BP Management Research Articles

Towards an extended BPMS prototype: Open challenges of BPM to flexible and robust orchestrate of uncertain processes

Nowadays, uncertainty is widely discussed as serious a challenge against business decision-making. The current business process management systems (BPMSs) are only able to manage certain processes, where there is practically a huge gap between what is expected and what is realized due to uncertainty. This study developed an extended BPMS prototype to facilitate and improve any business process management subject to uncertainty. This prototype can model, design, control and optimize in uncertainty modes, in addition to classic BPMSs operations. For developing a new prototype, the authors first provided a meta-model for designing new engine functions. Thereafter, by defining the architecture style and abstract model, defining user interfaces and component interfaces, uncertain BPMS prototype with CORBA standards created. Furthermore, flexible components are implemented to deal with uncertainty during run-time. This paper has used three evaluation methods to validate the proposed uncertain BPMS prototype. Firstly, an executable prototype has been built and evaluated with a rating model, which obtains quantitative metrics. The comparison between the proposed uncertain BPMS prototype and other classic BPMSs has effectively demonstrated the ability of an extended BPMS prototype in BP management under uncertainty modes. Secondly, a case study in oil and gas industry was studied with a focus on the industry 4.0. The results have revealed the improvement in planning service time after using the proposed prototype. Thirdly, the efficiency of uncertain BPMS prototype has been investigated through different object-oriented software metrics. These results also show the ability of the extended BPMS prototype to flexibly and robustly orchestrate uncertain processes.

Abstract P128: Intensive Blood Pressure Management in Chronic Kidney Disease Patients: An Analysis of the SPRINT Dataset

Introduction: Systolic Blood Pressure Intervention Trial (SPRINT) determined that among non-diabetic patients with increased CV risk, intensive management of systolic blood pressure (SBP) to a target of 120 mmHg resulted in lower rates of CV events and all-cause mortality, as opposed to the standard goal of 140 mmHg. Current management of BP in the CKD population shows conflicting evidence on target SBP. With the use of patient-level SPRINT data, our study investigates the risks and benefits of intensive BP management in patients with CKD at baseline and is the largest study of intensive BP management in CKD patients (n=2646). Methods: The similarity between CKD patients in standard and intensive blood pressure management groups with regard to age, race, gender, estimated GFR (eGFR), and baseline SBP were assessed and no differences were found between the two groups. Differences in mortality, adverse events, and rates of achieving BP targets in intensive and standard BP management groups were examined. Cox proportional-hazards models were used for the events analysis. Multiple linear regression was used to assess the differences in achieving BP targets. Results and Discussion: We highlight three key findings. First, the average post-management SBP was higher in CKD patients than in non-CKD patients in both standard ( p = 0.017) and intensive ( p < .001) groups, controlling for age, race, gender, eGFR, and baseline SBP, possibly indicating greater difficulty in controlling BP in CKD patients . Second, intensively-treated CKD patients had increased risks for intervention-related adverse events, including events that resulted in disability, hospitalization, or harm that may have required medical or surgical intervention (p < .001). They also experienced higher rates of AKI related adverse events (p<.008). Third, intensive management showed a mortality benefit (HR: .725; 95% CI, .532 to .987), a finding that may help clarify conflicting reports in current literature. In conclusion, we present an analysis of CKD-specific SPRINT data in order to elucidate the clinical benefits and risks of intensive BP management in the CKD population.

Abstract P497: Re-analysis of the Systolic Blood Pressure Intervention Trial (SPRINT): The Renal Consequences of Intensive versus Standard Blood Pressure Lowering

Background: BP management guidelines suggest that persons with CKD should be treated to a SBP ≤ 140 mmHg. SPRINT compared this target to intensive SBP lowering (≤ 120 mmHg) in persons with and without CKD and found a reduced rate of CV events and all-cause mortality (ACM). However intensive therapy was associated with an increased risk of AKI. We extrapolated the results of SPRINT over a lifetime horizon to determine whether in the long-term, the benefit in terms of the primary outcome would be less economically attractive when the risks of more frequent AKI and subsequent CKD progression were considered. Methods: We re-configured the CKD Simulator, a Markov model of CKD progression, AKI events, fatal and non-fatal CV events, and ESRD. We recalibrated the model to be representative of the SPRINT cohort and compared intensive vs. standard blood pressure control among 10 million simulated persons with and without CKD over their lifetimes. Marginal treatment costs were calculated and hazard ratios for AKI, CV events and ACM observed in SPRINT were applied to the monthly probabilities of these events in the intensive SBP arm. Results: Lifetime average, discounted, costs per person associated with intensive vs. standard SBP lowering were predicted to be $35,811 and $30,584, respectively. Quality-adjusted, discounted average lifespans were 196.05 and 190.47 months, respectively. The cost of each quality-adjusted life-year gained by adopting intensive over standard BP lowering would be $11,220, significantly below the accepted cost-effectiveness threshold of $50,000. Intensive SBP control would reduce the lifetime incidence of at least one CV event by 5.5%, but increase the incidence of at least one AKI episode and ESRD by 1.7% and 0.7%, respectively. These differences were associated with average lifetime cost savings per person of $459 for CV events, but losses of $161 and $2,889 for AKI and ESRD. Discussion: Intensive SBP management would be cost-effective and associated with a significant lifetime reduction in CV events. However, there would be an increase in the lifetime risk of AKI and ESRD, contributing to 58% of the total increase in cost of intensive relative to usual SBP control. Intensive SBP lowering should be adopted judiciously in persons at high risk of ESRD.

Total Safety Management: What Are the Main Areas of Concern in the Integration of Best Available Methods and Tools

“BP released findings from its own internal investigation of the oil spill in the Gulf of Mexico, revealed inefficient Organization interfaces among BP management, the rig crew and well site leader. Also according to the investigation, one important contributor to the accident was inadequate guidelines for critical tests and operations”. (Pires and Mosleh 2011) Over the recent past, the accumulation of major mishaps, crises and accidents have made it clear that organisations must still improve their capabilities to address safety “not as a stand-alone activity that is separate from the main activities and processes of the organization” but as an integrated part of total performance management. The requirements for safety management in existing and upcoming standards and regulations, as for example the ISO 31000 and or the Seveso II directive, call for a proactive strategic approach, anticipating risks and demonstrating a capacity to keep safety at the centre of changes driven by commercial competition, and ensuring that safety evidence itself becomes an effective driver of change. However there is often a gap between the state principles and an actual roadmap to their implementation. Furthermore organisations, especially the one dealing with safety critical operations, find it difficult to integrate their different functional units in a common programme of operations management or change; there is no clear consensus about what it means to be ‘proactive’; there is no integrated framework for analysing or managing all the human related functions in an operational system. Innovation may rely on assembling the best practices, tools and methods already available for functional analysis, risk assessment, interactive emergency scenarios analysis, performance monitoring, design review, training and knowledge management, in an integrated framework able to address safety management in the main aspects of a product or process lifecycle the cornerstone of which is the building of a common operational picture to support the capacity to perform more participatory and dynamic risk identification and solutions loops in: - Design (new plants, processes /procedures availing new visualization tools) - Ad hoc critical activities (management of change or scheduled overhaul) - Operations management (establishing of dynamic risk registers). This is the scope of a new EU funded research project called TOSCA and the present paper will introduce the current framework being built.

Cost-benefit effectiveness of angiotensin-II receptor blockers in patients with uncomplicated hypertension: A comparative analysis

ObjectiveThe treatment of hypertensive patients (HTs) requires a long-term commitment of compliance for the patient and resources by the healthcare system. This poses an economic dilemma in countries where universal healthcare is standard. The aim of this study was to evaluate the costs/health benefit and effectiveness of treatment with angiotensin-II receptor blockers (ARBs) in uncomplicated essential hypertension. Design and methodsThe daily and annual economic commitment for treating patients with ARBs was estimated using pharmacy dispensing records and the BP-lowering effects of candesartan, irbesartan, losartan, olmesartan, telmisartan and valsartan was evaluated retrospectively. In 114 HTs (mean age 59.4±13.5year, 57.5% men), the BP-lowering effect of ARBs as in monotherapy and in fixed-dose combination (FDC) with hydrochlorothiazide at the doses commonly used in the market to reach BP control (i.e. BP <140/90mmHg) was analyzed. The BP lowering-effect was evaluated after an average of 6-month follow-up consulting medical professionals. Analysis of variance for repeated measures was provided. ResultsTreatment with candesartan (14.1%) and olmesartan (32,4%) versus other ARBs resulted in a significant decrease in BP as for mono- than for FDC therapy. Our studies suggest that daily (data not shown) and annual costs of olmesartan were higher than candesartan as in mono- (4577.71±1120.55 vs. 894.25±127.75 €) than for FDC therapy (5715.90±459.90 vs. 1580.45±113.15 €). ConclusionsTreatment: of BP with candesartan appears to be the most favorable option in terms of cost-effectiveness coupled with favorable health outcomes. These data have some limitations, but open the question if candesartan should be preferred to olmesartan in BP management. Further prospective studies comparing ARBs based on their effect on BP control in uncomplicated HTs are needed for validation

Abstract WP189: The Association of Blood Pressure Control with Belief of Self-Efficacy in Preventing Stroke

Background: Hypertension (HTN), including uncontrolled HTN, is one of the greatest contributors to stroke risk. A Risk Behavior Diagnosis Scale (RBD) was used to assess individual perceptions of stroke including efficacy for managing HTN associated with stroke risk. Methods: Data came from the 10-year risk factor telephone interview and in-home assessment of REGARDS participants. REGARDS is a national, population-based, longitudinal study of black and white adults ≥ 45 years, enrolled 2003-2007. Participants were asked about agreement with four constructs of RBD: response efficacy (controlling my BP is effective in preventing stroke), self-efficacy (having skills to control my BP to prevent stroke), severity (belief that stroke is extremely harmful), and susceptibility (it is likely I will have a stroke.) Analysis was restricted to 8,269 individuals with self-reported physician-diagnosis of HTN. BP control was defined as SBP &lt; 140 mmHg or DBP &lt; 90 mmHg. Logistic regression was used to examine the association of hypertension control with agreement with each construct, adjusting for demographics, socioeconomic factors, and history of previous stroke. Results: Of those who reported HTN, 6,799 (82%) had controlled HTN. In the multivariable model, control of BP was strongly associated with agreement with “having the skills to control BP to prevent stroke” (OR = 1.37; 95% CI: 1.13 - 1.66). There were no associations (p &gt; 0.05) between hypertension control and agreement with any other constructs (see table.) Conclusions: Among persons with self-reported HTN, those who agreed they had the skills to control their blood pressure to prevent stroke were more likely to have their hypertension controlled. Although self-efficacy is difficult to influence, strategies to improve skills and confidence related to BP management may improve BP control.

COGNITION DISORDERS IN HYPERTENSIVE PATIENTS OF OLDER AGE AND SENILE

Aim . To assess cognitive status of the older age patients with arterial hypertension, in outpatient setting. Material and methods . Totally, 356 patients included, age 74,9±6,1 y., 80,4% females. For cognition assessment before and after the treatment, neuropsychological test was done, with MMSE — short scale of psychic status assessment, drawing test; literal and categoric associations test. Results. In the group <80 y.o. the prominence of MMSE disorders correlated with blood pressure values (BP): for systolic BP (r=-0,22, р=0,0003), for diastolic BP (r=-0,13, p=0,03), i.e. in higher BP patients there were lower points in cognition scale by Spearman correlation. In the group ≥80 y. both correlations were non-significant, for systolic BP (r=-0,05, p=0,64), and for diastolic BP (r=-0,13, р=0,25). Conclusion . In older age and senile patients with arterial hypertension there should be differential approach to BP management according to the age and cognition disorders, complex approach to treatment in these patients might prevent further worsening of cognitive decline.

SY 08-2 HYPERTENSION MANAGEMENT FOR SECONDARY PREVENTION OF STROKE

Stroke is known to frequently recur in patients with a history of cerebrovascular disease, and the control of hypertension is extremely important for the treatment of those patients. The robust relationship between the recurrent cerebrovascular disease and blood pressure control has been demonstrated in large-scale clinical studies. The antihypertensive drug therapy significantly reduces the recurrence rate of all types of cerebrovascular disease, incidences of myocardial infarction and all vascular events. Evidence suggests that any class of antihypertensive drugs including diuretics, Ca channel blockers, ARBs, and ACE inhibitors are shown to be similarly effective for the secondary prevention of stroke, except in some small study such as MOSES. Thus, most of the benefit obtained from drugs can be ascribed to a decrease in blood pressure. Then, how far should blood pressure be lowered? Target of blood pressure control has been somewhat controversial, since an excessive reduction of blood pressure might exacerbate cerebral ischemia in the area perfused by cerebral artery with a significant stenosis. In fact, some Japanese clinical study has shown that in patients with impaired perfusion demonstrated by PET-CT, the risk of recurrent stroke was high when the systolic blood pressure was There have been very few studies which have primarily investigated the optimum blood pressure level in the secondary prevention of stroke. The sub-analysis of the large clinical trial, PROGRESS, indicated that the incidences of cerebral hemorrhage and cerebral infarction were lower in patients in whom blood pressure was controlled at a lower level (a systolic blood pressure of about 120 mmHg). In the Bleeding with Antithrombotic Therapy (BAT) Study in Japan, 4,009 patients taking antithrombotic drugs for the prevention of recurrent cerebrovascular or heart disease were prospectively enrolled, and hemorrhagic events were investigated over 19 months. The results suggest that the incidence of cerebral hemorrhage is lower when the blood pressure immediately before/after onset is lower, suggesting that blood pressure should be reduced to In the Secondary Prevention of Small Subcortical Strokes (SPS3) Trial, a randomized comparative study was conducted in patients with chronic-phase lacunar infarction by dividing them into two groups: a group with a systolic blood pressure of We have been conducting a multicenter, randomized, open-label study (RESPECT study; Clinical Trials.gov Identifier: NCT01198496) since 2010, in which hypertensive patients with a history of strokes are randomly assigned to either a standard therapy group (£140/90 mmHg; if having current DM/CKD/MI, £130/80 mmHg) or a strict therapy group (BP lowering target: £120/80 mmHg). The patients were treated with stepwise multi-drug therapy using an angiotensin-receptor antagonist, diuretic, calcium channel blocker and additional other classes of drug if necessary. The recurrent stroke rates in both groups will be compared from various aspects, and whether strict BP management is useful for the prevention of recurrent strokes will be verified. The first interim analysis of this study has been recently performed. At present, in the JSH2014 Guidelines, the target of blood pressure control for patients with chronic-phase cerebral infarction is established as

Use of Short Messaging Service for Hypertension Management: A Systematic Review.

Mobile phone Short Message Service (SMS) is a tool now used by the health research community, providing the capability for instant communication between patients and health professionals. Greater understanding of how to best use SMS as a means to improve healthcare delivery and outcomes will foster innovation in research and provide an opportunity to progress as a public health community. The purposes of this systematic review are 2-fold: (1) to provide insight on the most used mobile phone SMS practices and characteristics in hypertension (HTN) outcome-focused publications and (2) to critically evaluate empirical evidence associated with SMS utilization and BP outcomes. Two independent systematic literature searches were completed. The final selected studies each then underwent data extraction and quality-rating assessment, followed by an evaluation for a meta-analysis to measure mean difference of the change in BP. A total of 6 studies meeting the inclusion criteria were included in the review. Feasibility assessment for a meta-analysis was found unfavorable because of the variation among studies. Short Message Service interventions focused on BP management were most effective in studies featuring 2-way communication and individual patient-tailored content, and guided by evidence-based HTN management practices. Short Message Service interventions for HTN management were supported through evidence provided by the studies reviewed. Short Message Service holds strong potential to bring greater innovation to HTN management and care, especially in racial/ethnic minority populations that face psychosocial and structural barriers in healthcare access and utilization.

Abstract WMP52: Shake, Rattle &amp; Roll Trial - Effects on Blood Pressure Control and Therapy

Background: In Kaiser Permanente Northern California (KPNC), a setting where all members have similar access to healthcare and a very high overall rate of HTN control, blacks still had poorer BP control than whites. It has been suggested that greater difficulty in controlling BP and lifestyle differences may account for this difference. The “Shake, Rattle and Roll” (SRR) trial is named for: 1) “shake” the salt habit; 2) “rattle” the intensity of current BP management; and 3) adapt and “roll” out the interventions to other communities. Methods: SRR is a pragmatic clustered randomized controlled trial. All PCPs at Kaiser Oakland and their panels of black patients were randomized, stratified by panel size, to one of 3 arms: 1) usual care (UC); or 2) enhanced monitoring (EM) of current KPNC BP management protocol; or 3) culturally tailored diet and lifestyle (LS) coaching focused on the DASH eating plan. Black patients from KPNC HTN registry with an identifying high BP reading ≥ 140/90 qualified to be recruited into SRR. The intervention period lasted 12 months. We assessed rates of BP control using the latest follow-up BP measurements between enrollment and 15 months post-enrollment. Data on demographics and anti-hypertensives were collected from participants’ EMRs. Results: We cluster randomized 107 PCPs to one of 3 arms. There were 1185 enrolled in UC, and 318 in EM and 259 in LS. Median ages ranged from 63-65 years [Table]. Among those enrolled, BP control rates were higher in EM and LS than in UC (53% in UC, 69% in EM, and 71% in LS, p&lt;0.001). However, a significant proportion of UC did not have a follow-up BP measurement during the trial period. There were also significant differences in anti-hypertensive usage across the 3 arms [Table]. Conclusions: Preliminarily, among those enrolled in SRR, EM and LS arms had better BP control than UC and there were differences in the types of anti-hypertensive therapy used. Further analyses of all aspects of BP management in SRR are under way.

Prognostic Significance of Hyperglycemia in Acute Intracerebral Hemorrhage: The INTERACT2 Study.

We aimed to determine associations of baseline blood glucose and diabetes mellitus with clinical outcomes in participants of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). INTERACT2 was an international prospective, open, blinded end point, randomized controlled trial of 2839 patients with spontaneous intracerebral hemorrhage (<6 hours) and elevated systolic blood pressure randomly assigned to intensive (target systolic blood pressure <140 mm Hg) or guideline-based (systolic blood pressure <180 mm Hg) BP management. Associations of hyperglycemia at presentation (>6.5 mmol/L) and combined and separate poor outcomes of death and major disability (scores of 3-6, 3-5, and 6, respectively, on the modified Rankin scale) at 90 days were determined in logistic regression models. In 2653 patients with available data, there were 1348 (61%) with hyperglycemia and 292 (11%) with diabetes mellitus. Associations of baseline blood glucose and poor outcome were strong and near continuous. After adjustment for baseline variables, the highest fourth (7.9-25.0 mmol/L) of blood glucose was significantly associated with combined poor outcome (adjusted odds ratio 1.35, 95% confidence interval 1.01-1.80; P trend 0.015). Diabetes mellitus also predicted poor outcome (adjusted odds ratio 1.46, 95% confidence interval 1.05-2.02; P=0.023), though more important for residual disability than death on separate analysis. Hyperglycemia and diabetes mellitus are independent predictors of poor outcome in patients with predominantly mild to moderate severity of intracerebral hemorrhage. These data support guideline recommendations for good glycemic control in patients with intracerebral hemorrhage. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00716079.

Challenges in the Management of Hypertension in Older Populations.

The prevalence of hypertension increases with age making it a significant health concern for older persons. Aging involves a range of physiological changes such as increases in arterial stiffness, widening pulse pressure, changes in renin and aldosterone levels, decreases in renal salt excretion, declining in renal function, changes in the autonomic nervous system sensitivity and function and changes to endothelial function all of which may not only affect blood pressure but may also affect individual response to pharmacotherapy used to manage hypertension and prevent end organ damage and other complications associated with poor blood pressure control.Unlike many chronic conditions where there is limited evidence for management in older populations, there is good evidence regarding the management of hypertension in the elderly. The findings from multiple large, robust trials have provided a solid evidence-base regarding the management of hypertension in older adults, showing that reduction of blood pressure in older hypertensive populations is associated with reduced mortality and morbidity. Diuretics, agents action on the renin angiotensin system, beta blockers and calcium channel blockers have all been well studied in older populations both in view of the benefits associated with blood pressure lowering and the risks associated with associated adverse events. While all antihypertensive agents will lower blood pressure, when managing hypertension in older persons the choice of agent is dependent not only on the ability to lower blood pressure but also on the potential for harm with older persons. Understanding such potential harms in older populations is essential with older persons experiencing increased sensitivity to many of the adverse effects such as dizziness associated with the use of antihypertensive agents.Despite the wealth of evidence regarding the benefits of managing hypertension in the old and very old, a significant proportion of older individuals with hypertension have suboptimal BP control. While there is good evidence supporting blood pressure lowering in older antihypertensive agents, these have not yet been optimally translated fully into clinical guidelines and clinical practice. There appear to be considerable differences between guidelines in terms of the guidance given to clinicians. Differences in interpretation of the evidence, as well as differences in study design and populations all contribute to differences in the guideline recommendations with respect to older populations, despite the strength of the underlying scientific evidence. Differences around who is considered "old" and what BP targets and management are considered appropriate may lead to confusion among clinicians and further contribute to the evidence-practice lag.

Towards Internal Modelling of the Information Systems Application Domain

Model-driven IS engineering methods invoke the IS application domain modelling met- hods to acquire essential characteristics of organizational systems (enterprises). Business modelling for value creation is a relatively separate area, meanwhile it correlates with the IS application domain modelling methodologies and gives new insights for enhancement of enterprise modelling, business process modelling and BP management modelling approaches. The IS application domain and the business domain modelling are not isolated and could be investigated using the same paradigm of modelling. Yet there is some uncertainty in model-driven approaches towards the understanding of the enterprise management activities. A problematic consistency of modelling approaches indicate a need for a systemic analysis of IS application domain modelling concepts. The internal modelling paradigm is used for analysis of an enterprise management activity as a self-managed system, and hereby the lack of the conceptual basis for domain modelling in IS engineering is determined. This approach is aimed to reveal hidden information transactions of the business management activities. The understanding of the IS application domain as a self-managed system allowed to redefine such concepts as management transaction, management function and enterprise process. The metastruc- ture of management transaction is defined and illustrated for business management layer and IS development layer.

Determinants and Prognostic Significance of Hematoma Sedimentation Levels in Acute Intracerebral Hemorrhage

Background: This study aimed at identifying the determinants and prognostic significance of a sedimentation level (fluid-blood level) in the hematoma among patients with acute intracerebral hemorrhage (ICH) who participated in the main Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). Methods: Post-hoc analysis of the INTERACT2 dataset, a randomized controlled trial of patients with acute ICH with elevated systolic blood pressure (SBP), randomly assigned to intensive (target SBP <140 mm Hg) or guideline-based (<180 mm Hg) BP management. Patients with a sedimentation level at baseline assessment on CT, and modified Rankin Scale score at 90-day, were included in these analyses. Factors associated with a sedimentation level and its significance in relation to 90-day clinical outcomes were assessed in univariable and multivariable logistic regression models. Results: Of 2,065 participants, 19 (1%) had sedimentation level on baseline CT, which was independently associated with warfarin use (p = 0.006) and lobar ICH (p = 0.025). Sedimentation level was also associated with death or major disability at 90-day in both crude (84 vs. 53%; p = 0.014) and multivariable analyses adjusted for age, gender, Chinese region, warfarin use, baseline National Institutes of Health Stroke Scale score, onset to CT time, volume and location of ICH, intraventricular extension, and randomized intensive BP lowering (OR 3.94, 95% CI 1.01-15.37; p = 0.049). Conclusions: The presence of hematoma sedimentation level on baseline CT is associated with warfarin use and lobar location of ICH, and predicts a worse outcome. Although uncommon, sedimentation level is an easily detectable prognostic factor in acute ICH.

Abstract 13197: Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Outpatient Setting

Background: Hypertensive urgency is a commonly encountered outpatient problem. Prevalence and short term outcomes of this condition are unknown. JNC VII recommends aggressive BP control over several days. However, a small percentage of patients are sent to the emergency department. It is unknown whether hospital management of these patients is better than outpatient BP management. Methods: Retrospective cohort study of all patients presenting to an office in a large health care system from 2008-2013 with SBP ≥180mmHg or DBP ≥ 110mmHg. We excluded pregnant women and patients referred to the hospital for symptoms or treatment of other conditions. Patients were divided into 2 groups: those sent home and those referred to hospital. We recorded baseline demographic and clinical data. Propensity matched outcomes recorded included MACE (acute coronary syndrome, stroke/TIA) uncontrolled hypertension (≥140/90 mmHg) and hospital admissions. Results: Of 2,199,019 office visits, 58,583 (5%) had hypertensive urgency. Mean age was 63±15 yrs, 58% were females, 76% Caucasian, mean BMI was 31±8 kg/m2 and mean SBP and DBP were 182±16 and 96±16 mmHg. Only 426 (0.7%) patients were referred to the ED/hospital. On propensity matched analysis between the patients referred to the hospital and sent home, there was no significant difference in MACE events at 7 days (0% vs. 0.13%, p=1), 30 days (0.25% vs. 0%, p=1) or 6 months (0.5% vs. 0.13%, p=0.26). Compared to patients sent home, patients referred to the hospital had less uncontrolled hypertension at 1 month (81% vs. 88%, p=0.001) but not at 6 months (65% vs 69%, p=0.16). They also had higher 7- and 30-day hospital admission rates (8.5% vs. 4.9%, p=0.01; 11.8% vs 7.6%, p=0.02). Conclusion: Hypertensive urgency occurs commonly, but the rate of MACE in asymptomatic patients is very low. ED visits increased hospitalizations, but did not improve outcomes. Most patients with hypertensive urgencies still had uncontrolled hypertension at 6 months.

Are admission systolic blood pressures predictive of outcomes in patients with spontaneous intracerebral haemorrhage after aggressive blood pressure management?

High blood pressure (HBP) is observed frequently in patients with spontaneous intracerebral haemorrhage (SICH). Although HBP at admission has been associated with poor outcomes, most studies from which such conclusions were derived had been carried out decades earlier, when aggressive BP management was not implemented. In our institution, SICH patients showing HBP undergo aggressive BP management by intravenous nicardipine with target systolic BP (SBP) less than 140 mmHg. We investigated whether responsiveness to intravenous nicardipine, haematoma expansion rate and activity of daily living 90 days after admission differed by the degree of admission SBP. A retrospective study was carried out by reviewing charts of 120 SICH patients admitted within 6 h of onset who were quadrichotomized on the basis of SBP: <140 mmHg (n=6), 140-184 mmHg (n=49), 185-219 mmHg (n=38) and ≥220 mmHg (n=27). The six patients with SBP less than 140 mmHg were excluded, and demographic and outcome variables of the latter three groups were compared. Whether plasma catecholamine levels differed among the three groups was also investigated. Optimal BP management (target SBP<140 mmHg) within 2 h of arrival was achieved in 98%, haematoma expansion occurred in 7% and the 90-day mortality rate was 11%. Responsiveness to intravenous nicardipine, haematoma expansion rate and activity of daily living were not significantly different. Furthermore, plasma catecholamine levels did not differ significantly. The lack of difference in the demographic and outcome variables in SICH patients managed by aggressive treatment to normalize the BP indicates that the previously reported association between HBP at admission and poor outcomes needs to be re-evaluated.

Gender Differences in Risk Factors for Prehypertension and Hypertension in Bangladeshi Adults

Background: Bangladesh, a small country of approximately 160 million people is facing an epidemiological transition with a growing burden of non-communicable diseases. Nationally representative information on the risk factors for high blood pressure in Bangladeshi adult males and females is limited. Objective: Estimate the risk factors for prehypertension and hypertension in Bangladeshi adults and highlight gender differences to inform policy makers on appropriate interventions. Methods: Blood pressures of 3,871 males and 3,960 females, aged 35 years and older were measured and socio-demographic information was collected, from a multi-stage, geographically clustered probability-based sample of households in 2011. Multiple linear regression models were used to estimate adjusted mean blood pressure, and multinomial logistic regression models were used to estimate adjusted odds ratios for prehypertension and hypertension compared to normal blood pressure, separately for males and females. Findings: Women were more likely to have prehypertension (32% vs. males 29%, p = 0.0174) and hypertension (25% vs. males 16%, p < 0.001) compared to men. Older age and high BMI were significantly associated with prehypertension and hypertension for both sexes but the effect were much greater for women. Higher education and socioeconomic status were associated with higher blood pressure for men. Residence in some regions of the country was positively associated with high BP. Conclusion: Policy makers should consider the gender differences of identified risk factors in implementing public health measures. Healthcare providers should be trained on gender-specific aspects of BP management. Further researches are required to address the regional variation in high blood pressure risks.

Abstract 96: What Critical Volume of Intraventricular Hemorrhage is Important in Intracerebral Haemorrhage? Interact2 Results

Background and purpose: Intraventricular haemorrhage (IVH) predicts outcome in acute intracerebral haemorrhage (ICH), but there is uncertainty over the strength of association and what clinically relevant threshold volume is relevant to prognosis. We aimed to elucidate risk associations of IVH and outcome in participants of the INTERACT2 study. Methods: INTERACT2 was an international, multicenter, prospective, open, blinded endpoint, randomized controlled trial of 2839 patients with ICH (&lt;6 hr) and elevated systolic BP (SBP) who were randomly assigned to intensive (target SBP &lt;140mmHg) or guideline-based (SBP &lt;180mmHg) BP management in 2008-2012. Associations of 740 (26%) patients with IVH on poor outcome (mRS &gt;3) at 90 days, were determined in logistic regression models. Results: Patients with ICH-IVH were significantly older, had greater clinical severity, and more with prior ischemic stroke and deep and large hematoma volume, after adjustment for other variables. Poor outcome occurred in 67% of ICH-IVH patients compared with 49% of ICH-alone patients (odds ratio [OR] 0.5, 95% confidence interval [CI] 0.42-0.60; p&lt;0.01). There was a strong linear relation between ICH volume and poor outcome. Compared to lowest quartile (Q1) IVH volume (0-2.07mL), OR for poor outcomes increased in Q2 (2.08-5.84 mL) 0.74 (95%CI 0.46-1.18 mL), Q3 (5.97-13-74 ml) 1.27 (95%CI 0.78-2.06), and Q4 (13.82-117.55) 1.56 (95%CI 0.94-2.58), p trend 0.03. Associations were stronger for death, where a baseline IVH volume of 5-10mL emerging as a statistically (and clinically) significant threshold for risk. Conclusion: While a linear relation exists between IVH and outcome in ICH, a 5-10mL volume appears an appropriate cut-point for clinical-decisions over use of interventions with risk.

Abstract W P346: Sustainable Reduction in IV TPA Door to Needle Time Using Key Elements from Target Stroke Tool Kit

Current literature clearly demonstrates decreased in-hospital mortality and increased functional outcomes with every 15 minute reduction in door-to-needle (DTN) time for IV-TPA treatment. At VCU Health System, 70% of eligible acute ischemic stroke (AIS) patients received IV-TPA treatment within 60 minutes of hospital arrival, with a median DTN time of 56 minutes for the time period between May 2012 to April 2013. The goal was to further increase percentage of eligible AIS patients receiving IV-TPA within 60 minutes of hospital arrival and decrease DTN time for IV-TPA treatment. A systematic approach was used to retrospectively analyze IV-TPA charts, identify rate limiting factors in administration of IV-TPA and implement clinical process changes. As a result of implementing an organized team approach, pre-hospital stroke alerts, immediate aggressive BP management, pre-mixing IV-TPA and prompt feedback, the number of eligible AIS patients that received IV-TPA within 60 minutes increased 43% from 70% to 100%. The median DTN time decreased 36% from 56 minutes to 36 minutes for the time period between May 2013 to May 2014.

Survival from out-of-hospital cardiac arrest: A New Zealand perspective

ularly in those of a younger age (RR=2.7 in those < 55 years; RR=1.4 in those 55 years). Although 96% of those with uncontrolled hypertension were prescribed one or more medications, by 12 months 27% were no longer on treatment. Conclusion: Hypertension is a common problem in general practice, particularly affecting those of Māori and Pacific ethnicity. Uncontrolled hypertension with low number of BP-lowering medications suggests opportunities exist to improve BP and CVD risk management.