Elevated Blood Pressure Readings Research Articles

Health Screening Among a Rural, Hourly Workforce: North Carolina SERVIRE Project

This study demonstrates the feasibility of a novel, business-partnered, and worksite-based approach to healthcare access to facilitate chronic disease screening and diagnosis among rural hourly workers. The prevalence of undiagnosed and untreated diabetes and hypertension among screening participants was determined. From February 2021 to June 2023, investigators partnered with 29 businesses to screen 1,114 workers. Health screenings included a demographic questionnaire, A1c testing for prediabetes (A1c of 5.7-6.4) and diabetes (A1c≥6.5), hypertension (Stage 1: systolic blood pressure of 130-139 mmHg; Stage 2: systolic blood pressure ≥140 mmHg), kidney disease (estimated glomerular filtration rate <60; urine protein ≥1+), and questionnaire assessment of stroke (CHA2DS2-VASc) and sleep apnea (STOP-bang) risk. Of the 1,114 individuals screened (n=632, 56.7% male; n=497, 44.6% Black)), 388 (36%) screened positive for prediabetes or diabetes. Diabetes was previously undiagnosed in 273 (70.4%) of these participants. More than half of the participants (n=680, 62.4%) had an elevated blood pressure reading during the screening, and the majority of these participants (n=445, 65.4%) had not been previously diagnosed with hypertension. In addition, 241 (21.6%) participants were at an increased risk of stroke (CHA2DS2-VASc≥2), and 182 (23.7%) had a STOP-Bang score ≥4, indicating an increased risk of obstructive sleep apnea. By partnering with local businesses to deliver worksite-based health screenings, high rates of undiagnosed and uncontrolled diabetes and hypertension were identified among the rural, hourly workforce. This worksite-based approach to healthcare access could facilitate early detection of chronic disease, improve patient engagement in the healthcare system, and ultimately yield better long-term public health outcomes.

Analysis of older adult blood pressure readings and hypertension treatment rates among the unsheltered population of Miami-Dade County.

To assess prevalence of elevated blood pressure readings, rates of established hypertension diagnosis, and blood pressure control medication prescription rates in a cohort of older people experiencing unsheltered homelessness presenting to a Street Medicine clinic in Miami-Dade County, Florida. In addition, we will compare outcomes found in the study cohort to that of the general population. Demographic information, clinical history, blood pressure control medication prescription, and blood pressure measurements were taken by a Street Medicine team of medical providers. The team routinely provides medical evaluations and care for people experiencing unsheltered homelessness who reside in rough sleeper tent encampments located on the street. Clinical information and vitals were recorded in REDCap. De-identified data from patients 65 years and above were downloaded and compared to a general population data set-the Centers for Disease Control National Health and Nutrition Examination Survey (CDC NHANES) 2017-2020 Pre-pandemic cohort. Data analysis was performed using R Studio version 4.3.2. Blood pressure was reported in 120 distinct interactions with older people experiencing homelessness. Compared to the age-matched NHANES data, older people experiencing unsheltered homelessness were at significantly increased relative risk for elevated blood pressure within the range of Stage 1 Hypertension (RR: 3.914, 95% CI: 2.560-5.892, P < 0.001), and within range of Stage 2 Hypertension (RR: 5.550, 95% CI: 4.272-7.210, P < 0.001). According to NHANES, 49.6% of adults over 60 with diagnosed hypertension receive treatment. Of study participants, 69% of those with elevated blood pressure had previously received a diagnosis of hypertension and 15.9% on medication to control blood pressure. Our cohort of older people experiencing unsheltered homelessness had higher rates of elevated blood pressure and reduced rates of hypertension diagnosis and treatment as compared to the general population. Older people experiencing unsheltered homelessness are a growing population, and future research should seek to evaluate and understand older adult care vulnerabilities, including chronic disease management, to improve health outcomes for those who are aging, hypertensive, and unhoused.

Treatment deferral for elevated blood pressure at a dental school clinic.

Current guidelines by the American Dental Association (ADA) recommend deferral of elective dental care for elevated blood pressure. However, it is unknown how frequently this impacts dental treatment. The purpose of this study was to evaluate rates of asymptomatic hypertension and treatment deferral at a dental school clinic. This was a retrospective study with data extracted from a chart review of all patients presenting for care at a dental school teaching practice. Differences in dental procedures, the time between visits, and the number of antihypertensive medications were calculated between patients with and without a blood pressure reading exceeding current guidelines for elective treatment. Among 26,821 individuals, 1265 had a visit with elevated blood pressure. Blood pressure readings at the next visit were significantly lower (systolic blood pressure 137 [95% confidence interval {CI} 135-138] mmHg, diastolic blood pressure 82 [95% CI 81-83mmHg], p<0.001), although only 24 patients reported taking a new medication. Only 4.1% of these patients had a procedure deferred; for those that did, the average intervisit time was 88.2 days (95% CI 77.7-98.7 days). The majority of patients with blood pressure readings exceeding current ADA recommendations for treatment were treated without evidence of harm. Patients were also unlikely to return to the clinic with new medications for blood pressure after a visit with an elevated blood pressure reading. Oral health providers must weigh the risks and benefits of care deferral and can consider an expanded role in hypertension management in dental settings when caring for patients with elevated blood pressure.

Abstract P354: Leveraging Electronic Health Records For Quality Improvement Among Patients With Markedly Elevated Blood Pressure

Introduction: Electronic health records (EHR) can improve quality of care for patients with markedly elevated blood pressure (BP). This study aimed to develop EHR-based computable algorithms to identify barriers to BP control and enhance triage and patient management. Methods: We conducted a retrospective analysis using EHR data from Yale New Haven Health System (YNHHS) employees and their dependents. Patients with markedly elevated BP had ≥2 outpatient BP readings ≥160/100 mmHg within a 180-day period. We assessed 3-month follow-up visits after BP elevation, along with the proportions of patients prescribed antihypertensives, filled prescriptions, and self-reported adherence using EHR data sources. Results: The study included 46,361 adult patients, with a mean age of 45.7 (14.5) years; 65% were female, 59% were White, and 17% were Black. Among them, 1,437 (3.3%) had markedly elevated BP, and 880 (1.9%) had consecutive markedly elevated BP readings. Among patients with markedly elevated BP, 626 (43.6%) had follow-up visits with relevant specialties within 3 months after the BP elevation. Moreover, 970 (67.5%) patients had antihypertensive prescriptions, of whom 927 (95.6%) filled their prescriptions, and among those who filled prescriptions, 806 (87.2%) reported taking the medications. Black patients were more likely to receive antihypertensive prescriptions but less likely to fill them or report taking medications (Figure). Conclusion: This study demonstrates the potential of EHR data and computable algorithms to enhance patient triage, interventions, and resource allocation for effective BP reduction among YNHHS employees.

Hypertension among persons living with HIV-Zambia, 2021; A cross-sectional study of a national electronic health record system.

Hypertension is a major risk factor for cardiovascular disease, which is a common cause of death in Zambia. Data on hypertension prevalence in Zambia are scarce and limited to specific geographic areas and/or populations. We measured hypertension prevalence among persons living with HIV (PLHIV) in Zambia using a national electronic health record (EHR) system. We did a cross-sectional study of hypertension prevalence among PLHIV aged ≥18 years during 2021. Data were extracted from the SmartCare EHR, which covers ~90% of PLHIV on treatment in Zambia. PLHIV with ≥2 clinical visits in 2021 were included. Hypertension was defined as ≥2 elevated blood pressure readings (systolic ≥140 mmHg/diastolic ≥90 mmHg) during 2021 and/or on anti-hypertensive medication recorded in their EHR ≤5 years. Logistic regression was used to assess for associations between hypertension and demographic characteristics. Among 750,098 PLHIV aged ≥18 years with ≥2 visits during 2021, 101,363 (13.5%) had ≥2 recorded blood pressure readings. Among these PLHIV, 14.7% (95% confidence interval [CI]: 14.5-14.9) had hypertension. Only 8.9% of PLHIV with hypertension had an anti-hypertensive medication recorded in their EHR. The odds of hypertension were greater in older age groups compared to PLHIV aged 18-29 years (adjusted odds ratio [aOR] for 30-44 years: 2.6 [95% CI: 2.4-2.9]; aOR for 45-49 years: 6.4 [95% CI: 5.8-7.0]; aOR for ≥60 years: 14.5 [95% CI: 13.1-16.1]), urban areas (aOR: 1.9 [95% CI: 1.8-2.1]), and on ART for ≥6-month at a time (aOR: 1.1 [95% CI: 1.0-1.2]). Hypertension was common among PLHIV in Zambia, with few having documentation of treatment. Most PLHIV were excluded from the analysis because of missing BP measurements. Strengthening integrated management of non-communicable diseases in HIV clinics might help to diagnose and treat hypertension in Zambia. Addressing missing data of routine clinical data (like blood pressure) could improve non-communicable diseases surveillance in Zambia.

The Implementation of Renal Denervation in the Management of Resistant Hypertension Despite Use of Multitherapy Antihypertensives at Maximally Tolerated Doses: A Contemporary Literature Review.

Refractory hypertension is highly prevalent among the hypertensive population, and current clinical management has failed to provide optimal control for these individuals. This subtype of arterial hypertension is defined as a persistently elevated systolic blood pressure reading of 140 mmHg, or higher, despite multiple antihypertensive use at maximally tolerated dosing. These patients have an elevated risk of cardiovascular and renal complications, urging for the need of more effective therapeutic management. Renal sympathetic efferent nerves have been noted to play an important role in volume and blood pressure homeostasis. Before the implementation of oral antihypertensives, the use of surgical lumbar sympathectomy for the reduction of persistent hypertension was considered a life-saving approach. However, individuals were left with debilitating side effects, such as postural hypotension, syncope, and impotence. A new and minimally invasive technique has been proposed, where the kidneys undergo selective denervation in hopes of providing decreased cardiovascular morbidity and mortality for patients with resistant hypertension. Some studies demonstrated promising outcomes with a reduction in blood pressure, a decrease in medication reliance, and a potential long-lasting effect of the procedure with an overall improvement in cardiovascular health. Unfortunately, most of the available data was obtained from observational, uncontrolled studies with short-term follow-up, small sample sizes, and high variability in blood pressure measurement. Therefore, further evidence is needed to determine whether renal denervation provides long-term benefits for blood pressure control and improves outcomes for mortality and cardiovascular events in this patient population.

Clinical characteristics and sequelae of intrapartum hypertension – a retrospective cohort study

BackgroundIn a significant proportion of pregnant women, elevated blood pressure may first present during the intrapartum period. This phenomenon, intrapartum hypertension, is often overlooked as blood pressure during delivery is attributed to labour pain, analgesic agents and haemodynamic changes. Thus the true prevalence and clinical significance of intrapartum hypertension remains unknown. This study sought to define the prevalence of intrapartum hypertension in previously normotensive women, identify associated clinical characteristics, and its impact on maternal and fetal outcomes.MethodsIn this single-center retrospective cohort study, all available partograms were reviewed over a 1-month period at an outer metropolitan hospital in Sydney (Campbelltown Hospital). Women with diagnosed hypertensive disorders of pregnancy during the incident pregnancy were excluded. A total of 229 deliveries were included in the final analysis. Intrapatum hypertension (IH) was defined as two or more systolic blood pressure (SBP)⩾140 mmHg or diastolic blood pressure (DBP)⩾90 mmHg during the intrapartum. Demographic data at the time of the first antenatal visit for the incident pregnancy as well as final maternal outcomes (intrapartum and post-partum) and fetal outcomes were collected. Statistical analyses were carried out using SPSSv27 with adjustments for baseline variables.ResultsAmongst 229 deliveries, 32 women (14%) had intrapartum hypertension. Older maternal age (p = 0.02), higher body mass index (p < 0.01) and higher diastolic blood pressure at the first antenatal visit (p = 0.03) were associated with intrapartum hypertension. A longer second stage of labour (p = 0.03), intrapartum non-steroidal anti-inflammatory medications (p < 0.01) and epidural anaesthesia (p = 0.03) were associated with intrapartum hypertension, while IV syntocin for labour induction was not. Women with intrapartum hypertension had a longer inpatient admission following delivery (p < 0.01), and elevated postpartum BP (p = 0.02) with discharge on antihypertensive medications (p < 0.01). Intrapartum hypertension was not associated with poor fetal outcomes, though subgroup analyses showed that women who had at least a single elevated blood pressure reading during the intrapartum experienced poorer fetal outcomes.ConclusionIn previously normotensive women, 14% developed intrapartum hypertension during delivery. This was associated with postpartum hypertension, longer maternal admission and discharge with antihypertensive medications. There was no difference in fetal outcomes.

TRAUMATIC “ANGIOEDEMA”: EXTENSIVE SUBCUTANEOUS EMPHYSEMA MASQUERADING AS ANGIOEDEMA

<h3>Introduction</h3> COVID 19 pandemic related precautions have resulted in suboptimal physical examination of the patients which may have affected the patient care and training of medical professionals. We present a case of a patient whose subcutaneous emphysema was misdiagnosed as angioedema. <h3>Case Description</h3> 25 years old female with cerebral palsy and developmental delay presented to hospital in June, 2020 with asymmetric left facial and periorbital swelling which developed an hour after her regular Depo-Provera injection. She had elevated blood pressure readings with tachycardia without hives, respiratory or gastrointestinal symptoms. Facial swelling did not improve after IM epinephrine, IV steroids and antihistamines. Flexible laryngoscopy noted mild edema of lingual surface of the epiglottis. Allergy service was consulted to evaluate for drug-induced anaphylaxis. Our physical examination revealed significant asymmetric periorbital edema, neck and chest swelling with distant breath sounds and distinct palpable crepitus. Serum Trytpase and C1-Estrase inhibitor levels were normal at 3.2ug/L and 28 mg/dl, respectively. Emergent imaging was recommended, which demonstrated multiple rib fractures, pneumomediastinum with extensive chest wall subcutaneous emphysema tracking to extra-cranial soft tissue. Patient was intubated and chest tube was placed due to concerns for airway compromise. She stayed in ICU for one week before being discharged to home. <h3>Discussion</h3> Facial edema, concerning for angioedema, is potentially life threatening condition and an allergic reaction should be higher on the differential diagnoses. Our case represents a learning opportunity regarding other potentially life threatening conditions that can mimic angioedema, requiring higher index of clinical suspicion and thorough physical examination.

Rumpel-Leede Phenomenon

We report a case of Rumpel-Leede phenomenon in an 80-year-old man presenting in the context of lightheadedness, dizziness, and elevated at-home blood pressure readings. In this case, the finding was found quite incidentally, by a routine blood pressure measurement, and was characterized by a purpuric rash on both upper extremities, which was nonpalpable and nonblanching with pressure. The pathophysiology of this rare clinical entity involves acute rupture of dermal capillaries from capillary fragility, resulting in a self-limiting nonpurpuric rash that resolves spontaneously without intervention.

Abstract P240: Nearly Half Of Participants In A Rural, Worksite-based Health Assessments Have Undiagnosed Or Uncontrolled Hypertension

Introduction: Untreated hypertension can result in stroke, heart failure, and kidney damage. Recent reports suggest the prevalence of hypertension is 10% higher in rural areas compared to urban centers.Identifying rural residents with uncontrolled hypertension is the first step to initiating treatment and preventing end organ damage. The objective of this study is to determine the prevalence of elevated blood pressure readings or uncontrolled hypertension in participants living in a rural area through worksite-based assessments. Hypothesis We assessed the hypothesis that there are elevated rates of hypertension among those living in rural areas with limited access to health care providers or systems. Methods: Rural worksites were identified for free screenings that include a series of questionnaires and bio-metrics. Screenings conclude with a one-on-one provider meeting to discuss results and referrals as needed. Results/Conclusions: A total of 654 individuals (46.3% Black) (57.2% male) participated in our screening clinics. When asked about health insurance coverage, 526 (88.7%) reported having insurance. Nearly seventy percent (66.9%) of participants had seen a healthcare professional within the previous year. Undiagnosed hypertension (SBP ≥140) was found in 169 (26.1%) participants and 114 (17.6%)participants had diagnosed but uncontrolled hypertension. In conclusion, nearly half of participants had uncontrolled/undiagnosed hypertension. Our worksite-based health screening clinics provided a convenient, walk-in service, immediate results, and provider consultation as a bridge to accessing ongoing care.

Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance.

Lloyd R, Morgenthaler TI, Donald R, etal. Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance. J Clin Sleep Med. 2022;18(11):2673-2680.

Piloting opportunistic cardiovascular risk assessment at a faith community event

Abstract Funding Acknowledgements Type of funding sources: None. Background Ethnic minority populations in the United Kingdom (UK) are known to have higher rates of undiagnosed and poorly controlled hypertension and metabolic disease (1). Muslims in the UK make up a significant proportion of these populations, and have lower reported rates of well-being and satisfaction with health services (2). Tailoring interventions to target under-served populations and activate positive health behaviours has been shown to improve uptake and outcomes (3). Purpose We undertook an opportunistic pilot intervention to explore the potential of using faith-placed community assets to identify undiagnosed and poorly managed cases of hypertension, diabetes, and explore cardiovascular disease (CVD) risk. Methods A community event was organised for Indian-origin Tamil speaking Muslims who gathered from across the UK in November 2021. We piloted a short CVD risk assessment intervention to take place during this event, delivered by doctors from the same community. Participants consented for assessment of body mass index (BMI), blood pressure (BP), random capillary blood glucose (CBG), and manual pulse rhythm check (with a commercially available smartphone based single-lead electrocardiogram device where needed). We also calculated the 10-year CVD risk using a nationally validated 10-year CVD risk calculator. The intervention was culturally tailored, specifically with men and women examined by the same sex and participants being given an Islamic reminder on good health to encourage their involvement. Results 35 attendees were assessed in total. 33/35 (94%) attendees were 60-years-old or less. 18/35 (51%) had an elevated blood pressure reading (systolic BP ≥ 140mmHg or diastolic BP ≥ 90mmHg on both arms), with only 3/18 (17%) having a prior diagnosis of hypertension. Only 17/35 consented to CBG measurement, of which 4/17 (23%) had random CBG levels of &amp;gt;11.1 mmol/L with 3/17 having CBG levels of &amp;gt;25 mmol/L - none of them were known to have diabetes. 9/35 (26%) had 10-year CVD risk of &amp;gt;10%. 6/9 (67%) of these were not on statin therapy. 24/35 (69%) had elevated BMI, with 9/24 (37%) having a BMI of ≥ 30 kg/m2. None of the attendees had an irregular pulse to suggest arrhythmia. Full characteristics are shown in Figure 1 and results are further detailed in Figure 2. In Summary, 29/35 (83%) had at least one abnormal finding on assessment. All participants with abnormal findings were signposted to seek formal diagnosis and management through their general practitioner, and were offered lifestyle advice. Conclusions This brief and targeted intervention was successful at detecting undiagnosed cases of probable hypertension and hyperglycaemia, as well as identifying cases who would benefit from primary CVD risk prevention. Further research is needed to understand the scalability and feasibility of this approach to wider populations.

Prevention of metabolic diseases through measures at the workplace

Abstract Background Metabolic diseases such as type 2 diabetes pose a risk for both individuals and companies. According to the current Austrian health report, only 13.5% of adults participate in preventive medical examinations. As a result, there is a lack of information on important health parameters. To counteract this, a modular system with health checks that take place directly at the workplace was developed. Methods In 2018 and 2019, a health check was carried out on 877 people (male: 70.7%; female: 29.3%) at their workplace. In addition to checking the abdominal girth and calculating the BMI, parameters such as blood pressure, blood sugar, LDL, and total cholesterol levels were measured. Results 62.5% of all participants were overweight or obese (male: 66.3%; female: 53.5%). The proportion of people with obesity was 11.5% (male: 11.4%; female: 11.7%). The abdominal girth was too high in 50.2% of the participants (male: 47.6%; female: 56.5%). 36.5% of the examined persons had elevated blood pressure readings (male: 42.3%; female: 22.5%). Total cholesterol was too high in 37.6% of the persons (m: 38.8%; w: 34.9%), LDL cholesterol was too high in 22.5% (m: 24.2%; 20.4%). The blood sugar levels were too high in 9.9% of the participants (male: 9.4%; female: 12.6%), regardless of whether they fasted or not. 81% of the participants stated that they had received new information about their state of health in the course of the examinations. Conclusions Measures to monitor the central metabolic parameters directly at the workplace represent an important component in prevention, which is essential for both the individual and the company. Key messages Metabolic diseases and obesity, as well as their consequences, pose a risk for both individuals and the companies they work for. Health checks directly at the workplace represent an important component in prevention and support companies in keeping their employees healthy.

How to give home BP monitoring patients the correct cuff: using BMI as a surrogate estimate of arm circumference

Abstract Background The key role of patient self-monitoring, already well established by large-scale forward planning initiative such the British National Health Service's (NHS) long-term plan, has been emphasised by the COVID19 pandemic. In the management of hypertension, much can be achieved through the provision of blood pressure monitors to patients, along with appropriate education and online blood pressure (BP) recording facilities. However, it is important to ensure that patients have the correct equipment to reliably measure their own blood pressures and to ensure they purchase or are supplied with validated monitors and, as undersized cuffs yield artefactually elevated BP readings, with correctly sized cuffs. Purpose To demonstrate the use of Body Mass Index (BMI) as an estimate of Middle Upper Arm Circumference (MUAC) for purposes of blood pressure monitor cuff size requirement estimation and the application of this strategy to a national Home Blood Pressure Monitoring (HBPM) programme. Methods The relationship between MUAC and BMI is well established; MUAC is used surrogate measure of BMI particularly in identifying underweight patients especially in environments where accurate recording of weight and height is challenging. Here, we reverse this relationship to use the BMI (one of the most commonly recorded datum in primary care patient records) to estimate patient MUACs. First, using manufacturer recommended cuff arm-circumference ranges and aggregate pre-established MUAC to BMI linear equations, we generate a simplified BMI to cuff-size scheme. Second, we apply this scheme to a UK Integrated Care System (a regional NHS organisation supporting 1.7 million adult patients in an English city) to estimate cuff requirement under NHS England's BPM@h HBPM initiative (in which patients with poorly controlled hypertension are allocated free home BP monitors). Lastly, we propose a patient-level tool for BP monitor cuff size prediction. Results Our simplified scheme proposes the following cuff predictions: Small (S: 17–22cm): BMI &amp;lt;18kg/m2; Medium (M: 22–32cm): BMI ≥18 and &amp;lt;28kg/m2; Large (M: 32–42cm): BMI ≥28 and &amp;lt;38kg/m2 and Extra-large (X: 42–50cm): BMI ≥38kg/m2. In our population of approximately 157,000 adult hypertensive patients, 6,039 were eligible for a BP monitor under the NHS England's BPM@h HBPM initiative. Using our simplified scheme, we predict cuff requirements as follows: S: 2%, M: 32%, L: 46%, X: 19%. Conclusion Patient BMIs are a useful predictor of BP monitor cuff size requirement. They are readily available or calculatable from primary care records and their application to cuff size identification will improve accuracy of BP readings in HBPM initiatives. Our preliminary results suggest that the most commonly supplied “standard” cuff may be unsittable for well over 50% of patients and that extra-large cuff may be required for nearly 1 in 5 patients. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Barts CharityHealth Data Research UK

ATYPICAL PRESENTATION OF AORTIC DISSECTION DURING COVID-19 PANDEMIC

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Aortic dissection (AoD) is extremely rare, with an annual incidence of 2.5-3.5 per 100,000 persons and a mortality rate between 13% - 50%. AoD commonly presents with either sudden onset chest pain or back pain, with systemic hypertension being the most significant predisposing risk factor. We report an atypical presentation and unfortunate misdiagnosis of aortic dissection during the COVID-19 pandemic that could further improve this patient population's screening and outcomes. CASE PRESENTATION: A 59 year old male with a history of hypertension was transferred to our institution for Neurosurgery evaluation due to head CT results consistent with subarachnoid hemorrhage. Repeated images revealed normal findings. Upon arrival, he presented with blood pressure readings of 252/110 mmHg accompanied by altered mental status. Further questioning of the patient's spouse revealed the patient's non-compliance with his antihypertensives, and abuse of energy drinks (> 4 drinks/day). In addition she revealed that symptoms began one day prior to admission, as the patient stood in the living room and reported an intense, non-localized headache accompanied by loss of sensation in lower extremities and loss of consciousness. Physical examination was remarkable for obesity, drowsiness, epigastric tenderness, and no focal neurologic deficits. The patient was admitted with an initial diagnostic impression of hypertensive emergency with the CNS as target for which Clevidipine drip was started. Given the marked clinical deterioration 48 hours after admission consisting of an elevated temperature, tachycardia, and leukocytosis during the COVID-19 pandemic led to suspicion, PCR testing and isolation. The PCR was non-reactive. Portable Chest X-Ray report yielded a magnification of cardiomediastinal silhouette with mediastinal widening. Subsequent chest and abdominal/pelvic CT confirmed the suspected diagnosis of AoD. Cardiology and Endovascular Surgery were consulted for further management. Recommendations were given against surgical management. After 35 days of hospitalization, the patient was discharged in a stable condition. DISCUSSION: AoD are caused by a tear in the aortic intima creating a false lumen. Despite the rarity of AoD, it has typical findings. Pain, most commonly in the chest and back, is present in over 90% of AoD patients, all of which were absent in our patient. Transient neurological symptoms including altered mentation;and elevated blood pressure readings, must be evaluated for aortic dissection when risk factors are present despite concurrent inflammatory responses amid a pandemic. CONCLUSIONS: A new pandemic and the surrounding uncertainty can influence but most not be allowed to sway other differential diagnoses. It is of utmost importance to recognize atypical presentations in high risk populations in order to obtain better outcomes. REFERENCE #1: Astarita A, Covella M, Vallelonga F, et al. Hypertensive emergencies and urgencies in emergency departments: a systematic review and meta-analysis. J Hypertens 2020;38:1203. REFERENCE #2: Martin JF, Higashiama E, Garcia E, et al. Hypertensive crisis profile. Prevalence and clinical presentation. Arq Bras Cardiol 2004;83:131. REFERENCE #3: Clouse WD, Hallett JW Jr, Schaff HV, et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc 2004;79:176 DISCLOSURES: No relevant relationships by Felix Aponte Santos, source=Web Response no disclosure on file for Andres Cordova Toro;No relevant relationships by Adriana Suarez Cruz, source=Web Response

Improving Blood Pressure Accuracy in the Outpatient Adolescent Setting

Hypertension (HTN) is increasing in the pediatric population, and hypertensive children become hypertensive adults. Blood pressure (BP) is often overlooked due to factors including distrust in readings, lack of time in visits, and discomfort prescribing antihypertensive medications. The objective of our multistage, clinically based quality improvement project was to improve BP measurement and HTN diagnosis and intervention in adolescents. Study investigators performed interventions in an adolescent medicine clinic at Children's Hospital Colorado (ages 12-24 years), which included equipment inventory, mapping clinic processes, manual/automated BP training for staff, education of faculty/staff on guidelines, and creation/implementation of updated best practice alerts (BPAs) based on age-appropriate guidelines for stage 1, 2 HTN in patients younger/older 18years. With equipment updates, medical assistant manual BP certifications, educational sessions for faculty/staff, and creation of a BPA with instruction before the go-live date, confidence in using automated and manual BP measurements increased for faculty/staff. The number of unique patient visits presenting with elevated BPs decreased significantly in the postintervention period reflecting the education/training. Staff used the new order set minimally, but there was an increase in correct diagnoses of elevated BP and laboratory workup. Having appropriate equipment while introducing BP guideline education in the ambulatory setting with electronic health record reminders and utility of BPAs can decrease erroneous BP values saving providers and staff encounter time. Real-time alerts can aid in accurate diagnosis rates and improved intervention for youth with elevated BP readings. Providers still inconsistently interact with order sets despite such parameters.

Elevated Blood Pressures Are Common in the Emergency Department but Are They Important? A Retrospective Cohort Study of 30,278 Adults

We determine the frequency of elevated blood pressure (BP) readings in the emergency department (ED), the proportion of patients with prior or subsequent diagnosis of hypertension assigned in other settings, and the association between ED BP levels and cardiovascular outcomes after ED discharge. This was a retrospective cohort study using electronic medical records for all adults treated and released from a large-volume ED in 2016 that were linked to administrative records for all health care encounters in the province for 2 years before and after the index ED visit. The primary outcome measure was a composite of stroke or transient ischemic attack, acute coronary syndrome, new heart failure, or death. Of 30,278 adults treated and released from the ED, 14,717 (48.6%) had elevated BP readings; 10,732 (72.9%) had no prior diagnosis of hypertension. Of the 3,480 patients with no prior diagnosis of hypertension but an ED BP greater than or equal to 160/100 mm Hg, 907 (26.1%) subsequently received a diagnosis of chronic hypertension or were prescribed antihypertensive therapy in other settings within 2 years. Among patients without a history of hypertension, those with an ED BP greater than or equal to 160/100 mm Hg were more likely to meet the composite outcome (stroke, transient ischemic attack, acute coronary syndrome, heart failure, or death) in the subsequent year (3.3% versus 2.5%) or 2 years (5.9% versus 3.8%) than those with ED BPs 120 to 139/80 to 89 mm Hg; however, after adjusting for age, sex, diabetes, atrial fibrillation, and prior cardiovascular disease, their risk was not elevated (adjusted hazard ratio 0.84; 95% confidence interval 0.71 to 1.004 during 2 years). Elevated BP readings in the ED are common and are often the first time hypertension is detected; however, they were not associated with adverse cardiovascular outcomes within 2 years of the visit.

High blood pressure readings on in-store machines: a qualitative study of the perspective of pharmacy staff

ObjectivesEmergency department (ED) visits for high blood pressure are on the rise. Yet the majority of these patients are discharged home after their ED evaluation, particularly those who present following an elevated reading on an in-store pharmacy machine. We aimed to gain insight on the practice and referral patterns of pharmacy staff who encounter a patient with an elevated in-store blood pressure (BP) reading.MethodsWe conducted a qualitative study using semi-structured interviews with pharmacy staff (pharmacists and pharmacy technicians/assistants) from California, United States and Ontario, Canada. Interview questions were designed to examine the practice and referral patterns of pharmacy staff for patients with elevated in-store BP readings. Standard descriptive content analysis techniques were used to analyze the data and to develop themes for current practice and referral patterns.ResultsTwenty-four interviews were completed: six with pharmacy technicians/assistants and 18 with pharmacists. Canadian pharmacy staff (83%) reported being approached frequently (defined as from weekly up to multiple times per day) by patients concerned about an elevated BP reading on an in-store machine, versus 50% reported by American participants. Participant definition of an elevated BP varied, with systolic values ranging from 120 to 150 mmHg and diastolic values from 60 to 90 mmHg. Participants emphasized the need to converse with and assess their patients prior to providing advice. The most frequently reported advice was to seek referral from an outside health care provider: ED, urgent care, or a primary care practitioner. Severity of the BP reading and symptomatology were reported as determining factors for referring patients to the ED. Pharmacists (92%) reported a lack of corporate and/or governing body policy for managing patients with in-store markedly elevated BP readings.ConclusionsManaging patients with an elevated BP reading in the community pharmacy setting is complex and not standardized. Referral to an external health care provider, including the ED, was a common theme. The development of a pharmacy referral tool/algorithm may be helpful to refer in-store patients with elevated BP readings to the most appropriate healthcare resources.

A 62-year-old man with very elevated blood pressure

A 62-year-old man presented to the emergency department after being referred by his internist when excessively elevated blood pressure readings were recorded. He had presented to his physician after having several episodes of headache in the past week. He has diagnosed hypertension and was aware that headache can mean excessively high blood pressures.

Haemodynamic changes and peripheral vascular characteristics associated with pathophysiological alterations in Preeclampsia patients at the University Teaching Hospital, Lusaka, Zambia

Background: The circadian blood pressure changes in pregnancy are poorly documented though the severity of hypertensive disorders especially in pregnancy is said to be better detected by 24hour blood pressure monitoring. The contribution of peripheral vascular variations to these alterations is yet to be elicited. The association of these changes to the renal pathological dysfunction is also not fully understood.Materials and method: Ambulatory blood pressure measurements and kidney function tests (i.e. creatinine, protein, sodium and uric acid) were done in patients admitted to UTH for hypertension in second and third trimesters of pregnancy. The Complior was used to determine the pulse waveform, pulse wave velocity (PWV) and augmentation index (Aix) as surrogate parameters for peripheral vascular compliance.Results: Twenty-six (26) women, between 22-42 years old and 24-36 gestational weeks, participated in this study. The majority of our population were either non- or reverse dippers (91.6%). The type A pulse waveform was dominant in all three groups indicating endothelial dysfunction. Dippers had a higher creatinine concentration in both urine and serum and uric acid in serum than non-dippers (7.051mmol/24hrs; 108.703ìmol/L;0.507mmol/L; respectively p&lt;0.0001). The observed association of diurnal variations inhemodynamic parameters and dipping status indicates significant vascular pathology that may herald these individuals' increased risk of cardiovascular complications. The dominance of the type A pulse waveform in this population is indicative of significant endothelial dysfunction.Conclusion: The association seen between elevated blood pressure readings and proteinuria indicates a possible common pathophysiological process that leads to increased porosity at the glomeruli.