Hypertensive Urgency Research Articles

PS-C01-1: CARDIOVASCULAR EVENTS PREDICTION RELATED TO AGE IN PATIENTS WITH HYPERTENSIVE CRISES IN 12-MONTHS FOLLOW-UP GREEK STUDY

Objective: Few data have been published regarding the long-term prognosis of patients with hypertensive crises (hC). The aim of our study was to record the prevalence and clinical phenotype of patients with hypertensive urgencies (hU) and emergencies (hE) assessed in the emergency department (ED) and during hospitalization and a 12-month follow-up to record new events in a Greek tertiary hospital. Design and method: The registry population consisted of patients admitted to the ED with acute increase in blood pressure (BP) (systolic BP > or = 180mmHg and/or diastolic BP > or = 120mmHg) and depending on the presence or absence of acute hypertension-mediated target organ damage they were divided into the HE and the HU group, respectively. In all patients the demographic and clinical parameters were recorded for 12 months and there was a 12-month follow-up for new end points. Results: Out of 38,589 patients assessed in the ED during a period of 12 months, 353(0.91%) had hC, out of whom 256(72.5%) had HU and 97(27.5%) had hE. The mean age of all patients was 67.4 ± 12.9 years, 49% were males and 80% had a history of hypertension. During the study period 81 patients were excluded for not completing the follow-up. We stratified the total population of hC by age separating patients into two groups, e.g. > or = 65 and < 65 years old, and analyzed the composite end point consisting of deaths or hospitalizations caused by cardiovascular disease. Patients > or = 65years old presented more composite events (36 vs 8 events, p = 0.019, hR for patients > or = 65years 2.68, 95% CI 1.18–6.12). Cox regression models were adjusted for age, gender, cardiovascular disease, chronic kidney disease and diabetes mellitus. Conclusions: Our study implies that age > or = 65years is an independent risk factor for deaths or hospitalizations caused by cardiovascular disease in patients with hC. There is an arising necessity for more intensive follow-up of these patients and the need for further research in this setting.

PS-C20-5: WARM IV INFUSION IN HYPERTENSIVE URGENCY

Background: Hypertensive Urgency is defined as marked elevation in systemic blood pressure without any evidence of end organ damage. At present, the condition is managed with intravenous (IV) antihypertensives, of which most common is Sodium Nitroprusside. Aim: In this abstract we explore the possibility of slow IV infusion of warm (37–38oC) Normal Saline along with IV antihypertensives for a better and faster management of Hypertensive Urgency. Content: The slow IV will gradually increase the core body temperature of the patient while preventing fluid overload. Homeostatic regulation of Systemic Blood Pressure is maintained by an intricate network of correlated mechanisms, most of which are temperature dependent. The raised body temperature will be useful to control the Blood Pressure through the following mechanisms - Cardiac Output: reduces as core body temperature increases. Baroreflex: decreased post-synaptic adrenergic vasoconstrictor responses. Chemoreceptors: vascular responsiveness to adrenergic receptor stimulation reduces at higher temperatures. RAAS: Kosunen et al recorded reduced Systolic and Diastolic Blood Pressures at raised body temperatures despite increased levels of Angiotensin II & Aldosterone. Endothelin: Serum concentration of Endothelin-I reduces at higher temperatures. Sweat: Thermal stimulation of sweat gland will help excretion of both salt and water, thus maintaining the sodium balance. VEGF: VEGF-A, a potent vasodilator, is increased during elevated body temperature. However, apart from Blood Pressure, a change in core body temperature causes change in many other parameters as well, which must be considered during this discussion. Coagulation profile - Valeri et al noted no change in in-vivo coagulation states till 100oF Effect on other visceral organs - Internal visceral organs like Liver, Kidneys and Brain were not affected till 100oF Infection Control - Core body temperature close to 100oF has also been found to have a protective role against invasive fungal infections in the ICU Discussion: Though the effects of various antihypertensive drugs to raised body temperatures need to be tested, the above points prove that introducing a protocol of warm IV saline Infusion in patients of Hypertensive Urgency may be extremely beneficial, and also prevent clinical inertia.

Pharmacodynamic benefits of combined renin angiotensin system inhibition and alpha-1 adrenergic antagonism in the management of hypertension and cardiovascular disease in people with African ancestry

Abstract Genetic differences exist between Blacks and whites through sympathetic-vascular transduction signaling mechanisms. However, the lack of benefit of alpha-1 blockers in whites may not be applicable in Africans. The angiotensin II (Ang II) and alpha-1 receptor pathways are critical for vasoconstriction in Blacks. This article reviewed the consequence of the dual blockade among Nigerians, those with and without cardiovascular disease. Both receptors exhibited crosstalk and mutual regulations. Synergistic inhibition of Forearm vasoconstriction and hypotensive response to enalapril + prazosin (alpha-1 blocker [A1B]) occurred (P < 0.05). High efficacy of dual blockade by angiotensin converting enzyme inhibitor (ACEI) + A1B was reported in hypertensive urgency, hypertensive crises, and heart failure (HF) with reduced ejection fraction congestive HF compared to ACEI (P < 0.05). The high efficacy of dual blockade by ACEI + A1B + diuretics is beneficial for widespread use in Nigerians with cardiovascular disease.

PS-BPC03-3: CARDIOVASCULAR EVENTS PREDICTION RELATED TO GENDER IN PATIENTS WITH HYPERTENSIVE EMERGENCIES IN 12-MONTHS FOLLOW-UP GREEK STUDY

Objective: Currently, epidemiological data on prognosis of patients with hypertensive crises (hC) are limited. The purpose of our study was to register the prevalence and clinical characteristics of patients with hypertensive urgencies (hU) and emergencies (hE) admitting to the emergency department (ED) and during hospitalization and a 12-month follow-up to record new end points in a Greek tertiary hospital. Design and method: The study population included patients reporting to the ED with acute rise in blood pressure (BP) (systolic BP >or = 180mmHg and/or diastolic BP >or = 120mmHg), categorizing as hE and hU depending on the presence or absence of acute hypertension-mediated target organ damage, respectively. In all patients the demographic and clinical information were registered for 12 consecutive months. In addition, there was a 12-month follow-up for new events. Results: Out of 38,589 patients assessed in the ED during a period of 12 months, 353(0.91%) had HC, out of whom 256(72.5%) had hU and 97(27.5%) had hE. The mean age of the hE patients was 73 ± 12years, 51.5% were males and 86.4% had a history of hypertension. During the study period 3 hE patients did not complete the follow-up. After stratification of hE population by gender, we created two subgroups, males and females, and analyzed the composite end point involving deaths or hospitalizations by cardiovascular causality. Men reported more composite events than women (21 vs 11 events, p = 0.042, hR for males 2.2, 95% CI 1.03–4.6). Cox regression models were adjusted for age, gender, cardiovascular disease, chronic kidney disease and diabetes mellitus. Conclusions: The results indicate male gender as an independent risk factor for deaths or hospitalizations caused by cardiovascular disease in patients with hE. Our registry highlights the commitment for a more intensive follow-up of hE patients, especially for men, and underlines the need for further research in this pathological entity.

PS-C08-4: TEC4HOMEBP: DEVELOPING A HOME BLOOD PRESSURE TELE-MONITORING PATHWAY TO SUPPORT PATIENTS DISCHARGED FROM THE EMERGENCY DEPARTMENT WITH ELEVATED BLOOD PRESSURE

Objectives: Elevated blood pressure (BP) in the emergency department (ED) is common, but clinical uncertainty exists on how best to manage asymptomatic hypertension. Telehealth for Emergency-Community Continuity of Care Connectivity via Home Blood Pressure Telemonitoring (TEC4Home BP) evaluates how home blood pressure telemonitoring (HBPTM) can support patients with elevated BP manage their health at home after visiting the ED. The aim of this study is to assess the effect of HBPTM on BP control among those discharged home from the ED with severely elevated BP. We also examined adherence to HBPTM, medical therapy and patient satisfaction. Methods: We conducted a prospective, single-centre, observational study and recruited 50 participants from Vancouver General Hospital (VGH), ED with hypertensive urgency, asymptomatic severely uncontrolled BP (> 160/100 mm Hg averaged over 3 readings) or referred to the VGH Hypertension Clinic from the ED for high BP. All participants received a validated home BP monitor (A&D UA-651BLE) and App (Sphygmo App, Calgary, AB) to automatically teletransmit 2 readings in the morning and evening daily for 3 months. Proportion of patients diagnosed with hypertension with controlled home BP defined as less than 135/85 mmHg, adherence to HBPTM, and medication therapy using the Hill Bone medication adherence scale, at 1and 3 months following discharge from the ED. Results: From May to December 2021, 50 participants (60 years old, 61% females, average baseline BP (SD) in ED 191 +/−26/ 99 +/−15 mm Hg) were recruited. Our recruitment and enrollment rate were 41% and 88%, respectively. At 1 and 3 months, average home BP (SD) was 136 +/−15/80 +/−11 and 128 +/−10 /77 +/−10 mm Hg. At 3 months, there was a 66% improvement in proportion of those who achieved target BP control. Adherence to HBPTM at 1 and 3 months was 84 and 54%, respectively. There were no differences in medication adherence at baseline and 3 months of study. Participants were highly satisfied with the HBPTM program and 79% would highly recommend the program. More detailed data analysis is currently underway and will be presented. Conclusions: HBPTM is a feasible, effective, and acceptable strategy to triage and monitor patients with significantly elevated BP when discharged from the ED. Future studies are need to advise the integration of HBPTM pathway a key clinical strategy to improve patient flow in the ED, reduce length of stay in the ED, and improve BP control in patients with hypertension.

Pattern and Prevalence of Patient Admission in Pediatric Intensive Care Unit of Bharatpur Hospital, Chitwan, Nepal

Healthcare professionals consistently document patient data during each hospital visit; however, the utilization of this data for informed decision-making in hospital management remains limited. This study aims to harness patient records from the Pediatric Intensive Care Unit of Bharatpur Hospital, employing a retrospective approach. The analysis encompasses one hundred and twenty cases spanning a two-month duration from 2022 April, incorporating variables such as gender, age, caste, district of origin, primary and final diagnoses, and patient outcomes. Employing descriptive analysis and logistic regression, the findings highlight consistent patient flow patterns between genders, while variations emerge across age groups, castes, and districts of origin. Notably, a meticulous matching analysis between primary and final diagnoses reveals full alignment for conditions like Severe Anemia, AFI, COPD, and Hypertension Urgency, corroborating initial medical assessments. Specifically, the secondary diagnosis of COPD demonstrates a robust correspondence rate of 96.77%, representing the highest admission count, whereas Bill Pneumonia exhibits a lower alignment rate of 33.33%. This discrepancy is attributed to a small sample size of only three cases, limiting generalizability. Overall, 89.09% of primary diagnoses align with the final diagnoses. The application of logistic regression indicates significantly higher admission probability for the Pediatric Intensive Care Unit among individuals aged 64 to 85, compared to other age groups. The implications of this research extend to policymakers, hospital management stakeholders, and scholars pursuing hospital-focused studies.

An Atypical Case of GFAP Astrocytopathy

Objective To describe a case of anti-GFAP astrocytopathy with atypical features. Background Glial fibrillary acidic protein (GFAP) astrocytopathy is a steroid-responsive autoimmune meningoencephalitis that is commonly characterized by preceding viral illness followed by encephalopathy and papillitis without significant effect on visual acuity. We describe an atypical case of GFAP astrocytopathy presenting with profound vision loss and intracranial hypertension. Design/Methods Case Report Results 31 yo male with a history of hypertension developed flu-like symptoms for one week. Subsequently, he experienced blurry vision and presented to the hospital. He was found to be hypertensive with acute kidney injury. He was treated for hypertensive urgency and discharged. However, patient's vision continued to deteriorate and he developed non-threatening visual hallucinations. He was readmitted to the hospital. His eye exam revealed bilateral loss of visual acuity, retinal hemorrhages and severe papilledema. His laboratory work-up was notable for LP findings of lymphocytic pleocytosis, elevated protein and opening pressure of 54. He was started on acetazolamide and transferred to tertiary medical center. There, he developed encephalopathy with psychosis. An extensive infectious/ autoimmune/malignancy workup was completed. This included three repeat LPs showing persistent intracranial hypertension, lymphocytic pleocytosis, high protein and oligoclonal bands. He underwent imaging with CT chest/abdomen/pelvis, MRV and MRI head/orbits, which showed no evidence of malignancy, patent vasculature and pachymeningeal enhancement, respectively. His work-up was notable for positive IgG GFAP in CSF leading to diagnosis of GFAP astrocytopathy. He was treated with pulse dose IV steroids followed by slow steroid taper and concurrent PLEX therapy. Due to severity of case, he was later started on cyclophosphamide. For papilledema, he was continued on acetazolamide and underwent bilateral optic nerve sheath fenestration. Overall, his encephalopathy resolved but vision remained poor. Conclusions This case illustrates an unique manifestation of GFAP astrocytopathy including rapid visual loss, persistent intracranial hypertension and absence of characteristic MRI findings.

Initiation of oral antihypertensives in hospitalized patients with hypertensive urgency: A descriptive study.

In hypertensive urgency, guidelines recommend oral antihypertensives, but with limited guidance on implementation. The objective of this study was to determine whether time to initiation of oral antihypertensives impacts blood pressure (BP) reduction in patients with hypertensive urgency. A descriptive study was conducted of adult hospitalized patients with hypertensive urgency from November 2018 through November 2021. Patients with a systolic BP (SBP) of 180 mm Hg or higher or a diastolic BP (DBP) of 120 mm Hg or higher and receipt of oral antihypertensives within 48 hours of presentation were included. The primary outcome was the percentage change in SBP from baseline at 12 to 24 hours and 24 to 48 hours. Secondary outcomes included the change in DBP and mean arterial pressure (MAP), time to 3 consecutive goal SBP readings, continuation of home oral antihypertensives, administration of intravenous (IV) antihypertensives, and length of stay (LOS). Patients were stratified by quartile (Q1 through Q4) based on time to first oral antihypertensive. A total of 220 patients were included. A significant difference in SBP was observed among the quartiles, due to the greater sustained SBP reduction in Q1 at 12 to 24 hours and 24 to 48 hours (median [interquartile range, IQR], 22.9% [13.1%-30.5%] and 22.5% [IQR, 15.8%-32.9%] reduction, respectively). There were also reductions in DBP and MAP, with Q1 consistently having larger reductions than Q4. Patients in Q1 had 3 consecutive goal SBP readings earlier than those in the other quartiles (median [IQR], 13.1 [7.0-21.5] hours). Continuation of home medications, number of IV antihypertensives, and LOS did not differ among the quartiles. In this analysis, earlier administration of oral antihypertensives was associated with a larger sustained reduction in SBP.

Hypertension crisis as the first symptom of renovascular hypertension in children

BackgroundRenovascular hypertension (RVH) is one of the main causes of hypertensive crisis (HTN-C). It is characterized by acute onset and severe disease, and early diagnosis and treatment are difficult. The objective was to describe the characteristics of RVH and factors associated with RVH leading to HTN-C in children. At present, there are few clinical studies on RVH in children with large cases in China.MethodsThis study retrospectively analyzed the clinical data of inpatient children with RVH. Patients were divided into non-hypertensive crisis (non-HTN-C) group, and HTN-C group according to the first symptoms and blood pressure. Further, HTN-C were classified as hypertensive urgency (HTN-U) or hypertensive emergency (HTN-E).ResultsFifty-four pediatric cases (41 boys and 13 girls) were included. 83.3% of the RVH cases were ≥ 6 years old. Three cases were classified into the non-HTN-C group. Of the 51 HTN-C cases, 18 cases were grouped as HTN-U and 33 as HTN-E. The HTN-U group were mainly asymptomatic (50.0%, 9/18) while the HTN-E group mainly presented with neurological symptoms (72.7%, 24/33). The number of unknown etiology children was 32 (59.2%). The top three known etiologies were Takayasu’s arteritis (50.0%, 11/22), congenital renal dysplasia (27.3%, 6/22) and fibromuscular dysplasia (13.6%, 3/22). As for the target organ damage of RVH, patients had a higher prevalence of left ventricular hypertrophy (71.4%, 35/49) and retinopathy (77.8%, 21/27).ConclusionsMost RVH patients with HTN-C as the first symptoms, especially for males over 6 years old, should be assessed for RVH even if they were asymptomatic. Most asymptomatic patients with RVH already had target organ damage, and symptomatic patients even developed life-threatening complications. As preventive measures, routine monitoring of BP during children’s physical examinations is advised.

Prevalence of neurological complaints among emergency department patients with severe hypertension

ObjectiveSevere hypertension can accompany neurological symptoms without obvious signs of target organ damage. However, acute cerebrovascular events can also be a cause and consequence of severe hypertension. We therefore use US population-level data to determine prevalence and clinical characteristics of patients with severe hypertension and neurological complaints. MethodsWe used nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected in 2016–2019 to identify adult ED patients with severely elevated blood pressure (BP) defined as systolic BP ≥ 180 mmHg and/or diastolic BP ≥120 mmHg. We used ED reason for visit data fields to define neurological complaints and used diagnosis data fields to define acute target organ damage. We applied survey visit weights to obtain national estimates. ResultsBased on 5083 observations, an estimated 40.4 million patients (95% CI: 37.5–43.0 million) in EDs nationwide from 2016 to 2019 had severe hypertension, equating to 6.1% (95% CI: 5.7–6.5%) of all ED visits. Only 2.8% (95% CI: 2.0–3.9%) of ED patients with severe hypertension were diagnosed with acute cerebrovascular disease; hypertensive urgency was diagnosed in 92.0% (95% CI: 90.3–93.4%). Neurological complaints were frequent in both patients with (75.6%) and without (19.9%) cerebrovascular diagnoses. Hypertensive urgency patients with neurological complaints were more often older, female, had prior stroke/TIA, and had neuroimaging than patients without these complaints. Non-migraine headache and vertigo were the most common neurological complaints recorded. ConclusionIn a nationally representative survey, one-in-sixteen ED patients had severely elevated BP and one-fifth of those patients had neurological complaints.

Cryopreservation Impairs Engraftment in Bone Marrow Transplantation

Introduction: Due to the covid-19 pandemic, a recommendation was made, especially for non-related allogeneic hematopoietic stem cell transplantation (allo-HSCT), to cryopreserve hematopoietic stem cells products and start the conditioning regimen only after the product be received at the receptor service. There are conflicting data on how the procedure of cryopreservation (and thaw) of bone marrow affects outcomes. In this study we evaluated the primary graft failure incidence using cryopreserved bone marrow grafts compared to non-cryopreserved bone marrow grafts. We also evaluated transfusion needs during the first 30 days after transplant and the occurrence of severe adverse events (AEs) related to the product infusion, during covid-19 pandemic in a single Brazilian center. Methods: From January 2020 to 30 June 2022, we retrospectively analyzed clinical and laboratory data from 9 cryopreserved (cryo) (all of them unrelated) and 15 non-cryopreserved (non-cryo) bone marrow grafts (2 of them unrelated), here defined as control group. Haploidentical transplants were excluded due to a higher risk of primary graft failure reported on this type of transplant. Children and adults with malignant and non-malignant disorders were included. We evaluated engraftment, red blood cells (RBC) and platelets (Pl) units transfused during the first 30 days, and adverse effects associated with product infusion. Neutrophil engraftment was defined as the first of 3 consecutive days with absolute neutrophil counts of ≥ 500/µL and primary graft failure was defined as failure to achieve a neutrophil engraftment by day 28 after bone marrow infusion. Results were given as median (range) and comparison between the groups was performed employing the Mann-Whitney U test. Percentages were compared with the chi-square or the Fisher exact test. Results: Only two cryopreserved grafts have not been used (one patient died before the start of the conditioning regimen and the other did not receive the graft yet). Baseline characteristics were similar in both groups. The median (range) age was 21 (1-37) and 20 (6-32) years, with 42.86% and 40% under 18 years of age in the cryo and non-cryo groups, respectively. Also, 85.7% and 53.3% were male, and 14.3% and 13.3% had malignant disease (acute leukemia) in the cryo and non-cryo groups, respectively (Table 1). The numbers of infused total nuclear and CD34+ cells/kg in the cryo and non-cryo groups were not significantly different (p= 0.14, and p= 0.41, respectively) (Table 1). Three (42.8%) patients from the cryo group, all of them children (with osteopetrosis, aplastic anemia, and acute leukemia) did not achieve neutrophil engraftment by day 28, whereas all 15 patients from non-cryo group had hematologic recovery (RR= 4.75, 95% CI: 1.61-11.75; p= 0.02). Furthermore, there was a slight tendency toward delayed neutrophil engraftment in the cryo group: 21.5 (19-23) and 19.0 (15-28) days (p= 0.20). The numbers of RBC and Pl units transfused during the first 30 days after product infusion were higher in the cryo than non-cryo group: RBC 5.0 (3-9) and 1.0 (0-4) (p< 0.0001); Pl 15.0 (7-18) and 5.0 (1-20) (p= 0.0014), respectively (Figure 1). Three patients (42.8%) had severe AEs (seizure, hypertension urgency associated with second-degree atrioventricular block: Mobitz type 1, and acute renal failure) during or right after bone marrow infusion, all of them in the cryo group (relative risk= 4.75, 95% CI: 1.61-8.43, p= 0.02). All of them recovered completely from AE. Conclusions: Transplantation of cryopreserved bone marrow grafts seems to be associated with a higher risk of primary engraftment failure and, consequently, a higher transfusion needs, and with more severe adverse events related to the product infusion. Because of these findings and in spite of the ongoing pandemic, we recommend a careful evaluation of the necessity to adopt this practice. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 14194: Risk Factors of Hypokalemia and Hyperkalemia in Hypertensive Emergency

Introduction: Potassium disorders are common among hypertensive patients. There is a paucity of data on the prevalence and risk factors of dyskalemia in patients with hypertensive emergency. Hypothesis: We sought to investigate the prevalence and risk factors of potassium disorders in patients presenting with hypertensive emergency. Methods: A retrospective, cross-sectional study was employed by retrieving electronic medical records (EMR) of patients with a diagnosis of hypertensive emergency admitted from September 2016–December 2021 under Yale New Haven Health system. Hypertensive emergency patients were identified using the International Classification of Diseases, Tenth Edition (ICD-10) diagnosis. We selected patients who carried the diagnosis code of hypertensive emergency (I16.1) and at least 1 additional diagnosis for concurrent end organ damage (EOD). We manually examined all the electronic medical record (EMR) (n = 2664) to assure the correct establishment of diagnosis and removed 345 patients who are hypertensive urgency misclassified as hypertensive emergency. Hypokalemia is defined as serum potassium &lt;3.5 mg/dL and hyperkalemia is defined as &gt;5.5 mg/dL. Results: Among a total of 2,319 patients included in the study, 1,157(49.9%) were women and 1162(50.1%) were men. The mean age of the patients was 67.3 years. We have941(40.6%) African Americans, , 1048( 45.2%) Caucasian, and the rest of 240 (14.2%) are either Asians or unspecified. Average systolic blood pressure on presentation was 193 mmHg and average diastolic blood pressure was 106 mmHg. 143 (6.2%) patients had hyperkalemia and 260 (11.2%) patients had hypokalemia. After multivariable adjustment, older age, lower serum bicarbonate, elevated serum sodium and elevated serum creatinine were independently associated with hyperkalemia, and younger age, African American, higher serum bicarbonate, lower serum sodium, and lower serum creatinine were independently associated with hypokalemia. Conclusions: We identify a potential clinical phenotype of hypertensive emergency patients who present with potassium disorder. The risk for hypo- and hyperkalemia in hypertensive emergency can be stratified with common laboratory results and socio-demographic variable.

Temporal fluctuations of cardiovascular parameters after intravitreal injections.

Despite the effectiveness of intravitreal injection (IVI) of anti-vascular endothelial growth factor in treating retinal diseases, there remains a paucity of evidence on potential systemic risks associated with this procedure. This study aims to investigate cardiovascular parameters and the risk of hypertensive urgency after IVIs. Patients who received IVIs for retinal/macular diseases were enrolled retrospectively. Patients who received cataract surgeries were enrolled as controls. Systolic and diastolic blood pressure (BP) and heart rate were measured 10 minutes before, immediately after, and more than 30 minutes after IVIs and cataract surgery. Multivariate analysis was performed to evaluate risk factors for hypertensive urgency. Seventy patients who received IVIs and 95 patients who received cataract surgeries were enrolled. A higher preoperative systolic BP was found in the IVI groups than in the control group (147.0 ± 22.9 vs 136.3 ± 21.8 mmHg, respectively). The patients who received IVIs had a higher increase in perioperative systolic BP immediately after the procedure than the controls (17.43 ± 20.53 mmHg vs 9.11 ± 18.92 mmHg, p = 0.009). The IVI procedure (odds ratio [OR] 4.84, p = 0.008), preoperative systolic BP ≥160 mmHg (OR 17.891, p = 0.001, compared to preoperative systolic BP <140 mmHg), and underlying hypertension (OR 3.305, p = 0.041) were risk factors for hypertensive urgency immediately after the IVIs. We found a transient increase in BP after IVIs, which may have been associated with hypertensive urgency and related cardiovascular disorders in older patients and in those with relevant comorbidities. Clinicians should pay more attention to these patients before performing IVIs.

PMON270 Coexistence of 46, XX Testicular Disorder of Sex Development and 11β-Hydroxylase Deficiency: In Vivo and In Vitro Studies

Abstract Background 46, XX testicular disorder of sex development and 11β-hydroxylase deficiency (11β-OHD) are two extremely rare types of disorder of sex development (DSD). No coexistence has been reported yet. Clinical Case A 22-year-old male showed small testes (volume=4ml) and gynecomastia for 2 years. At the age of 3.5, he was diagnosed as simple virilizing type of 21-hydroxylase deficiency (21-OHD) for the manifestations of the enlarged penis (length=7.5cm), hyperpigmentation, and normal blood pressure. Adrenal ultrasound suggested bilateral adrenal hyperplasia (both length * width = 2.4*0.9cm) and X-ray showed accelerated bone age (12.5 years old). Irregular cortisone acetate 6.25mg per day was administrated since then. At the age of 18, he was sent to emergency for aortic aneurysm rupture and heart failure, and hypertension urgency was diagnosed. Sanger sequencing revealed that he carried compound heterozygous variants in CYP11B1 gene: NM_000497.3: c.905_907delinsTT and NM_000497.3: c.954+7C&amp;gt;T, which were respectively inherited from his father and mother. Pathogenesis of the novel intron variant (c.954+7C&amp;gt;T) was further verified in COS7, CHO, and 273T cell lines by transfecting wild-type and mutant-type minigene, extracting RNA of cells, reversing RNA into cDNA, PCR, and Sanger sequencing. The result showed that the c.954+7C&amp;gt;T variant introduced a cryptic donor splice site at a site 5 bp downstream of the 3' natural splice donor site of exon 5. The level of adrenal steroids detected by liquid chromatography-tandem mass spectrometry (LC-MS/MS) was consistent with the characteristics of 11β-OHD. The patient was treated by neoplasty of thoracic aortic aneurysm and added anti-hypertension drugs in addition to glucocorticoid after surgery. Unexpectedly, the abnormalities of male characteristics including small testes and gynecomastia appeared since adolescence. Laboratory tests showed an elevated level of FSH and LH and azoospermia. Scrotum Ultrasound showed bilateral testicular dysplasia (right: 1.9*1.4*0.8cm, left: 1.9*1.3*0.8cm). To figure out the unexplainable results, whole-exome sequencing was performed and revealed two copy number variants: the duplication of Xp22.33-q28 which spans 151.32Mb, and the deletion of Yp11.2-q11.23 which spans 23.34Mb. Meanwhile, the karyotype test by culturing blood lymphocytes showed 46, XX (100/100), which confirmed the diagnosis of 46, XX testicular DSD. Fluorescence in situ hybridization (FISH) revealed the presence of the SRY gene, which is translocated into the short arm of the X chromosome. Testosterone replacement is unnecessary for the normal level of testosterone (T) (4.44ng/ml, N: 1.75-7.81ng/ml), which is the result of the combined action of 11β-OHD with adrenal T accumulation and 46, XX testicular DSD with testicular T deficiency. Assisted reproduction consulting should start early. Conclusion This is the first case demonstrating the possibility of coexistence of 46, XX testicular DSD and 11β-OHD and hinting at the significance of a combination of clinical and molecular diagnostic methods. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

ODP061 When cortisol and catecholamines combine in a severe endocrine condition

Abstract Introduction While the majority of ACTH dependent Cushing's Syndrome cases are the result of over secretion of ACTH from the pituitary gland, ectopic ACTH production can occur. Pheochromocytoma, a tumor originating from the adrenal chromaffin cells and classically associated with catecholamine excess, has also been very rarely shown to secrete ACTH. A 54 year old male with a history of obesity, type 2 diabetes, and resistant HTN presented to ED with a tonic clonic seizure, hypoxia and altered mental status. Labs were notable for thrombocytopenia and hypokalemia. His thrombocytopenia was treated with IVIG and solumedrol. Renin activity and renal doppler were normal. He was discharged on additional blood pressure medication, antipsychotics and Keppra. After 2 weeks he was readmitted with hypertensive urgency, anemia and worsening thrombocytopenia. Bone marrow biopsy did not elucidate the etiology of thrombocytopenia. CT abdomen showed a 5.4 cm, 54 Hounsfield unit, right adrenal mass. MRI brain showed no intracranial pathology. MRI abdomen/pelvis showed bilateral adrenal thickening. The right adrenal mass had characteristics of hematoma as well. Additional labs showed urine metanephrines 1412mcg/24Hr and normetanephrines 978mcg/24Hr, Urine free cortisol was 4494 mcg/24h, random serum cortisol was 207mg/dl, and ACTH was 1091 pg/ml. Dexamethasone suppression test cortisol was 151 ug/dL. Interesting the patient lacked cushingoid phenotypical characteristicsexcept for truncal obesity. The patient was placed on doxazosin for alpha blockadeand etomidate drip to control cortisol. The diagnosis of ACTH secreting pheochromocytoma was reaffirmed after both octreoscan and dotatate PET CT showed the presence of somatostatin receptors in the rightadrenal mass. After 14 days with controlling treatment, the patient underwent successful right adrenalectomy. Pathology was notable for a well circumscribed dark brown mass that had replaced the adrenal medulla that stained patchy positive for ACTH and was positive for synaptophysin and chromogranin. Post surgical labs demonstrated cortisol of 26.3ug/dLand ACTH of 7pg/ml. The patient was discharged 14 days after surgery. Discussion and conclusion Pheochromocytomas are rare tumors for which classical features are often absent. Symptoms of palpitations, headache and sweating are only present in 17% of patients. ACTH secreting pheochromocytomas represent 5% of ectopic ACTH syndrome with less than 100 documented cases worldwide. While obesity, hypertension and diabetes are common in our society, this patient's rapid clinical deterioration was the key clue to this rare diagnosis. This case highlights how the decisive actions of a well-coordinated, multidisciplinary team can result in a good outcome for a very challenging and critically ill patient. Presentation: No date and time listed

Non-adherence to antihypertensive medications in Lebanese adults hospitalized for hypertensive urgency and its cost

BackgroundDrug non-adherence is assumed to play an important role in development of hypertensive urgency, which is a common health problem resulting in frequent emergency department admissions and thus increased healthcare spending wastage. The objective of this study is to assess the rate of non-adherence to antihypertensives and to evaluate influencing factors predicting this behavior in Lebanese hypertensive adults. In addition, this study aim to estimate the cost of hospitalization for hypertensive urgency covered by the Ministry of Public Health in patients’ non-adherent to their antihypertensives.MethodsA multi-methods approach is used comprising a cross-sectional study, additionally to an observational, retrospective, cost of illness study. A cross-sectional questionnaire based study is conducted from May to Dec, 2019 to address the study objective. Using the Ministry of Public Health hospitalization data during 2019, the cost of hospitalization for hypertensive urgency is assessed. Multivariable analysis is performed to calculate the adjusted odd ratios by fitting a logistic regression model.ResultsThe cross-sectional study includes 494 participants and shows that 43.0% of patients hospitalized and covered by the Ministry of Public Health are non-adherent. The univariate regression model shows that adherence to antihypertensive medications is significantly associated with age (p-value = 0.005) and follow-up visits (p-value = 0.046). The odds of adherence for participants earning more than USD 2000 was 3.27 times that for those who earn less than USD 1000 (p = 0.026). The estimated cost of hospitalization for non-adherent patients is USD 452,353 in 2019.ConclusionNon-adherence associated hospitalization costs represents a financial burden to Lebanese health system.

LBSAT63 Cushing Syndrome As A Presentation Of Adrenocortical Carcinoma.Case Report

Abstract Introduction adrenocortical carcinoma is a rare endocrine malignancy (1) Case: 44 year old afro American female with no past medical history. No regular medications. Amenorrhea for 2 years. smokes cigarettes. Irrelevant family history. She presented with itchiness after cat scratch and was found to have hypertension urgency 229/123. Review of systems was positive for weight gain and easy bruises. Physical examination alert and oriented with body mass index of 31 kg/m2 heart rate 75 beats per minute normal heart sounds and clear lungs with scratch marks on left hand. bilateral lower extremities pitting edema, supraclavicular fat pad and violet abdominal striae. No facial plethora or hirsutism or lymphadenopathy or acne. Laboratory work up was remarkable for hypokalemia and metabolic alkalosis. High plasma morning cortisol level 53.6ug/dl normal between 6.2 and 29, 24hour urine cortisol and DHEAS and low ACTH FSH and LH. Estradiol 261pg/ml 17hydroxyprogesterone 49ng/dl and prolactin 31.7ng/ml. HBA1C 6.7. Normal renin aldosterone TSH and plasma and 24hour metanephrine and normetanephrine. Normal creatinine liver function and complete blood count. CT abdomen and pelvis with contrast showed large lobular heterogeneously enhancing mass in the left adrenal gland of 9. 0×10.1×10.1cm with left kidney posterior displacement and left renal vein compression. The pancreatic tail and splenic vein were draped over the mass. The right adrenal gland and other abdominal organs were unremarkable. DEXA scan showed osteopenia. CT chest showed 5mm right lower lobe nodule and compression fracture in the 7th thoracic vertebrae. Echocardiogram showed dilated left ventricle dimension with reduced ejection fraction 45%. The diagnosis was made for ACTH independent Cushing syndrome with adrenal mass. She underwent open left adrenalectomy distal pancreatectomy splenectomy and left nephrectomy in another institution. Histopathology showed 12×7.5×7 cm stage III adrenal cortical malignancy T3N0M0. Extensive necrosis and capsular invasion but negative surgical margins. Possibility of lung metastasis. Postoperative cortisol level 6. 02ug/dl. She was kept on postoperative slow tapering hydrocortisone with plan of chemotherapy and Mitotane. Conclusion adrenocortical carcinoma has a poor prognosis. It usually metastasizes to distant organs at time of diagnosis and rarely presents as Cushing syndrome. Surgical resection is the main management of localized tumors with controlling the effects of secreted hormones. Adjuvant therapies are chemotherapy radiotherapy and Mitotane according to the tumor stage and size. Mitotane is adrenal cytotoxic agent showed increase survival of advanced stages(1).

ODP271 Primary Aldosteronism and Primary Hyperparathyroidism: A Report of Dual Endocrine Hypertension

Abstract Background Primary aldosteronism (PA) is one of the common causes of secondary hypertension. Primary hyperparathyroidism (PHPT) is a less common etiology of secondary hypertension. The concomitance of both PA and PHPT is very rare, with a possible bilateral positive feedback loop between the adrenal cortex and the parathyroid gland[1]. Clinical case: A 64-year-old female was referred to the endocrine clinic for secondary hypertension assessment. She was diagnosed with hypertension 30 years earlier, poorly controlled on three antihypertensive medications, nifedipine 90 mg daily, lisinopril 40 mg daily, and atenolol 50 mg daily. She started experiencing muscle cramps two years prior to the referral and was found to be hypokalemic on multiple occasions, with potassium ranging between 2.5 to 3 mmol/L. She also had multiple admissions to the emergency department for hypertensive urgencies within the last year. Family history was positive for poorly controlled hypertension in the patient's mother. Physical examination showed class I obesity with a BMI of 31, but otherwise unremarkable. Workup showed elevated aldosterone concentration of 38 ng/dl and suppressed renin concentration (&amp;lt;1 pg/ml) with an aldosterone/renin ratio of 38. Overnight dexamethasone suppression test was normal (cortisol of 1.5 mcg/dl, suppressed ACTH of 5.5 pg/ml, and appropriately elevated dexamethasone of 324 ng/dl). 24-hour urine metanephrine and normetanephrine levels were normal. Imaging showed bilateral adrenal adenomas of about 13-14 mm in widest diameter, with an average density of 10 Hounsfield units. Adrenal venous sampling revealed hyperfunctioning left adrenal with normal right adrenal. The left adrenal gland was removed laparoscopically, and blood pressure normalized postoperatively on the single antihypertensive agent (lisinopril). Interestingly, during the initial workup, the patient also had elevated calcium of 11 mg/dl and low phosphate at 2.5 mg/dl. In addition, parathyroid hormone (PTH) was elevated at 103 and 95 pg/ml on two occasions, with normal 25-OH vitamin D levels. 24-hoururine calcium was 240mg/dl, and creatinine in urine was 76.4 mg/dl. The calcium creatinine clearance ratio was 2.5%. Diagnosis of primary hyperparathyroidism was made. She had no renal stone, chronic kidney disease, or fractures, with a normal DEXA scan. There was no current indication for parathyroidectomy, and the patient continued to be followed up in the clinic. Clinical lesson: Recent evidence shows cross-talk between the adrenal cortex and parathyroid gland. Our patient may represent such a case, with concomitance of two rare endocrinopathies resulting in difficult-to-control hypertension [1,2]. Thus it is essential to investigate multiple etiologies of secondary hypertension. Reference: Brown JM, Vaidya A. Interactions between adrenal-regulatory and calcium-regulatory hormones in human health. Curr Opin Endocrinol Diabetes Obes . 2014;21(3): 193-201. doi: 10.1097/MED. 0000000000000062 Maniero C, Fassina A, Guzzardo V, et al. Primary hyperparathyroidism with concurrent primary aldosteronism. Hypertension. 2011 Sep;58(3): 341-6. doi: 10.1161/HYPERTENSIONAHA.111.173948. Epub 2011 Aug 8. PMID: 21825220. Presentation: No date and time listed

Treatment of Hypertensive Urgencies

Hypertensive urgency can be expressed as a systolic blood pressure of at least 180 mmHg and/or diastolic blood pressure of at least 110 mmHg, without correlated end-organ damage. Elevated blood pressure causes endothelial injury by elevating the endothelial permeability and local activation of the clotting cascade (platelet and fibrin deposition), resulting in fibrinoid necrosis and intimal proliferation. In hypertensive urgencies, blood pressure should be lowered over a period of hrs to days with slower reductions in elderly patients to avoid and elevated risk of cerebral or myocardial ischemia resulting from excessively rapid reduction of blood pressure. Captopril is an angiotensin-converting enzyme inhibitor. Captopril administration is well tolerated and known to be able in decreasing blood pressure in hypertensive urgencies. Its hypotensive effect, when it is taken orally, is evident within 15 to 30 minutes.

“CLINICAL PRESENTATION OF HYPERTENSIVE EMERGENCY AND URGENCY PATIENTS”

Arterial hypertension affects approximately a billion people worldwide and approximately 30 % of them remain undiagnosed.1% - 2% of known hypertensive patients will have hypertensive emergency at some time in their life Though hypertensive crisis contributes one fourth of all emergency visits and trend is increasing in last few years still there is lack of data over the actual incidence of hypertensive crisis The present study aims to know the incidence and clinical presentation of the hypertensive crisis ( hypertensive emergency and urgency ) in a tertiary hospital and will help us to know the incidence and pattern of clinical presentation with respect to different aspects. Methods; This is a prospective observational study of 100 cases of hypertensive crisis (hypertensive emergency and hypertensive urgency) presenting to the emergency department. Study conduct during 2016 to 2018. Results; The incidence of hypertensive crisis was found to be 20%.Most of the patients were belonged to the 5th and 6th decades of life and Male patients were more than female patients Majority of the patients were known hypertensives for 6 to 10 years and 22% of the known hypertensive patients has discontinued their anti hypertensive medications Cardiovascular symptoms in the form of dyspnoea &amp; chest pain were the most common accompanying symptoms Acute coronary syndrome was the most common clinical manifestation followed by neurological decit. Conclusion; As the trend of hypertensive crisis is increasing efforts should be made to reduce the occurrence of hypertension Preventive measures should be taken in the form of community education for dietary modication and routine exercise Routine blood pressure check ups compliance to the anti hypertensive treatment and control of associated comorbidities is essential to reduce the risk of hypertensive crisis.