Hypertensive Crisis Research Articles

Predictive Models for Sustained, Uncontrolled Hypertension and Hypertensive Crisis Based on Electronic Health Record Data: Algorithm Development and Validation.

Assessing disease progression among patients with uncontrolled hypertension is important for identifying opportunities for intervention. We aim to develop and validate 2 models, one to predict sustained, uncontrolled hypertension (≥2 blood pressure [BP] readings ≥140/90 mm Hg or ≥1 BP reading ≥180/120 mm Hg) and one to predict hypertensive crisis (≥1 BP reading ≥180/120 mm Hg) within 1 year of an index visit (outpatient or ambulatory encounter in which an uncontrolled BP reading was recorded). Data from 142,897 patients with uncontrolled hypertension within Atrium Health Greater Charlotte in 2018 were used. Electronic health record-based predictors were based on the 1-year period before a patient's index visit. The dataset was randomly split (80:20) into a training set and a validation set. In total, 4 machine learning frameworks were considered: L2-regularized logistic regression, multilayer perceptron, gradient boosting machines, and random forest. Model selection was performed with 10-fold cross-validation. The final models were assessed on discrimination (C-statistic), calibration (eg, integrated calibration index), and net benefit (with decision curve analysis). Additionally, internal-external cross-validation was performed at the county level to assess performance with new populations and summarized using random-effect meta-analyses. In internal validation, the C-statistic and integrated calibration index were 0.72 (95% CI 0.71-0.72) and 0.015 (95% CI 0.012-0.020) for the sustained, uncontrolled hypertension model, and 0.81 (95% CI 0.79-0.82) and 0.009 (95% CI 0.007-0.011) for the hypertensive crisis model. The models had higher net benefit than the default policies (ie, treat-all and treat-none) across different decision thresholds. In internal-external cross-validation, the pooled performance was consistent with internal validation results; in particular, the pooled C-statistics were 0.70 (95% CI 0.69-0.71) and 0.79 (95% CI 0.78-0.81) for the sustained, uncontrolled hypertension model and hypertensive crisis model, respectively. An electronic health record-based model predicted hypertensive crisis reasonably well in internal and internal-external validations. The model can potentially be used to support population health surveillance and hypertension management. Further studies are needed to improve the ability to predict sustained, uncontrolled hypertension.

More hypertensive crises in women than in men in a single emergency department

Abstract Introduction Hypertensive crises are a common presenting complaint in the emergency department. A hypertensive crisis includes hypertensive urgencies defined as a systolic and/or diastolic blood pressure greater than 180/120 mmHg and hypertensive emergencies with additional hypertension-mediated organ damage (HMOD). In the literature there is very little data regarding the distribution between men and women in hypertensive crises. Most data suggest a balanced distribution or a higher frequency in men, especially compared to premenopausal women. Methods We retrospectively analysed patient data in our hospital information system from 2022 using ICD-10 diagnoses at discharge. We included inpatient as well as outpatient cases that presented to our emergency department between 01/01/2022 and 31/12/2022 with one of the following ICD-diagnoses at discharge: - I10.01, Benign essential hypertension With mention of hypertensive urgency - I10.91, Essential hypertension, unspecified With mention of hypertensive urgency - I11.01, Hypertensive heart disease with (congestive) heart failure With mention of hypertensive urgency - I11.91, Hypertensive heart disease without (congestive) heart failure With mention of hypertensive urgency - R03.0, Elevated blood-pressure reading, without diagnosis of hypertension Then we compared the difference of the median age at presentation between men and women using the independent t-test. Results We identified 397 patients with a hypertensive crisis in the year of 2022. Overall the percentage of women in the collective of patients with any type of hypertensive crisis diagnosis was 73.0 % and thus a lot higher than the percentage of men. Women were on average 7.7 years older at presentation (p < 0.0001). Discussion: On the basis of the available data the causes for the distribution between men and women in hypertensive crises can only be speculated. On the one hand women may measure their blood pressure more frequently than men and the urge to call an ambulance or seek medical attention may be higher. On the other hand it could be possible that arterial hypertension in general has differences in the course and underlying mechanism with a higher frequency in blood pressure peaks, symptoms at lower blood pressure values and antihypertensive medication could be less effective depending on the type of drug. Also arterial hypertension may be underdiagnosed in women. The difference in the age at presentation is probably due to a later hormonal adjustment after the menopause as shown in the literature. The findings of this small observational study should be further investigated in larger trials.

One-year risk of all-cause death and major cardiovascular events in patients presenting with hypertensive crisis. A report from a global federated research health network

Abstract Background Few data are available about the clinical course of patients presenting with hypertensive crisis who are discharged alive from hospital. Purpose To assess the long-term risk of adverse events in patients with hypertensive crises. Methods Retrospective study utilizing a research health network. Based on the ICD-10-CM codes recorded between 2000 and 2022, from 85 health care associations mainly located in the United States, patients with hypertensive crisis were subdivided into hypertensive urgencies (I16.0) and hypertensive emergencies (I16.1). In those with hypertensive emergencies, the type of target organ damage was reported, ie. central nervous system (ischemic stroke, hypertensive encephalopathy, intracerebral hemorrhages), cardiovascular (CVS: myocardial infarction (MI), heart failure (HF), aorta dissection (AD)), or renal (acute kidney failure). Primary outcomes were the one-year risks of all-cause death, and major cardiovascular events (MACE: MI, stroke, cardiac arrest, AD, and HF). Secondary outcomes were the risks for each type of MACE. Cox regression analysis after propensity score matching (PSM) 1:1 was used to produce hazard ratios (HRs) and 95% Confidence Intervals (95%CIs). Results Overall, we identified 25 294 patients with hypertensive emergency (age 62.4±15.7, 46.1% females) and 21,737 patients with hypertensive urgency (age 63.5±17.2, 55.5% females). Patients with hypertensive emergency were more likely males, Black or African American origin and showed a higher prevalence of chronic hypertensive-related complications, vs. those with hypertensive urgency. After PSM, patients with hypertensive emergency showed a higher risk of all-cause death (HR, 1.34, 95%CI 1.25-1.44) and MACE (HR 4.09, 95%CI 3.87-4.33), vs. those with hypertensive urgency. Of the secondary outcomes, patients with hypertensive emergency had increased risks of MI (HR 3.33, 95%CI 3.03-3.67), stroke (HR 4.73, 95%CI 4.33-5.17), cardiac arrest (HR 1.30, 95%CI 1.07-1.58), AD (HR 5.49, 95%CI 3.90-7.73), and HF (HR 3.01, 95%CI 2.74-3.14). All the different types of organ involvement during the hypertensive emergency were each associated with similar long-term risks of adverse events (Figure 1). Conclusion Patients with hypertensive emergency have a high long-term risk of MACE and all-cause death. Preventing the onset of target organ damage in patients with hypertensive crisis is crucial to mitigate their long-term risk of adverse events.

Cardiovascular emergency in indonesian primary health care (PUSKESMAS): a national multicentre service evaluation study based on ESC guidelines adherence

Abstract Background Early diagnosis and prompt treatment are crucial in reducing cardiovascular (CVD) burden in the global level, especially in Indonesia with more than a half million CVD death annually. As frontliner, more than 10,000 primary healthcare (PUSKESMAS) spreading around Indonesia are pivotal in delivering CVD emergency care. However, due to the scarcity of healthcare resources, significant disparities exist between guideline recommendations and their implementation in Indonesian primary health care. Purpose Our study aims to describe current cardiovascular emergency care, assess guideline adherence, and identify key factors influencing the trend. Methods This multicentre study was conducted in 40 PUSKESMAS across Indonesia from October to December 2023. Data related to cardiovascular emergencies diagnosis, work-ups, treatment, and outcomes were gathered and then evaluated according to the ESC Guidelines. Recommendations, particularly Class I, were converted into points with respect to diagnostic and treatment domains. Guideline adherence scores were then calculated based on the percentage of accomplished points. Linear regression analysis was employed to identify factors that could explain variations in guideline adherence across all PUSKESMAS. Results 215 CVD emergency patients were reported. The most prevalent diagnosis was hypertensive crisis (n=137; 64%) with ECG done in only 26% of cases and none underwent imaging. Oral amlodipine (59%) and captopril (55%) were mostly used as antihypertensive, with none receiving intravenous. The second most common diagnosis was ACS (n=42; 20%), with ECG performed in only 71% of cases. Among 13 patients with STEMI, 69% only received aspirin, and 46% were given DAPT. Malignant arrhythmia occurred in 26 patients, with none receiving cardioversion. The most used anti-arrhythmic are bisoprolol, propranolol, and atropine. Among 23 cases of acute HF, only 39% received oxygen, while IV furosemide was used in only one case. Cardiac arrest occurred in two patients, both received CPR and epinephrine. In terms of guideline adherence, mean diagnostic score (%) was demonstrated highest in Cardiac Arrest at 100 and the lowest in Hypertensive Crisis and Acute HF at 53, while mean treatment score (%) was highest in Hypertensive Crisis at 86 and lowest in arrhythmia at 25. Linear regression suggests that human resources have a positive and significant association with diagnostic adherence scores (R2: 0.3485, p-value: 0.0450), whereas essential medicine has a strong but non-significant correlation with treatment adherence score (R2: 1.0768, p-value: 0.460). Conclusion This study has demonstrated a huge disparity between the current CVD emergency practices and guidelines in Indonesian primary healthcare. These gaps emphasised the need for improved human resources and essential medicine for primary healthcare along with the implementation of data-driven policy making concerning cardiovascular disease in Indonesia.Cardiovascular Emergency Diagnosis in InCardiovascular Emergency Work-up and Tre

Cardiovascular events and consequent risk of death in hematopoietic stem cell transplant recipients

Abstract Background Hematopoietic stem cell transplant (HSCT) represents a potentially curative approach for various hematologic cancers and bone marrow disorders. Advancements in safety and efficacy have broadened the application of HSCT to older individuals and those with concurrent medical conditions predisposing them to cardiovascular (CV) issues. Despite the significant survival benefits offered by HSCT, it is accompanied by both short- and long-term complications, leading to considerable morbidity and mortality. CV complications, including heart failure, arrhythmias, acute thrombosis, pulmonary hypertension, and pericardial effusions, are among the potential adverse events following HSCT. Aim for the present registry is to determine how much CV complications are related to short-term survival in patients after HSCT. Methods Observational, monocentric cohort study consecutively enrolling all patients undergoing HSCT from 2019 to 2023. Inclusion criteria was >18 years, autologous or allogeneic HSCT, and written informed consent for the participation in the study. All patients underwent a complete cardiological examination, including 12-lead ECG, echocardiography, and cardiac biomarkers, before HSCT, and after 2,6 and 12-months. CV-related adverse events were defined as systolic dysfunction (even asymptomatic), thromboembolism (both VTE and PE), stroke, arrhythmias, pericarditis and hypertensive crises. Results 91 patients (34% female; mean age 54 +/- 12 years) were followed-up for a median of 2 years after HSCT. Major risk factors' prevalence was overall low (hypertension 28%, dyslipidaemia 33%, diabetes 9%, and only 11 patients (12%) had a positive history for CV events (6 atrial fibrillation, 4 coronary heart disease, 1 stroke) before HSCT. During follow-up, 26 patients (29%) experienced at least one CV-related adverse event, of which 7 (8%) were serious enough to require an hospital admission. CV adverse events included 5 new heart failure diagnosis, 5 new atrial fibrillation diagnosis, 10 episodes of VTE/PE, 4 pericarditis, one stroke and one hypertensive crisis. Twenty of all CV-related adverse events were reported within the first six months after HSCT (77%). Having a CV-related AE within the first six months after HSCT is associated with an increased risk of all-cause death (39% vs. 17%; log-rank p=.01; Figure 1). Conclusions CV-related adverse events are common in patients undergoing HSCT and strikes an overall young and healthy population. Having a CV-related adverse event in the six months following HSCT is a heavy prognostic factor for all-cause mortality. Therefore, an optimal prevention strategy including arrhythmia monitoring, echocardiographic follow-up and guideline-driven thromboembolic prophilaxis could improve patients' survival after HSCT.Figure 1

Cerebral damage after malignant hypertensive crisis: cerebral MRI follow-up data

Abstract Background Malignant hypertension (MHT) crisis is characterized by acute and diffuse microvascular damages, and the brain is a primary target organ. While a recent MRI study has revealed extensive and frequent cerebral injuries during the acute phase of MHT crisis (1), there is a scarcity of follow-up data. Purpose This study aims to investigate the evolution of MRI markers of cerebral injury following the management of the acute phase of MHT. Methods In this retrospective analysis, we examined brain MRI data from patients admitted for acute MHT between 2008 and 2022 at our center. Eligible patients had at least one follow-up brain MRI available. A skilled operator conducted a comprehensive analysis of each brain MRI, searching for posterior reversible encephalopathy syndrome (PRES), acute stroke or cerebral hemorrhage and microangiopathy markers, blinded for clinical and demographical data. Results Among 149 patients enrolled, 104 had a brain MRI at inclusion, 47 individuals had at least one follow-up brain MRI and were included in the analysis. 72,3% were male, mean age was 48,2 ± 10.8 years and 45,7% presented blood pressure control at the time of the follow-up brain MRI. Median interval between initial and follow-up brain MRI was 228 (84 – 726) days. Five (10,6%) new recent strokes, 2 (4,3 %) cerebral hemorrhage and 0 PRES were recorded during follow-up. On the follow-up brain MRI, more patients presented chronic lacunar infarct and/or microbleeds, in higher numbers. On the contrary, overall Fazekas score was stable in 31 patients (66,0%), improved in 15 patients (31,9 %) and worsened in 1 patients (2,1%). Comparison of subgroups dichotomized according to blood pressure control or follow up duration showed no difference in brain MRI markers. Conclusion This study offers valuable insights into the risk of new cerebrovascular events and the evolution of brain MRI markers after managing the acute phase of MHT. Our findings emphasize the dynamic nature of cerebral microvascular burden and the potential for regression of white matter hyperintensities. A better understanding of these phenomena might contribute to improved diagnosis, tailored treatment, and proactive patient care in the context of MHT.

Evaluating an integrated clinical pharmacy service model in an ambulatory cardiac clinic- a single centre study

Abstract Background Evidence suggests that multidisciplinary cardiology clinics improve patient outcomes. Currently, there is limited data on the type of pharmacist-led interventions occurring in cardiac ambulatory clinics in the Australian setting. Purpose The primary aim of this pilot audit is to examine the frequency and type of pharmacist-led interventions in the ambulatory clinics of this specialist hospital. The secondary aim is to assess factors associated with hospital readmissions within 30 days of Pharmacists' reviews. Methods A retrospective pilot audit was conducted for patients who attended an integrated multidisciplinary Heart Failure (HF) and Hypertension (HTN) clinic from April 2023 to February 2024. Patients’ demographics, Charlson comorbidity index (CCI), and the number and types of pharmacist interventions and readmission data 30 days post clinic review were recorded. Descriptive statistics were used to evaluate patient characteristics and logistic regression for hospital readmissions. Results A total of 398 patients were reviewed by pharmacists, with 300 (75%) from the HF clinics and 98 (25%) from the HTN clinics. Patients’ median age was 63± 14.8 years and median CCI was 4± 3.7. Pharmacists documented medication histories for all patients (100%) and provided 355 recommendations, of which 213 (60%) were actioned by the cardiologist. Pharmacists had a face-to-face consultation and provided education and counselling to 175 (44%) patients. The most common types of interventions were related to guideline-directed prescribing and deprescribing (68, 39%), followed by up-titration of current therapies (61, 35%). Pharmacists also provided education on medication adherence and lifestyle modifications (28, 16%) as well as optimizing medications related to other comorbidities (18, 10%). A total of 8 patients (2%) were re-admitted l within 30 days of clinic review from either heart failure exacerbation or hypertensive crisis. Patients who had a face-to-face consultation and education with a pharmacist were less likely to be readmitted within 30 days (P=0.048). However, none of the other predictors tested for readmission such as age (P= 0.572), gender (0.296), history of non-compliance (0.834), CCI (0.984) or a diagnosis of HF or HTN (0.473) were predictors for readmission within 30 days of clinic review. Conclusion Pharmacists play an integral role in the cardiac ambulatory setting by providing expert medication advice and patient education to optimize patients’ outcomes. This study demonstrates that the activities performed by pharmacists working in Australian cardiac clinics are consistent with other international ambulatory clinics. The study also identified opportunities to develop a similar service for other ambulatory clinics at this hospital such as lipid and atrial fibrillation clinics. Additionally, further research is required to assess long term benefit of pharmacist led interventions on cardiac patients.

'Great Masquerader': a history of diagnosing pheochromocytoma.

Pheochromocytoma is a unique tumour with a variety of clinical presentations. Coined as 'the great masquerader', it can present with the classical triad of headache, sweating and tachycardia and sometimes in an acute hypertensive crisis. This paper describes the evolutionary history of the diagnosis of this condition. A literature review was conducted using Medline Database from 1900 to 2023 outlining the methods of diagnosis for pheochromocytoma. There have been diagnostic dilemmas and localization challenges of pheochromocytoma over the last century. From the first description of pheochromocytoma in 1886 to the first successful resection in 1926, there was poor recognition of its atypical symptoms and lack of reliable diagnostic tests. Over the next few decades, there were significant advances in screening and biochemical tests. Further understanding of catecholamine release and metabolic pathways led to the development of tests to identify end products of catecholamine metabolism in plasma and urine. Computed imaging however heralded significant improvement in surgical planning and management. The evolution of histopathological diagnosis with the use of immunostains and genetic testing has further contributed to the identification of malignant pheochromocytomas and an understanding of their behaviours. Significant advances in the biochemical and imaging have shaped our understanding of pathophysiology and management. These diagnostic advances have enabled early and accurate detection and localization of pheochromocytomas to enable prompt surgical management.

Atherosclerotic Renal Arterial Stenosis with Multivascular Involvement in a Patient Presenting with Uncontrolled Hypertension and Cardiac Dysfunction

Renal artery stenosis (RAS) is the most common cause of secondary hypertension, with an incidence rate of 1–3% and atherosclerosis being the most common cause in 90% of the cases. The detection of atherosclerotic RAS may portend multivascular involvement; hence, a more comprehensive approach is essential. Clinical outcomes depend on renal condition and atherosclerotic burden with other coexisting cardiovascular diseases. A haemodynamically significant RAS can be considered with the onset of hypertensive crisis associated with worsening renal function and flash pulmonary oedema, known as Pickering syndrome. Despite the current controversy regarding the lack of randomised studies supporting the benefits of revascularisation over medical therapy, this may be considered in patients with RAS and Pickering syndrome. Reported here is the case of a 76-year-old woman with bilateral RAS who presented with persistent elevated blood pressure and heart failure symptoms. The patient underwent successful bilateral percutaneous transluminal renal angioplasty. Long-term monitoring requires maintaining adequate blood pressure control and renal function.

HYPERTENSIVE CRISES: HYPERTENSIVE EMERGENCY AND CRISIS MANAGEMENT DURING ANESTHESIA

Introduction: hypertensive crisis is characterized by an acute and massive increase in blood pressure. Hypertensive crises encompass several clinical situations with different severity and prognosis, including hypertensive urgency and hypertensive emergency. The difference between the latter depends on whether the situation is life-threatening for the affected individual. Objective: to detail current information related to hypertensive crises, especially hypertensive emergency, definition, differentiation, etiology, epidemiology, pathophysiology, histology, clinical history, physical examination, management, differential diagnosis, prognosis and complications. Methodology: a total of 28 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 15 bibliographies were used because the other articles were not relevant to this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: hypertensive crises, hypertensive emergencies, hypertensive emergencies, arterial hypertension. Results: approximately 1-2% of adults with hypertension suffer hypertensive crises. Multiple case series show that short-term treatment of hypertensive emergencies has good results; however, long-term results are unknown. The main drawback is that follow-up of individuals is lost and the medication regimen is frequently modified. Untreated hypertensive emergencies have very high morbidity and mortality and if the patient does not receive adequate education about the severity of hypertension, this trend is likely to continue. Conclusions: given the high prevalence of hypertension, it is crucial that health care professionals are able to differentiate between hypertensive emergencies and hypertensive emergencies to provide appropriate and timely treatment. Rapid blood pressure reduction is critical in the treatment of hypertensive emergencies. The choice of medications should consider both efficacy and safety to avoid further complications. A detailed clinical evaluation can help identify the underlying cause and guide treatment, highlighting the importance of an individualized approach. Lack of timely treatment can lead to severe consequences, emphasizing the need for proper management in critical situations. Constant training in the management of hypertensive emergencies is essential to reduce the morbidity and mortality associated with this condition.The management of hypertension during anesthesia is critical, as its prompt detection and control are fundamental to prevent serious complications. Despite the lack of specific criteria to suspend surgery in hypertensive patients, it is essential to evaluate each case individually, prioritizing target organ damage over blood pressure levels. KEY WORDS: crisis, emergency, urgency, hypertension.

Characterizing myocardial edema and fibrosis in hypertensive crisis with cardiovascular magnetic resonance imaging.

A hypertensive crisis is associated with an increased risk of cardiovascular events. Although altered cardiac structure, function, and myocardial architecture on cardiovascular magnetic resonance (CMR) have been associated with increased adverse events in hypertensive patients, the studies did not include patients with hypertensive crisis. Our study aimed to determine myocardial tissue characteristics in patients with hypertensive crisis using CMR imaging. Participants underwent comprehensive CMR imaging at 1.5T. The imaging protocol included cine-, T2-weighted-, contrasted- and multi-parametric mapping images. Blood and imaging biomarkers were compared in hypertensive emergency and hypertensive urgency. Predictors of myocardial edema was assessed using linear regression. The predictive value of T1- and T2 mapping for identifying hypertensive emergency (from urgency) was assessed with receiver operator characteristics curves. Eighty-two patients (48.5 ± 13.4 years, 57% men) were included. Hypertensive emergency constituted 78%. Native T1 was higher in patients with LVH compared to those without (1056 ± 33 vs. 1013 ± 40, P < 0.001), and tended to be higher in hypertensive emergency than urgency (1051 ± 37 vs. 1033 ± 40, P = 0.077). T2-w signal intensity (SI) ratio and T2 mapping values were higher in hypertensive emergency (1.5 ± 0.2 vs. 1.4 ± 0.1, P = 0.044 and 48 ± 2 vs. 47 ± 2, P = 0.004), and in patients with than without LVH (1.5 ± 0.2 vs. 1.4 ± 0.1, P = 0.045 and P = 0.030). A trend for higher extracellular volume was noted in hypertensive emergency compared to urgency (25 ± 4 vs. 22 ± 3, P = 0.050). Native T1 correlated with T2 mapping (rs = 0.429, P < 0.001), indexed LV mass (rs = 0.493, P < 0.001), cardiac troponin (rs = 0.316, P < 0.001) and NT-proBNP (rs = 0.537, P < 0.001), while T2 correlated with cardiac troponin (rs = 0.390, P < 0.001), and NT-proBNP (rs = 0.348, P < 0.001). Non-ischemic LGE pattern occurred in 59% and was 21% more prevalent in the hypertensive emergency group (P = 0.005). Our findings demonstrate that hypertensive crisis is associated with distinct myocardial tissue alterations, including increased myocardial edema and fibrosis, as detected on CMR. Patients with hypertensive emergency had a higher degree of myocardial oedema than hypertensive urgency. Further research is necessary to explore the prognostic value of these findings.

6695 When Pheochromocytoma Presents As Acute Renal Failure, With Complete Resolution, A Case Report

Abstract Disclosure: U.A. Siddiqui: None. D. Deyar: None. D. Bondarenko: None. M. Ahmad: None. K.K. Lessard: None. Pheochromocytomas and paragangliomas (PPGL), are rare neuroendocrine tumors (0.66/ 100,000 cases), often characterized by paroxysmal hypertension and associated symptoms. While cardiac complications have been well-documented in the literature, there is limited information regarding acute renal failure. We explore a unique case of pheochromocytoma presenting initially with hypertensive crisis, but also with an unexpected journey into acute renal failure and subsequent recovery. 62-year-old hispanic male without known past medical history presents to the emergency department with chest pain, epigastric pain, dyspnea, and emesis. He was tachypneic, febrile (101°F), hypoxic (83% on room air), and profoundly hypertensive (188/112 mmHg). CT scan showed pneumonia as well as a 7cm complex mass within the left adrenal gland. Admitting labs showed metabolic acidosis, acute kidney injury (Cr 2.52mg/dL) and elevated troponins. Echocardiogram showed a reduced ejection fraction 45-50% and coronary angiography showed mild nonocclusive coronary artery disease. MRI visualized a solid left adrenal mass measuring 6.8cm with enhanced, mixed T1/T2 signaling and drop out inconsistent with adenoma. Adrenal labs revealed ACTH 125 pg/mL (9-46 pg/mL) and cortisol 27mcg/dL free metanephrine (MN) 1,422 pg/mL (&amp;lt;57 pg/mL), and free normetanephrine (NMN) &amp;gt;20,000 pg/mL (&amp;lt;148 pg/mL), total free MN + NMN &amp;gt;40,000 pg/mL (&amp;lt;205 pg/mL). Preoperative MIBG scan showed increased tracer activity of the left adrenal consistent with pheochromocytoma. Alpha blockade was performed using doxazosin and carvedilol was continued. Unfortunately, he developed oliguria and rising creatinine ( 7.4mg/DL). Kidney biopsy showed findings of acute tubular necrosis and mild fibrosis. Hemodialysis was initiated, receiving 12 sessions prior to undergoing open left adrenalectomy with mass resection on day 22 of admission. Post-operative blood pressure was managed with volume re-expansion and tapering of alpha blocker. Within 72 hours, renal function fully recovered and dialysis was discontinued. Follow up metanephrines are within normal limits and genetic testing results remain pending. Cases of acute renal failure and PPGL are scarce, and this case report contributes to the topic. Mortality in p is usually due to cardiovascular complications such as stroke, cardiomyopathy, and dysrhythmia [2]. Renal complications result from hypertensive nephrosclerosis or nephrotic syndrome. To date, only one case report from 1961 exists on acute tubular necrosis and PPGL [3]. We present an interesting case of pheochromocytoma complicated by hypertensive crisis and acute renal failure requiring dialysis. Resection of the pheochromocytoma normalized renal function. This demonstrates the importance of timely resection of the tumor and meticulous blood pressure management to ensure optimal outcomes. Presentation: 6/2/2024

6457 You Are Never Too Old For Pheo

Abstract Disclosure: M. Masumy: None. B. McAdams: None. P. Mikkilineni: None. Introduction: Pheochromocytomas (PCC) are a rare neuroendocrine tumor derived from chromaffin cells. The incidence is estimated at 8 in 1 million individuals with no sex or ethnic predilection. It is estimated that 0.05-0.2% of hypertensives may have PCC. Its incidence generally peaks between the third and fifth decades of life. The classic PCC symptoms are headaches, hypertension, palpitations, pallor and tachycardia. However, most patients may not present with these symptoms, and may go undiagnosed. Untreated PCC can have significant morbidity and mortality such as MI, CVA, and hypertensive crises. The current standard of evaluation for PCC includes obtaining serum metanephrines, then if significantly elevated, obtaining CT imaging. Oftentimes, surgical resection is the treatment of choice, but PCC may recur, thus regular follow up is needed. We present a case of PCC in an elderly patient who developed symptoms over a year. Case presentation: A 72-year-old Caucasian female with diabetes presented to the emergency department with palpitations, severe headache, flushing and hypertension. She began experiencing these spells several months earlier with increasingly difficult to manage hypertension. She also had a CVA and NSTEMI earlier in the year. Her blood pressure regimen included amlodipine 20 mg, valsartan 160 mg, and carvedilol 12.5 mg bid. Despite this her blood pressure was uncontrolled. She also had palpitations and unease up to an hour after taking valsartan. Due to her symptoms; PCC was suspected. Serum metanephrines were obtained with her normetanephrines measured at 3334.7 pg/ml and metanephrines were 475.6 pg/ml, these were significantly elevated and thus an abdominal CT scan was done. On CT, she was found to have a 4.9 cm x 4.4 cm left adrenal mass with a density of 31 Hounsfield units. Her symptoms, labs and imaging were strongly indicative of PCC and she was referred to surgery. Her previous blood pressure medications were discontinued, and doxazosin was titrated to a goal SBP of 120 mmHg. Then metoprolol was added to attain a goal heart rate below 70 bpm. She then underwent a successful laparoscopic left adrenalectomy. She is now on 5mg of amlodipine for her blood pressure and metformin for her diabetes. She will be having regular follow ups to monitor for pheochromocytoma recurrence. Conclusion: Though pheochromocytoma is a rare entity that affects individuals primarily in the third and fourth decade of life, it may also occur in elderly patients. In patients with difficult hypertension, screening with metanephrines may be indicated if these are significantly elevated CT imaging should be obtained. When obtaining CT imaging, Hounsfield units are important in characterizing PCC. Achieving adequate alpha blockade before beta blockade is also essential pre-surgery for the best outcome. Even after surgery, patients will require lifelong follow up to monitor for recurrence. Presentation: 6/1/2024

7246 Cardiac Paraganglioma: A Rare Entity

Abstract Disclosure: L. Javed: None. L. Jonea: None. Cardiac paragangliomas are an exceptionally uncommon subset of neuroendocrine neoplasms. We present a case of a patient presenting with this condition. 70-year-old woman with pertinent past medical history of chronic veinous insufficiency complicated by recurrent abscesses of her right leg since venaseal procedure. The patient had positive IgG lambda on immunofixation that raised concerns for MGUS. Therefore, a F-18 FDG PET-CT scan was performed for further evaluation. PET-CT revealed a hypermetabolic mass in the upper inner right thigh and the right atrium (SUV 17.6) raising concern for septic thrombi. She was admitted in the hospital for initiation of antibiotic therapy. Transesophageal echocardiogram (TEE) revealed a 4.5 cm x 4.0 cm mass in the right atrioventricular (AV) groove region, extending over the root of the main pulmonary artery. Following discharge, despite completing six weeks of IV antibiotic therapy a CT scan on a subsequent clinic visit revealed the same mass as seen on TEE. CT imaging raised suspicion of neuroendocrine tumor. This led to referral to the endocrinology department. Laboratory results showed elevated normetanephrine and dopamine levels increasing likelihood of paraganglioma. Lab Results: 24 hr urine normetaneprhine :7197(N ≤ 376 mcg), 24 hr urinary dopamine :879 (N ≤400 mcg), 24 urinary metanephrine: 84 (N ≤96 mcg) &amp; 24 hr urinary epinephrine &amp;lt;3 (N ≤20 mcg). Her home systolic blood pressure readings varied between 120’s &amp; 170’s. She was initiated on Prazosin 1 mg daily in addition to the existing antihypertensive medications of nebivilol, amlodipine &amp; furosemide. Few months later, this patient successfully underwent cardiac mass resection. Histologic findings of the resected mass were consistent with paraganglioma. Post-surgery, anti-hypertensive medications were discontinued, and blood pressure normalized to systolic readings in the 90s to 120s and diastolic readings in the 60s to 80s. Repeat biochemical tests indicated a normalization of normetanephrine &amp; dopamine levels, validating the success of the resection. This case features an extremely rare entity cardiac paraganglioma that had an atypical clinical manifestation of being asymptomatic. Timely diagnosis and appropriate management are crucial for patient outcomes. Surgical intervention, although fundamental, bears significant risks, necessitating meticulous preoperative management to mitigate potential complications. The medical approach focuses on averting perioperative complications such as hypertensive crisis, cardiac arrhythmias and myocardial infarction. This is achieved by administering alpha and beta adrenoceptor blockers for a minimum of two weeks before the scheduled surgery. Regular follow up is also essential due to the unpredictable malignant potential of these tumors. Presentation: 6/3/2024

7906 Nanoencapsulated Curcumin-Piperine Complex: A Breakthrough In Targeting CYP17A1 For Castration Resistant Prostate Cancer Therapy

Abstract Disclosure: J. Yakubu: None. Nanoencapsulated Curcumin-Piperine Complex: A Breakthrough in Targeting CYP17A1 for Castration Resistant Prostate Cancer Therapy. Jibira Yakubu a,b,c, Oya Taritd, Evangelos Natsaridisd, Amit V. Pandey a,ba Translational Hormone Research Program, Department of Biomedical Research, Faculty of Medicine, b Paediatric Endocrinology, Diabetology and Metabolism, University Children’s Hospital, Inselspital, Bern, c Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland. d Biointerfaces, Institute of Chemistry and Bioanalytics, University of Life Sciences FHNW, Muttenz, Switzerland. Abstract: Androgens play a pivotal role in prostate cell survival and are implicated in both early-stage and advanced, castration-resistant prostate cancer (CRPC). In CRPC patients on CYP17A1 inhibitors, the development of drug resistance and hypertensive crisis through the inhibition of CYP21A2 and or its substrate are a recognized challenge. Given its crucial role in androgen production, CYP17A1 has become a major target for cancer therapies. In this study, we employed a mini-evaporation technique to nanoencapsulate curcumin, exploring its impact on CYP17A1 activity in human adrenal NCI-H295R cells. We performed steroid profiling with LC-MS, as well as gene and protein expression studies. Initial results demonstrated that curcumin nanoparticles exhibited superior efficacy in reducing CYP17A1 activity compared to known drug Abiraterone acetate. Curcumin and piperine combined in nano-capsules greatly increased the inhibitory effects on CYP17A1 activity. Furthermore, ongoing studies include western blot investigation of the drug's interaction with the CYP17A1 protein and cell cycle effects. We confirmed the efficacy of our nano formulation by testing its impact on the growth of androgen-sensitive prostate cancer cell lines. Notably, nanoencapsulation improved curcumin's inhibitory effects on DHEA production via CYP17A1. Surprisingly, the curcumin-piperine nano-capsules enhanced these effects while having no effect on CYP21A2, offering a promising option for prostate cancer treatment. Our study reveals the promise of nanoencapsulated curcumin-piperine as a game-changing method for targeting CYP17A1 for improved prostate cancer therapy. The synergistic benefits observed in our study open new avenues for addressing the difficulties associated with androgen deprivation therapy. Funding: Cancer Research Switzerland grant number: KFS 5557-02-2022 Presentation: 6/3/2024

7206 Perioperative Management of Pheochromocytoma: The Mayo Clinic Florida Experience

Abstract Disclosure: A. Verma: None. F. Elli: None. S. Rao: None. M. Smith: None. A. Shapiro: None. C. Moshe: None. R. Chadha: None. Introduction: Pheochromocytomas are rare, neuroendocrine tumors derived from chromaffin cells of the neural crest, typically within the adrenal medulla. The pathophysiologic effect of primary concern is the uncontrolled release of catecholamines into the bloodstream, which carry risk for episodic hypertension, palpitations, and life-threatening crises. Preoperative preparation with drugs that block adrenergic receptors is utilized to improve hemodynamic oscillation force and surgical outcomes. Widely used premedication include alpha-blockers, beta-blockers, and calcium channel blockers. Despite adequate pretreatment, hemodynamic instability continues to evoke massive risk. The objective of this study was to assess the incidence of intraoperative hypertensive episodes in patients undergoing robotic assisted laparoscopic adrenalectomy. Methods: This study is an observational retrospective analysis of patients who underwent elective laparoscopic robotic-assisted adrenalectomies from February 2019 to April 2023. 17 patients total patients were included. Preoperative information included age, BMI, ASA physical classification, preoperative blockade regiment, and urine metanephrines. Intraoperative information included operation duration, tumor size, intraoperative anti-hypertensives, and hypertensive spikes defined as a SBP greater than 175 mmHg for 5 consecutive minutes. Data analysis was performed to obtain frequency counts (%), means (standard deviations), and median (range) as appropriate. Results: The mean age at the time of surgery was 57.12 ± 17.2 years. The majority of patients (76%) were ASA status class III. 7 of the 17 patients did not have active pheochromocytoma based on symptomatology, the incidental diagnoses being made by imaging and workup. The average tumor diameter was 3.90 ± 1.8, with a range of 2.0 - 8.0. Mean operative time was 153.76 ± 53.9 minutes. Preoperative urinary metanephrines were observed to have a mean of 1,248.44 ± 2,866.9 pg/mL. In terms of preoperative preparation, 65% of patients received Doxazosin, and 29% of patients received an alternative anti-hypertensive. Yet, 64.7% of patients were found to have at least 1 intraoperative hypertensive spike Conclusion: Despite premedication with anti-hypertensives, a significant percentage of patients experienced intraoperative hemodynamic instability. This emphasizes the importance of anesthesiologist preparation for intraoperative hypertension management to aggressively prevent hypertensive crises. In addition, it questions the routine use of alpha blockade for all cases preoperatively as has been suggested in certain studies, and whether or not it should be driven by other patient characteristics. Presentation: 6/1/2024

7536 Missed Silent Retroperitoneal Paraganglioma

Abstract Disclosure: S. Lamichhane: None. D.T. Price: None. J.J. Faria-Briceno: None. A. Kaur: None. Introduction: Paragangliomas are rare neuroendocrine tumors comprising about 15-20% of all chromaffin cell tumors and can arise anywhere along the sympathetic and parasympathetic ganglionic chain from skull base to the pelvic floor. About 75% of sympathetic paragangliomas arise in the abdomen out of which majority are functional and secrete catecholamines responsible for the typical clinical features. While the diagnosis is usually made by clinical features and lab elevation of catecholamines, it is estimated that 10-15% of paragangliomas are non-functional and another 10% do not manifest clinically according to the hormone activity, thus posing a significant diagnostic challenge. We report a case of a retroperitoneal paraganglioma diagnosed by biopsy as it was initially missed owing to its silent nature clinically and biochemically. Case report:A 48-year-old smoker with panic disorder, remote history of spontaneous pneumothorax, and exploratory laparotomy for motor vehicle accident visited ER due to left-sided abdominal fullness and weight loss of 10-20 pounds for several months. Review of systems was negative except for mild constipation. He denied taking any medications and BP had been normal. CT abdomen showed a large 13.3 cm mixed cystic and solid mesenteric mass. Core biopsy revealed pheochromocytoma and patient was referred to Endocrinology. Labs showed elevated plasma free metanephrines (MN) 80 pg/ml, normetanephrines (NMN) 190 pg/ml, total MN 270 pg/ml, all less than twice the upper limit of normal and inconclusive, non-elevated 24-hour urine MN and NMN but with inadequate collection, and normal plasma catecholamines. MRI revealed a 13.5 cm mass in the left retroperitoneal sympathetic chain separate from the left adrenal gland and inferior to the left kidney. After pre-op optimization with alpha and beta blocker, patient had an uncomplicated open resection of the mass along with the retroperitoneal lymph nodes (LN). Pathology resulted in 3 benign LNs, a 16.5 cm paraganglioma negative for margin, lymph-vascular invasion, and necrosis. Genetic panel was negative. Follow-up post-surgery at 1 and 3 months with mildly elevated catecholamines and MRI abdomen at 3 months without evidence of recurrent or residual mass and metastasis. PET scan is pending prior authorization. Conclusion: Silent retroperitoneal paragangliomas are exceedingly rare. The diagnosis is often missed when the tumors are asymptomatic, and biomarkers are not elevated. The lack of specific imaging characteristics also adds to the diagnostic challenge. Early recognition can avoid the potential risk of life-threatening hypertensive crisis during surgical intervention. Our case highlights the importance of considering this rare entity in the differential diagnosis of retroperitoneal mass. Presentation: 6/1/2024

6402 Unsuspected Bladder Mass Turns Out To Be A Paraganglioma

Abstract Disclosure: S. Lamichhane: None. A. Flowers: None. D.T. Price: None. A. Kaur: None. Background: Urinary bladder (UB) paragangliomas are extremely rare tumors comprising of less than 0.05% of all bladder neoplasms and 10% of all paragangliomas. The diagnosis is usually suspected based on clinical features of painless hematuria, episodic headaches, hypertension, palpitations associated with micturition or bladder and confirmed biochemically by elevated urinary and/or plasma fractionated metanephrines (MN). Here, we present a case of a UB mass that was initially diagnosed on biopsy and subsequent biochemical workup revealed elevated MN. Case Report: A 64-year-old man with type 2 diabetes and hypertension, admitted for revision surgery of subdural hematoma was incidentally found to have a 3.3 x 3.4 x 3.9 cm polypoid heterogenous hyper enhancing UB mass attached to the anterior wall on CT abdomen done for abdominal pain. Cystoscopy and TURBT were complicated by hypertensive urgency. Pathology turned out to be paraganglioma. Detailed history at this time revealed a long-standing history of frequency, urgency, nocturia 4 times nightly, recurrent urinary tract infections, an episode of gross hematuria 1-2 years ago, and difficulty controlling blood pressure on 4 anti-hypertensives. Subsequently, labs showed plasma free MN of 97 pg/ml (ref range &amp;lt;=57), free normetanephrine (NMN) of 2392 pg/ml (ref range &amp;lt;=148), and total MN of 2489 pg/ml (ref range &amp;lt;=205). Genetic panel was negative for SDHA, SHD, AF2, SDHB, SHDC, SDHD, VHL, RET, TMEM127. He received 6 doses of Lantreotide due to suspicion of metastasis based on abdominal, pelvic, and inguinal lymphadenopathy seen on DOTATATE scan. After preparation with alpha and beta blockers, he underwent uneventful robot-assisted cystectomy with lymph node resection that resulted in a well-differentiated paraganglioma negative for margins, lymph node involvement, and extra bladder extension. A week later, MN reduced, plasma free MN 37 pg/ml, free NMN 178 pg/ml, and total plasma MN 215 pg/ml. His BP improved, and micturition-induced palpitations resolved. Conclusion: Due to the rarity of UB paraganglioma, the diagnosis can be missed and delayed. This has a serious implication due to the risk of hypertensive crisis during the surgery and increased risk of cardiovascular complications. This case highlights the need for awareness among physicians of the clinical presentation associated with UB paraganglioma, its early recognition and management. Presentation: 6/2/2024

7564 Adrenal Pheochromocytoma In A Clinically Inapparent Adrenal Mass

Abstract Disclosure: L. Medina Mora: None. S. Htoo: None. A. Sanchez Ruiz: None. M. Harshan: None. A. Busta: None. Introduction: Pheochromocytomas (PCC) are rare tumors that arise from the adrenal medulla, with an estimated annual incidence of 0.8 per 100,000 person-years. These tumors have been associated with significant morbidity and mortality and are considered among the most life-threatening endocrine diseases, particularly if left undiagnosed. Its symptoms can be related to the tumor's mass effect or catecholamine excess. As a result, they can mimic other conditions, often leading to delayed or incorrect diagnosis. A study conducted on 296 patients with PCC treated from 2005 to 2016 found that 61% were discovered incidentally through cross-sectional imaging (CSI). The widespread use of CSI in recent years has led to the identification of asymptomatic cases that would have otherwise gone undetected. In this case, we present a middle-aged female who was incidentally found to have a PCC. Case Report: A 59-year-old female with a history of hypertension, cerebrovascular accident, pulmonary hypertension, systolic heart failure, mitral valve replacement, and asthma presented to the clinic for evaluation of a right adrenal lesion measuring 4.2 x 3.5 cm found during an emergency room visit during the evaluation of chest pain. She had no known family history of brain or endocrine disorders. Her lab results showed elevated plasma metanephrine and normetanephrine to 578.4 (reference range: 0-88) and 459.9 (reference: 0-244), respectively. Additionally, her 24-hour urine metanephrine was elevated to 984 mcg (normal range: 36-209), and Chromogranin A was 164.3 (reference range: 0-101). The rest of her labs, including cortisol, renin, aldosterone, and DHEA-S were unremarkable. A CT with and without contrast revealed a 3.0 x 3.5 x 5.1 cm solid non-calcified right adrenal mass measuring 39 Hounsfield units (HU). In addition, it measured 53 HU in the venous phase and 61 HU in the 15-minute delayed phase (relative washout of &amp;lt;1%; absolute washout of &amp;lt;7%). The patient was treated with alpha-blockers and underwent a robotic-assisted right adrenalectomy. The pathology was significant for a 5.4 cm well-differentiated PCC. The tumor had extended into but not beyond the adrenal capsule. The postoperative course of the patient was uncomplicated. Discussion: After a PCC is detected, the most effective treatment option is to surgically remove it. This procedure necessitates a combination of alpha and beta-blockade to regulate blood pressure and prevent a hypertensive crisis. Despite the success of surgery, there is still uncertainty about the optimal follow-up after the procedure, which often leads to many patients being lost during the process. Furthermore, even a decade after the initial surgery, there remains a substantial likelihood of illness reoccurrence or metastasis, making the situation even more complex. Therefore, it is crucial to adhere to a lifelong follow-up plan that includes annual biochemical testing. Presentation: 6/2/2024

Risk of Acute Complications with Rocuronium versus Cisatracurium in Patients with Chronic Kidney Disease: A Propensity-Matched Study.

Neuromuscular blocking agents (NMBAs) play an integral role in modern anesthesia by facilitating endotracheal tube placement, assisting with mechanical ventilation, and creating optimal surgical conditions. However, NMBAs can have deleterious side effects. The purpose of this study was to retrospectively analyze acute complications of 2 pharmacodynamically similar but pharmacokinetically different NMBAs and their respective reversal agents. The global research network database, TriNetX, was used to evaluate deidentified patient information from 63 health care organizations. Cohort A was defined as patients aged 18 to 80 years who had chronic kidney disease (CKD) and were administered rocuronium with sugammadex. Cohort B was defined as patients aged 18 to 80 years who had CKD and were administered cisatracurium with neostigmine. Cohorts were propensity matched for age at event, ethnicity, race, sex, and relevant confounding pathologies. All outcomes besides mortality were analyzed from the same day to 1 week after administration of the indexed drug. Mortality was analyzed from the same day to thirty days after administration of the indexed drug. A total of 95,740 patients with CKD-administered rocuronium with sugammadex were matched with 10,708 patients with CKD-administered cisatracurium with neostigmine. Patients administered rocuronium with sugammadex had a significantly higher associated risk of respiratory failure (risk ratios [RR], 1.98, confidence interval [CI], 1.71-2.29, P < .0001), acute respiratory distress (RR, 2.70, CI, 1.31-5.58, P = .0052), hypertensive crisis (RR, 1.85, CI, 1.37-2.49, P < .0001), heart failure (RR, 1.14, CI, 1.06-1.23, P = .0004), pleural effusion (RR, 1.30, CI, 1.14-1.49, P < .0001), and 30-day mortality (RR, 1.31, CI, 1.10-1.56, P = .0021). From 2003 to 2023, patients who were administered rocuronium plus sugammadex were at a significantly higher risk for acute cardiovascular and pulmonary complications when compared to patients who were administered cisatracurium plus neostigmine.