Initial Systolic Blood Pressure Research Articles

Development and Worsening of Hypertension with Age in Male Wistar Rats as a Physiological Model of Age-Related Hypertension: Correction of Hypertension with Taxifolin

To preclinically study the effectiveness of new antihypertensive drugs, various animal hypertension models are used. However, most of them do not correspond to primary hypertension, which develops in people with age. We used male Wistar rats of 4, 10, 12 and 18 months old. The animals were divided according to systolic blood pressure (SBP) into normotensive (SBP ≤ 114 mmHg) or hypertensive (SBP ≥ 115 mmHg). Within hypertensive animals, two cohorts were distinguished—with SBP below and above 125 mmHg. The animals received 100 µg/kg of taxifolin intraperitoneally for 7 days. A significant difference was shown between animals with SBP above and below 115 mmHg, as well as between cohorts of hypertensive animals with SBP above and below 125 mmHg within each age. The number of animals with elevated SBP increased with age both for clusters with an SBP above 115 mmHg and for cohorts with an SBP above 125 mmHg. Administration of taxifolin led to a significant decrease in the SBP only in hypertensive animals. A physiological model of age-related hypertension was obtained in male Wistar rats. It has been shown that hypertension develops and worsens with age. In preclinical studies, it should be taken into account that drugs may have different effects depending on the initial SBP of the animals.

The polk county screening tool screening for detecting subarachnoid hemorrhage

IntroductionThe subarachnoid space in the brain contains crucial blood vessels and cerebrospinal fluid. Aneurysms in these vessels can lead to subarachnoid hemorrhage (SAH), a serious stroke subtype with high morbidity and mortality rates. SAH treatment includes procedures like coiling and clipping, but these are available only at comprehensive stroke centers (CSCs), necessitating urgent diagnosis and transfer to specialized facilities.MethodsThis IRB-approved study was conducted by Polk County Fire Rescue (PCFR) in Florida. PCFR, serving an 850,000-person population, implemented a three-step SAH protocol. The protocol uses both Ottawa SAH criteria and recurring symptoms, such as new-onset seizures and high systolic blood pressure, that were identified by EMS. Acute management included administering labetalol, levetiracetam, and ondansetron.ResultsOf 2175 stroke patients, 80 screened positive for SAH and were eligible for transfer. Patients had a median age of 66, and 33% had an initial systolic BP over 220 mmHg. The interfacility transfer rate dropped from 12.9 to 3.6% after implementing the protocol.ConclusionThe PCFR protocol’s effectiveness suggests its potential for nationwide implementation. Early SAH recognition and prompt transfer to CSCs reduce complications and improve outcomes. Accurate field diagnosis by EMTs can prevent unnecessary transfers and enhance patient care. Future improvements may include portable diagnostic tools and enhanced EMT training to further improve SAH patients’ pre-hospital care.

Post‐intubation hypotension risk factors in patients with COVID‐19 undergoing endotracheal intubation in the emergency department: A prospective observational study

AbstractIntroductionAcute respiratory distress syndrome, a severe manifestation of COVID‐19, prompts the critical intervention of endotracheal intubation (ETI). However, ETI is associated with complications, notably post‐intubation hypotension (PIH), linked to an increased adverse prognosis. Our purpose was to investigate risk factors for PIH in COVID‐19 patients in the emergency department (ED).MethodsThis observational study was conducted at the Afzalipour Hospital, Iran. Adult COVID‐19 patients undergoing ETI were included, with data collected on demographic variables, medical history, and hemodynamic parameters. PIH was defined as the occurrence of any of the following: reduction of systolic blood pressure (SBP) to 90 mmHg or less; reduction of mean arterial pressure (MAP) to 65 mmHg or less; reduction of SBP by at least 20% of the initial value; or the need for vasopressor support during the 30 min after intubation.ResultsAmong 145 patients, the mortality rate was 82.7%, and PIH occured in 22.7%. Univariate analysis revealed associations between PIH and initial SBP (SBP‐0) and initial MAP. Multivariable regression revealed that each 1 mmHg decrease in SBP‐0 increased the risk of PIH by 5%. Patients with SBP‐0 of less than 116 mmHg had a PIH odds ratio of 4.1. A history of hypertension (HTN) or ischemic heart disease (IHD) increased the likelihood of PIH sixfold. The receiver operating characteristic curves for SBP‐0 had an area under the curve (AUC) of 0.67 (95% CI: 0.54–0.79), lower than the AUC of 0.77 (95% CI: 0.64–0.86) for the model incorporating SBP‐0, history of HTN or IHD, and total severity score. Despite this, the Z score comparing the AUCs of SBP‐0 and the multivariable model did not indicate a statistically significant difference.ConclusionsHistory of HTN or IHD, as well as low SBP‐0, are independently associated with an increased risk of PIH in COVID‐19 patients.

Abstract P328: Regression to the Mean: Do confirmatory measurements influence the effect?

Background: Regression to the mean (RTM) in blood pressure (BP) is a well-established phenomenon wherein a group of individuals selected for high or low BP values will regress toward mean values over time. The influence of confirmatory measurements (CM) of BP, a metric captured within the AMA MAP™ Hypertension (HTN) program, has not been studied within large populations of patients in usual care settings. We compared consecutive outpatient systolic blood pressure (SBP) readings of adults with HTN to further characterize the influence of CM on RTM. Methods: A patient cohort (N= 197,819) comprised of adults with previously diagnosed HTN from 6 diverse healthcare organizations engaged in the AMA’s quality improvement program, was identified for analysis. Outpatient visits with no treatment adjustments, and with a subsequent outpatient visit at participating sites, were evaluated for change in SBP. Each SBP was identified as having derived from a repeat measurement (confirmatory) or a single reading. The analysis was restricted to paired observations of sequential visit BPs with the same measurement method, CM or single. Linear regression was used to evaluate SBP change, controlling for organization, race, sex, age, initial visit SBP, and days between visits, stratified by measurement type. Results: A cohort of 197,819 patients with HTN was identified, mean age of 62.2 ± 13.9, initial SBP 131.3 ± 15.2 mmHg. The figure shows the median and interquartile range for change in SBP by 10 mmHg increments of initial SBP, stratified by CM presence. Regression modeling demonstrated that RTM, measured as mmHg fall/mmHg initial, was statistically significantly lower with CM (0.55, 95% CI [0.54 – 0.56]) vs. without (0.59, 95% CI [0.58 – 0.59]). This difference translates to a roughly 5 mmHg decreased effect in RTM for visit pairings with an initial SBP of 140 mmHg. Conclusion: RTM remains a powerful influence on follow-up SBP, which complicates assessment of response to antihypertensive interventions. Confirmatory BP measurements reduce RTM and may improve assessment of the patient’s true BP and responses to clinical interventions.

Lung ultrasonography underdiagnoses clinically significant pneumothorax

BackgroundUltrasonography for trauma is an integral part of the Advanced Trauma Life Support algorithm and supported extensively in the literature. The reliability of chest ultrasonography as a screening examination for pneumothorax during initial trauma evaluation is unclear. We performed a prospective study where we hypothesized that chest ultrasonography would have low sensitivity for detecting clinically significant pneumothorax. MethodsA prospective observational analysis of patients with blunt chest trauma at a level 1 trauma center was performed. Patients included had supine chest radiography and chest ultrasonography performed prior to intervention as well as confirmatory computed tomographic imaging. All chest ultrasonography was performed in the trauma bay by a registered sonographer. All imaging was evaluated by an attending trauma surgeon and radiologist in real time. ResultsOf 2,185 patients screened with a diagnosis of blunt thoracic trauma, 1,489 patients had chest radiography, chest ultrasonography, and confirmatory computed tomography and were included for analysis. Patients were 71% male, with median age of 42 years, and mean Injury Severity Score of 6. The sensitivity of chest ultrasonography to detect pneumothorax was low. Chest ultrasonography had a false negative rate of 72% (n = 58), with 22% (n = 13) undergoing tube thoracostomy. Patients with false negative examinations had lower initial O2 saturation and systolic blood pressure and were more likely to have rib fractures compared with true negative chest ultrasonography examinations. ConclusionChest ultrasonography performed on initial trauma evaluation has low sensitivity with a high rate of false negative examinations. Because many of these false negative results are clinically significant requiring thoracostomy, using chest ultrasonography alone to screen for pneumothorax should be done with caution.

Prediction of vasopressor needs in hypotensive emergency department patients using serial arterial blood pressure data with deep learning

AbstractBackgroundShock is a life‐threatening condition that is associated with high mortality and morbidity. Therefore, the timely identification and management of this condition are important. We aimed to develop a prediction model for vasopressor use based on concise serial arterial blood pressure data.MethodsWe collected continuous arterial blood pressure from patients admitted to the emergency department (ED) resuscitation room. Patients with an initial systolic blood pressure lower than 90 mmHg were included in the study. We developed prediction models using convolutional neural networks (CNNs) and long short‐term memory (LSTM) networks. Discrimination performance was assessed using the area under the receiver operating characteristic curve (AUROC) and the area under the precision–recall curve (AUPRC).ResultsA total of 120 patients were enrolled in the study. The CNN and LSTM models yielded AUROCs ranging from 0.731 to 0.834 for predicting the need for vasopressor infusion within different time frames (30 min, 1 h, and 6 h). LSTM outperformed the CNN in terms of predicting vasopressor infusion within 30 min and 1 h (p value < 0.05). The AUPRC values ranged from 0.200 to 0.252, and sensitivity–specificity analyses indicated that the models have potential for clinical applications.ConclusionThis study used serial arterial blood pressure data to construct a promising prediction model for the need for vasopressors in hypotensive ED patients. The simplicity and accuracy of the model provide valuable insights for developing a clinical decision support tool for resuscitation in emergency settings.

Trauma team activation for older patients with pelvic fractures: Are current criteria adequate?

The present study aimed to identify the impact of age on current trauma team activation (TTA) processes and outcomes for patients with pelvic fractures. Adult patients with moderate and/or severe pelvic fractures (Abbreviated Injury Scale ≥ 2) between 1 January 2016 and 31 December 2021 were included utilising major trauma hospital data in Queensland. Characteristics of older (age ≥ 65) and younger patients including TTA, interventions and outcomes were examined. Multivariate analysis was used to determine factors associated with TTA in older patients. Data from 637 patients was included. Despite comparable injury severity, a TTA was activated in fewer older people (older: 65% vs. younger: 79%, P < 0.001). Older patients had more falls leading to the trauma presentation (54.4% vs. 22.6%, P < 0.001), with higher initial systolic BP (131 vs. 125 mmHg, P = 0.04). Outcomes were worse for older people, with greater rates of in-hospital complications (27.2% vs. 16.4%, P = 0.004), and longer hospital stays (12 vs. 8 days, P = 0.04). Fewer older patients could be discharged independently to home (46.3% vs. 74.5%, P < 0.001). In older patients, falls and haemodynamic parameters were strongly associated with the reduced likelihood of TTA (fall mechanism [odds ratio (OR)] 0.33; 95% confidence interval [CI] 0.15-0.74; P = 0.01; systolic BP [OR 0.98; 95% CI 0.97-0.99; P = 0.03], heart rate [OR 0.97; 95% CI 0.95-0.99; P = 0.02]). Current TTA criteria based on higher energy mechanisms and traditional vital sign thresholds are inadequate for identifying injury in older patients. Sensitive triage criteria and increased clinician awareness are required to enhance injury recognition and improve outcomes in older trauma patients.

Effect of low blood pressure on prognosis of acute heart failure

Low blood pressure (BP) is associated with poor outcomes in patients with heart failure (HF). We investigated the influence of initial BP on the prognosis of HF patients at admission, and prescribing patterns of HF medications, such as angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), and beta-blockers (BB). Data were sourced from a multicentre cohort of patients admitted for acute HF. Patients were grouped into heart failure reduced ejection fraction (HFrEF) and HF mildly reduced/preserved ejection fraction (HFmrEF/HFpEF) groups. Initial systolic and diastolic BPs were categorized into specific ranges. Among 2778 patients, those with HFrEF were prescribed ACEi, ARB, or BB at discharge, regardless of their initial BP. However, medication use in HFmrEF/HFpEF patients tended to decrease as BP decreased. Lower initial BP in HFrEF patients correlated with an increased incidence of all-cause death and composite clinical events, including HF readmission or all-cause death. However, no significant differences in clinical outcomes were observed in HFmrEF/HFpEF patients according to BP. Initial systolic (< 120 mmHg) and diastolic (< 80 mmHg) BPs were independently associated with a 1.81-fold (odds ratio [OR] 1.81, 95% confidence interval [CI] 1.349–2.417, p < 0.001) and 2.24-fold (OR 2.24, 95% CI 1.645–3.053, p < 0.001) increased risk of long-term mortality in HFrEF patients, respectively. In conclusion, low initial BP in HFrEF patients correlated with adverse clinical outcomes, and BP < 120/80 mmHg independently increased mortality. However, this relationship was not observed in HFmrEF/HFpEF patients.

Need for Blood Transfusion Volume Is Associated With Increased Mortality in Severe Traumatic Brain Injury

IntroductionMany patients suffering from isolated severe traumatic brain injury (sTBI) receive blood transfusion on hospital arrival due to hypotension. We hypothesized that increasing blood transfusions in isolated sTBI patients would be associated with an increase in mortality. MethodsWe performed a trauma quality improvement program (TQIP) (2017-2019) and single-center (2013-2021) database review filtering for patients with isolated sTBI (Abbreviated Injury Scale head ≥3 and all other areas ≤2). Age, initial Glasgow Coma Score (GCS), Injury Severity Score (ISS), initial systolic blood pressure (SBP), mechanism (blunt/penetrating), packed red blood cells (pRBCs) and fresh frozen plasma (FFP) transfusion volume (units) within the first 4 h, FFP/pRBC ratio (4h), and in-hospital mortality were obtained from the TQIP Public User Files. ResultsIn the TQIP database, 9257 patients had isolated sTBI and received pRBC transfusion within the first 4 h. The mortality rate within this group was 47.3%. The increase in mortality associated with the first unit of pRBCs was 20%, then increasing approximately 4% per unit transfused to a maximum mortality of 74% for 11 or more units. When adjusted for age, initial GCS, ISS, initial SBP, and mechanism, pRBC volume (1.09 [1.08-1.10], FFP volume (1.08 [1.07-1.09]), and FFP/pRBC ratio (1.18 [1.08-1.28]) were associated with in-hospital mortality. Our single-center study yielded 138 patients with isolated sTBI who received pRBC transfusion. These patients experienced a 60.1% in-hospital mortality rate. Logistic regression corrected for age, initial GCS, ISS, initial SBP, and mechanism demonstrated no significant association between pRBC transfusion volume (1.14 [0.81-1.61]), FFP transfusion volume (1.29 [0.91-1.82]), or FFP/pRBC ratio (6.42 [0.25-164.89]) and in-hospital mortality. ConclusionsPatients suffering from isolated sTBI have a higher rate of mortality with increasing amount of pRBC or FFP transfusion within the first 4 h of arrival.

Very early vs delayed invasive strategy in high-risk NSTEMI patients without hemodynamic instability: Insight from the KAMIR-NIH

Background High-risk non-ST-elevation myocardial infarction (NSTEMI) patients’ optimal timing for percutaneous coronary intervention (PCI) is debated despite the recommendation for early invasive revascularization. This study aimed to compare outcomes of NSTEMI patients without hemodynamic instability undergoing very early invasive strategy (VEIS, ≤ 12 hours) versus delayed invasive strategy (DIS, &gt;12 hours). Methods Excluding urgent indications for PCI including initial systolic blood pressure under 90 mmHg, ventricular arrhythmia, or Killip class IV, 4,733 NSTEMI patients were recruited from the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH). Patients were divided into low and high- global registry of acute coronary events risk score risk score (GRS) groups based on 140. Both groups were then categorized into VEIS and DIS. Clinical outcomes, including all-cause death (ACD), cardiac death (CD), recurrent MI, and cerebrovascular accident at 12 months, were evaluated. Results Among 4,733 NSTEMI patients, 62% had low GRS, and 38% had high GRS. The proportions of VEIS and DIS were 43% vs. 57% in the low GRS group and 47% vs. 53% in the high GRS group. In the low GRS group, VEIS and DIS demonstrated similar outcomes; however, in the high GRS group, VEIS exhibited worse ACD outcomes compared to DIS (HR = 1.46, P = 0.003). The adverse effect of VEIS was consistent with propensity score matched analysis (HR = 1.34, P = 0.042). Conclusion VEIS yielded worse outcomes than DIS in high-risk NSTEMI patients without hemodynamic instability in real-world practice.

Effects of Achieving Rapid, Intensive, and Sustained Blood Pressure Reduction in Intracerebral Hemorrhage Expansion and Functional Outcome.

The time taken to achieve blood pressure (BP) control could be pivotal in the benefits of reducing BP in acute intracerebral hemorrhage (ICH). We aimed to assess the relationship between the rapid achievement and sustained maintenance of an intensive systolic BP (SBP) target with radiologic, clinical, and functional outcomes. Rapid, Intensive, and Sustained BP lowering in Acute ICH (RAINS) was a multicenter, prospective, observational cohort study of adult patients with ICH <6 hours and SBP ≥150 mm Hg at 4 Comprehensive Stroke Centers during a 4.5-year period. Patients underwent baseline and 24-hour CT scans and 24-hour noninvasive BP monitoring. BP was managed under a rapid (target achievement ≤60 minutes), intensive (target SBP <140 mm Hg), and sustained (target stability for 24 hours) BP protocol. SBP target achievement ≤60 minutes and 24-hour SBP variability were recorded. Outcomes included hematoma expansion (>6 mL or >33%) at 24 hours (primary outcome), early neurologic deterioration (END, 24-hour increase in NIH Stroke Scale score ≥4), and 90-day ordinal modified Rankin scale (mRS) score. Analyses were adjusted by age, sex, anticoagulation, onset-to-imaging time, ICH volume, and intraventricular extension. We included 312 patients (mean age 70.2 ± 13.3 years, 202 [64.7%] male). Hematoma expansion occurred in 70/274 (25.6%) patients, END in 58/291 (19.9%), and the median 90-day mRS score was 4 (interquartile range, 2-5). SBP target achievement ≤60 minutes (178/312 [57.1%]) associated with a lower risk of hematoma expansion (adjusted odds ratio [aOR] 0.43, 95% confidence interval [CI] 0.23-0.77), lower END rate (aOR 0.43, 95% CI 0.23-0.80), and lower 90-day mRS scores (aOR 0.48, 95% CI 0.32-0.74). The mean 24-hour SBP variability was 21.0 ± 7.6 mm Hg. Higher 24-hour SBP variability was not related to expansion (aOR 0.99, 95% CI 0.95-1.04) but associated with higher END rate (aOR 1.15, 95% CI 1.09-1.21) and 90-day mRS scores (aOR 1.06, 95% CI 1.04-1.10). Among patients with acute ICH, achieving an intensive SBP target within 60 minutes was associated with lower hematoma expansion risk. Rapid SBP reduction and stable sustention within 24 hours were related to improved clinical and functional outcomes. These findings warrant the design of randomized clinical trials examining the impact of effectively achieving rapid, intensive, and sustained BP control on hematoma expansion. This study provides Class III evidence that in adults with spontaneous ICH and initial SBP ≥150 mm Hg, lowering SBP to <140 mm Hg within the first hour and maintaining this for 24 hours is associated with decreased hematoma expansion.

Risk Factors for Invasive Candidiasis in Critically Ill Patients Who Underwent Emergency Gastrointestinal Surgery for Complicated Intra-Abdominal Infection.

Background: Candida species account for approximately 15% of hospital-associated infections, causing fatal consequences, especially in critically ill patients. This study aimed to evaluate invasive candidiasis (IC) risk factors in critically ill patients undergoing surgery. Patients and Methods: We retrospectively reviewed the medical records of 583 patients who underwent emergency surgery for complicated intra-abdominal infections between January 2016 and December 2021. Patients were divided into two groups according to the presence or absence of IC during their hospital stay. IC was defined as culture-proven candidemia and intra-abdominal candidiasis. Results: This study included 373 patients for the final analysis, of whom 320 were discharged without IC (IC absent group) and 53 presented with IC (IC present group) during their hospital stay. The IC present group showed a higher in-hospital mortality rate (35.8 vs. 8.8%; p < 0.001), with 66.0% of the patients diagnosed within 10 days, whereas only 6.5% were diagnosed beyond 20 days after admission. Stomach (odds ratio [OR], 4.188; 95% confidence interval [CI], 1.204-14.561; p = 0.024) and duodenum (OR, 7.595; 95% CI, 1.934-29.832; p = 0.004) as infection origin, higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score (OR, 1.097; 95% CI, 1.044-1.152; p < 0.001), and lower initial systolic blood pressure (OR, 0.983; 95% CI, 0.968-0.997; p = 0.018) were risk factors of IC after emergency gastrointestinal surgery. Conclusions: Patients who had stomach and duodenum as infection origin, higher APACHE II scores, and lower initial systolic blood pressure had a higher risk of developing IC during their hospital stay after emergency gastrointestinal surgery. Prophylactic antifungal agents can be carefully considered for critically ill patients with these features.

Serum lactate normalization time associated with prolonged postoperative ileus after surgical management of the small bowel and/or mesenteric injuries

Back ground: Determining the optimal timing of postoperative oral feeding in trauma patients who have undergone abdominal surgery with small bowel and/or mesenteric injuries is challenging. The aim of this study is to investigate serum lactate as a factor that can predict oral feeding tolerance and prolonged postoperative ileus (PPOI) in patients who underwent surgery for small bowel and/or mesenteric injury due to trauma.Methods: The single center retrospective observational study was conducted on 367 patients who underwent surgery for small bowel and/or mesenteric injury between January 2013 and July 2021. The patient group was divided into two groups based on whether the peak serum lactate was over 2mmol/L (18 mg/dL). In the group of lactate > 2mmol/L, it was divided into prolonged postoperative ileus (PPOI) groups and groups rather than PPOI.Results: Patients in the peak serum lactate > 2 group had tendency to use vasopressors, lower initial systolic blood pressure, larger number of packed red blood cells for 24 h, higher injury severity score, higher PPOI incidence, and a tendency for delayed oral intake tolerance. In peak serum lactate greater than 2 mmol/L group, the lactate normalization time (OR 1.699, p = 0.04), quantity of FFP transfusion for 24 h (OR 1.145, p = 0.012), and creatine kinase (OR 1.001, p = 0.023) were related to PPOI. The lactate normalization time had the highest correlation.Conclusion: In patients undergoing surgical management for small bowel and/or mesenteric injury after trauma, serum lactate normalization time affects oral intake tolerance and prolongs postoperative ileus.

Teamwork matters: The association between nontechnical skills and cardiac arrest in trauma patients presenting with hypotension

BackgroundThe impact of trauma team dynamics on outcomes in injured patients is not completely understood. We sought to evaluate the association between trauma team function, as measured by a modified Trauma Non-Technical Skills assessment, and cardiac arrest in hypotensive trauma patients. We hypothesized that better team function is associated with a decreased probability of developing cardiac arrest. MethodsTrauma video review was used to collect data from resuscitations of adult hypotensive trauma patients at 19 centers. Hypotension at emergency department presentation was defined as an initial systolic blood pressure <90 mm Hg or an initial systolic blood pressure ≥90 mm Hg followed by a systolic blood pressure <90 mm Hg within the first 5 minutes. Team dynamics were scored using a modified Trauma Non-Technical Skills assessment composed of 5 domains with combined scores ranging from 5 (best) to 15 (worst). Scores were compared between cardiac arrest/noncardiac arrest cases in the trauma bay. Logistic regression was used to evaluate the independent association between the Trauma Non-Technical Skills assessment and cardiac arrest. ResultsA total of 430 patients were included (median age 43 years [interquartile range: 29–61]; 71.8% male; 36% penetrating mechanism; median Injury Severity Score 20 [10–33]; 11% experienced cardiac arrest in trauma bay). The median total Trauma Non-Technical Skills assessment score was 7 (6–9), higher in patients who experienced cardiac arrest in the trauma bay (9 [6–10] vs 7 [6–9]; P = .016). This association persisted after controlling for age, sex, mechanism, injury severity, initial systolic blood pressure, and initial Glasgow Coma Scale score (adjusted odds ratio: 1.28; 95% confidence interval:1.11–1.48; P < .001), indicating a ∼3% higher predicted probability of cardiac arrest per Trauma Non-Technical Skills point. ConclusionBetter team function is independently associated with a decreased probability of cardiac arrest in trauma patients presenting with hypotension. This suggests that trauma team training may improve outcomes in peri-arrest patients.

(159) Characteristics and Hypertension Management Trends in Hypertensive Men With and Without Erectile Dysfunction

Abstract Introduction Hypertension, defined as a blood pressure (BP) ≥ 130/80 mmHg and/or use of BP lowering medications, affects 47% of the U.S. population and is the most important modifiable risk factor for cardiovascular disease (CVD) prevention. Prevalence of BP control appears to be decreasing in the U.S. and currently only 1 in 4 adults with hypertension have controlled BP. Erectile dysfunction (ED), an early marker of subclinical CVD, often accompanies hypertension. Most BP lowering medications have been shown to not affect sexual function, but the drug class of angiotensin receptor blockers (ARBs) have generally been found to have favorable effects on erectile function through their inhibition of angiotensin II. Therefore, exploring the relationship between hypertension management and ED is advantageous for the ultimate control and treatment of these two common and highly prevalent diseases. Objective Assess the demographics of hypertensive men with and without ED and examine associations of ED with hypertension management and BP control outcomes Methods All men presenting for an initial visit for hypertension (ICD-10 codes I10, I11.0, and I11.9) between January 2017-December 2022 at an academic medical center were included for analysis. The electronic health record was queried for patient demographics, the diagnosis of ED, cardiovascular comorbidities, major drug classes of antihypertensives, and major PDE5-inhibitors. Descriptive statistics was used to describe patient characteristics by ED status. Chi-squared, t-test, and Mann-Whitney U tests was used to compare characteristics of patients by presence of ED. Results Of 24,723 hypertensive men in our health system during the study period, only 1,119 men (4.5%) were noted to have ED (Table 1). Hypertensive men with ED were younger (56 ± 11), than those without ED (61±15). There was no statistically significant difference in the use of ARBs amongst hypertensive men with and without ED. Initial systolic and diastolic BP was significantly higher amongst men with ED. After pooling all outpatient clinic visits prior to and after the diagnosis of ED, BP control did improve mildly over the study period, but this was coupled with a decrease in BP medication use across all drug classes. Finally, there was a significant increase in hypertensive males who were on a either sildenafil or tadalafil after their ED diagnosis (Table 2). Conclusions This study elucidates several key points in conceptualizing the ED and hypertension problem and lays a foundation for the next phase in addressing critical gaps in care. This research further validates the underdiagnoses and thus undertreatment of ED overall, with a significantly lower than expected number of men with ED. Despite the well-established benefits of ARBs in hypertensive men with ED, we observed a trend of underutilization of this beneficial BP medication option. Improvements in BP control over time for hypertensive men with ED emphasize the role ED could play in hypertension management. Leveraging ARBs and education on the interplay of ED and hypertension could lead to improved rates and control of both diseases. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Endo Pharmaceuticals, ForHims.

Abstract WMP78: Mobile Stroke Units Enable Hyperacute Interventions for Intracerebral Hemorrhage

Introduction: Mobile stroke units (MSUs) are an evolving means to expedited acute stroke management. Recent landmark trials BEST-MSU and B_PROUD have proven that MSUs facilitate quicker thrombolysis times and improved functional outcomes at 90 days when compared to conventional emergency medical services (EMS) for acute ischemic stroke patients. Despite the growing body of literature surrounding MSUs and acute ischemic stroke, literature describing the intracerebral hemorrhage experience in MSUs has been lacking. Methods: Retrospective analysis of consecutive patients with acute intracerebral hemorrhage triaged by MSU or EMS from January 2018 to December 2022 was performed at two tertiary institutions. In the EMS cohort, only patients seen between 8 am to 8 pm, corresponding to the operating hours of the MSU, were included. Goal blood pressure was defined as systolic blood pressure &lt;160. Chi-squared test for categorical variables and t-test for continuous variables were used for statistical analysis. Results: A total of 146 MSU patients were compared to 221 EMS patients. Both cohorts had similar baseline demographics. Median initial blood pressure in the MSU was 190/99, which dropped to a median blood pressure of 157/80 upon arrival to the hospital. Initial systolic blood pressure in the hospital was significantly higher for EMS compared to MSU patients (166 vs 157, p=0.011). The majority (77%) of MSU patients received anti-hypertensive medications while in the MSU. Times from door to CT completion (14 vs 33 min, p=0.000), anticoagulation reversal (99 vs 139 min, p=0.013), anti-hypertensive medication administration (21 vs 45 min, p=0.020), and goal blood pressure (35 vs 51 min, p=0.000) were significantly faster in the MSU cohort. Conclusions: MSUs provide faster medical treatment for patients with acute intracerebral hemorrhage. The target blood pressure goal was met much quicker in the MSU. Faster time metrics convey a hypothetical benefit towards improved patient outcomes.

Timing and volume of transfusion for adult major trauma patients with hemorrhagic shock: a registry-based cohort study

IntroductionTransfusion of blood components is vital for the resuscitation of injured patients in hemorrhagic shock. Delays in initiating transfusion have been associated with harm, as has excess transfusion. The aim...

MRI-based clinical-radiomics nomogram to predict early neurological deterioration in isolated acute pontine infarction: a two-center study in Northeast China

ObjectiveTo predict the appearance of early neurological deterioration (END) among patients with isolated acute pontine infarction (API) based on magnetic resonance imaging (MRI)-derived radiomics of the infarct site.Methods544 patients with isolated API were recruited from two centers and divided into the training set (n = 344) and the verification set (n = 200). In total, 1702 radiomics characteristics were extracted from each patient. A support vector machine algorithm was used to construct a radiomics signature (rad-score). Subsequently, univariate and multivariate logistic regression (LR) analysis was adopted to filter clinical indicators and establish clinical models. Then, based on the LR algorithm, the rad-score and clinical indicators were integrated to construct the clinical-radiomics model, which was compared with other models.ResultsA clinical-radiomics model was established, including the 5 indicators rad-score, age, initial systolic blood pressure, initial National Institute of Health Stroke Scale, and triglyceride. A nomogram was then made based on the model. The nomogram had good predictive accuracy, with an area under the curve (AUC) of 0.966 (95% confidence interval [CI] 0.947–0.985) and 0.920 (95% [CI] 0.873–0.967) in the training and verification sets, respectively. According to the decision curve analysis, the clinical-radiomics model showed better clinical value than the other models. In addition, the calibration curves also showed that the model has excellent consistency.ConclusionThe clinical-radiomics model combined MRI-derived radiomics and clinical metrics and may serve as a scoring tool for early prediction of END among patients with isolated API.

Impact of Prehospital Exsanguinating Airway-Breathing-Circulation Resuscitation Sequence on Patients with Severe Hemorrhage.

At the 2023 ATLS symposium, the priority of circulation was emphasized through the "x-airway-breathing-circulation (ABC)" sequence, where "x" stands for exsanguinating hemorrhage control. With growing evidence from military and civilian studies supporting an x-ABC approach to trauma care, a prehospital advanced resuscitative care (ARC) bundle emphasizing early transfusion was developed in our emergency medical services (EMS) system. We hypothesized that prioritization of prehospital x-ABC through ARC would reduce in-hospital mortality. This was a single-year prospective analysis of patients with severe hemorrhage. These patients were combined with our institution's historic controls before prehospital blood implementation. Included were patients with systolic blood pressure (SBP) less than 90 mmHg. Excluded were patients with penetrating head trauma or prehospital cardiac arrest. Two-to-one propensity matching for x-ABC to ABC groups was conducted, and the primary outcome, in-hospital mortality, was compared between groups. A total of 93 patients (x-ABC = 62, ABC = 31) met the inclusion criteria. There was no difference in patient age, sex, initial SBP, initial Glasgow Coma Score, and initial shock index between groups. When compared with the ABC group, x-ABC patients had significant improvement in vitals at emergency department admission. Overall mortality was lower in the x-ABC group (13% vs 47%, p < 0.001). Multivariable regression revealed that prehospital circulation-first prioritization was independently associated with decreased in-hospital mortality (odds ratio 0.15, 95% CI 0.04 to 0.54, p = 0.004). This is the first analysis to demonstrate a prehospital survival benefit of x-ABC in this subset of patient with severe injury and hemorrhagic shock. Standardization of prehospital x-ABC management in this patient population warrants special consideration.

Machine-learning based risk prediction of in-hospital outcomes following STEMI: the STEMI-ML score.

Traditional prognostic models for ST-segment elevation myocardial infarction (STEMI) have limitations in statistical methods and usability. We aimed to develop a machine-learning (ML) based risk score to predict in-hospital mortality, intensive care unit (ICU) admission, and left ventricular ejection fraction less than 40% (LVEF < 40%) in STEMI patients. We reviewed 1,863 consecutive STEMI patients undergoing primary percutaneous coronary intervention (pPCI) or rescue PCI. Eight supervised ML methods [LASSO, ridge, elastic net (EN), decision tree, support vector machine, random forest, AdaBoost and gradient boosting] were trained and validated. A feature selection method was used to establish more informative and nonredundant variables, which were then considered in groups of 5/10/15/20/25/30(all). Final models were chosen to optimise area under the curve (AUC) score while ensuring interpretability. Overall, 128 (6.9%) patients died in hospital, with 292 (15.7%) patients requiring ICU admission and 373 (20.0%) patients with LVEF < 40%. The best-performing model with 5 included variables, EN, achieved an AUC of 0.79 for in-hospital mortality, 0.78 for ICU admission, and 0.74 for LVEF < 40%. The included variables were age, pre-hospital cardiac arrest, robust collateral recruitment (Rentrop grade 2 or 3), family history of coronary disease, initial systolic blood pressure, initial heart rate, hypercholesterolemia, culprit vessel, smoking status and TIMI flow pre-PCI. We developed a user-friendly web application for real-world use, yielding risk scores as a percentage. The STEMI-ML score effectively predicts in-hospital outcomes in STEMI patients and may assist with risk stratification and individualising patient management.