-au-Prince. Randomly selected GPS locations across census blocks were selected in proportion to the estimated population of each block. One household at each waypoint was selected systematically and CHW collected household information and conducted three blood pressure measurements the same day on all adult household members (≥ 18 years) present at the time of the survey using AHA guidelines. Adults with HTN were referred to the GHESKIO clinic for repeat BP measurement and treatment. Results: Between March and September 2019, 585 households provided verbal consent for surveys and BP screening (97% response rate). These households had a total of 2542 people (1777 adults) with the median number of adults per household being 3 (IQR 2-4; range 1-9). A total of 913 adults (51%) were present at the time of survey, and all agreed to blood pressure screening. The majority were women (70%) with a median age of 36 years (IQR 27-52). Hypertension prevalence (SBP &gt; 140 and/or DBP &gt; 90) was 25.3% (15.5% Stage I, 9.8% Stage II). Figure 1 reports HTN prevalence by age group (18-30, 31-45, 46-60, &gt;60) and by sex, with HTN increasing by age group but without significant variation by sex. Conclusion: Community blood pressure screening is feasible and highly acceptable in Port-au-Prince, Haiti. Preliminary results show high rates of HTN among a population with limited access to screening, diagnosis and treatment. Further research is urgently needed to design linkage to care strategies and effective treatment interventions to curb the HTN epidemic in Haiti.

Multiple Modern Methods of Blood Pressure Measurement and the 2018 European Society of Hypertesion Guidelines

The new international guidelines on hypertension management have been issued in the past few years. The AHA (2017) and ESH (2018) Guidelines are similar in many key aspects. However, they differ substantially in the area of blood pressure (BP) measurement methodology. In this article, we aim to explain the ESC Guidelines position, specifically the conservative BP thresholds and a wider use of ambulatory BP measurement methods. In our opinion, the main reason behind this position is the introduction and a relatively widespread use of automatic office BP measurement (AOBP). On one hand, this method has questioned the results of the SPRINT trial – the key evidence source for the AHA Guidelines. On the other hand, AOBP has challenged the concept of “traditional office BP measurement”. Therefore, it is important to be aware of the current multiplicity of BP measurement methods and respective threshold values recommended for each method. It is essential to perform the office BP measurement correctly and thoroughly. Throughout all stages of the hypertensive patient management (diagnosis, antihypertensive treatment choice, and long-term observation), the use of out-of-clinic BP measurement is strongly advisable.

Abstract P3-02-08: Comparison of metabolic changes after neoadjuvant endocrine and chemotherapy in ER positive, HER2 negative premenopausal women with breast cancer

Abstract Background Survival of breast cancer has improved and treatments related changes and long term effect regarding weight gain and metabolic profile deterioration after neoadjuvant systemic treatment (NST) become important issues in cancer survivor especially young women. We sought to compare changes in body mass index (BMI), metabolic profiles and neutrophil lymphocyte ratio (NLR) in patients who underwent 6 months of neoadjuvant chemotherapy (NCT) and neoadjuvant endocrine therapy (NET) before/ after NST and 3 years after treatment. Methods Prospective, randomized, phase III trial (NEST) which compared 24 weeks of response of NCT with Adriamycin and cyclophosphamide(AC) followed by docetaxel (T) and NET with goserelin and tamoxifen. Among them, 123 patients from NEST trial in Asan Medical Center were retrospectively reviewed to evaluate metabolic changes such as BMI, blood pressure (BP), total cholesterol (TC), fasting glucose, and NLR.BP was classified according to 2017 AHA guideline such as normal, elevated, HTN stage I and HTN stage II. NLR was calculated from the differential leukocyte count by dividing neutrophil percentage by lymphocyte percentage in routine blood cell counts. Results The mean age of patients was 42 years old. BMI were significantly increased during NCT (22.6 to 23.7, p&amp;lt;0.05), and recovered after 3 year follow up. BMI change were not observed before and after NET and 3 year follow up (23.2, 22.0 and 23.2 respectively p&amp;gt;0.05, all) In the NCT group, the normal group of BP increased from 35 (58%) patients to 40(67%) patients and the elevated group decreased from 12 patients (20%) to 2 patients (3.3%). HTN stage I group was increased from 8 (13%) to 12 (20%) and HTN stage II group increased from 5 (8%) to 6 (10%) after NCT (p=0.001). There were no significant changes of BP during NET. The mean value of initial total cholesterol before NCT was 184.6mg/dL, 215.98 mg/dL after NCT (p&amp;lt;0.05, before vs after), 179 mg/dL after 3 years of treatment (p&amp;lt;0.05, after vs 3 yrs.). In the NET group, the mean initial cholesterol before NET was 185mg/dL, 176.3 mg/dL (p=0.04, before vs after) after NET, and 179.4 mg/dL after 3 yrs. follow up (p=0.23, before vs after 3years). In the NCT group, the mean fasting glucose were significantly increased while NCT (95.75mg/dL to 111.61mg/dL, p&amp;lt;0.05), and recovered after 3 year follow up (95.78 mg/dL, p&amp;lt;0.05). In the NET group, the mean fasting glucose changes were not observed before and after NET and 3 year follow up (97.78mg/dL, 99.04mg/dL and 99.06mg/dL respectively p&amp;gt;0.05, all). NLR was increased from 2.02 to 4.43 after NCT (p&amp;lt;0.05) and decreased from 2.13 to 1.57(p&amp;lt;0.05) after NET. Conclusion NCT causes worsening of metabolic profiles such as BMI, blood pressure, TG, and fasting glucose, which is recovered over 3 years. In the NET group, there were no significant changes in BMI, BP and fasting glucose but total cholesterol was significantly decreased after NET treatment. NLR was increased after NCT but decreased after NET. Citation Format: Ho-Hyun Ryu, Ji-Seon Kim, Il-Yong Chung, Jong-Won Lee, Beom-Seok Ko, Byung-Ho Son, Sei-Hyun Ahn, Hee-Jeong Kim. Comparison of metabolic changes after neoadjuvant endocrine and chemotherapy in ER positive, HER2 negative premenopausal women with breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-02-08.

Deviations from AHA guidelines during pediatric cardiopulmonary resuscitation are associated with decreased event survival

BackgroundDeviations (DEVs) from resuscitation guidelines are associated with worse outcomes after adult in-hospital cardiac arrest (IHCA), but impact during pediatric IHCA is unknown. MethodsRetrospective cohort study of prospectively collected data from the American Heart Association’s Get With The Guidelines-Resuscitation registry. Children who had an index IHCA of ≥1 min from 2000 to 2014 were included. DEVs are defined by the registry by category (airway, medications, etc.) A composite measure termed circulation DEV(C-DEV), defined as at least one process deviation in the following categories: medications, defibrillation, vascular access, or chest compressions, was the primary exposure variable. Primary outcome was survival to hospital discharge. Mixed-effect models with random intercept for each hospital assessed the relationship of DEVs with survival to hospital discharge. Robustness of findings was assessed via planned secondary analysis using propensity score matching. ResultsAmong 7078 eligible index IHCA events, 1200 (17.0%) had DEVs reported. Airway DEVs (466; 38.8%) and medication DEVs (321; 26.8%) were most common. C-DEVs were present in 629 (52.4%). Before matching, C-DEVs were associated with decreased rate of ROSC (aOR = 0.53, CI95: 0.43–0.64, p < 0.001) and survival to hospital discharge (aOR = 0.71, CI95: 0.60–0.86, p < 0.001). In the matched cohort (C-DEV n = 573, no C-DEV n = 1146), C-DEVs were associated with decreased rate of ROSC (aOR 0.76, CI95 0.60–0.96, p = 0.02), but no association with survival to hospital discharge (aOR 1.01, CI95 0.81–1.25, p = 0.96). ConclusionsDEVs were common in this cohort of pediatric IHCA. In a propensity matched cohort, while survival to hospital discharge was similar between groups, events with C-DEVs were less likely to achieve ROSC.

Abstract WP334: Stroke Case Volume After Implementation of the 24 Hour Extended Intra-Arterial Thrombectomy Window

Introduction: The results of the DAWN and DEFUSE 3 trials demonstrated improved functional outcome with mechanical thrombectomy (MT) in stroke patients who present with anterior circulation large vessel occlusion (LVO) up to a 24 hours after last known well. The AHA guidelines were updated to include this recommendation in 2018, but the impact of the increase in number of patients treated in clinical practice remains unknown. Methods: We reviewed ischemic stroke MT patients admitted to a comprehensive stroke center (DEFUSE 3 trial participating site), from July 2015- July 2019. Our center instituted a 24 hour IAT window protocol in March 2018 (Figure 1). Eligibility for MT in the 24 hour window followed the DEFUSE 3 criteria including the presence of LVO, National Institute of Health Stroke Scale (NIHSS) &gt; 6, and favorable CT perfusion imaging. Results: During this 4-year period, 290 stroke patients with LVO received MT at our institution. MT volumes increased in each subsequent year in this study as follows: July 2015 (44), July 2016 (58), July 2017 (73) and July 2018 (115). An increase in MT volume was observed after the expansion of the treatment window to 24 hours (Figure 2). In the period prior to the expanded 24 hour treatment window, MT volumes were 25-33 per 6 month period. After the 24 hour treatment window was started, MT volumes were 58-60 per 6 month period. Conclusions: Expanding the MT window to 24 hours has nearly doubled the MT case volume at our single center. This dramatic increase in IAT clinical utilization observed with expansion to the 24 hour window has implications for systems of care and resource optimization of the stroke patient.