Initial Systolic Blood Pressure Research Articles

Prehospital end-tidal carbon dioxide predicts hemorrhagic shock upon emergency department arrival.

In addition to reflecting gas exchange within the lungs, end-tidal carbon dioxide (ETCO2) also reflects cardiac output based on CO2 delivery to the pulmonary parenchyma. We hypothesized that low prehospital ETCO2 values would be predictive of hemorrhagic shock in intubated trauma patients. A retrospective observational study of adult trauma patients intubated in the prehospital setting and transported to a single Level I trauma center from 2016 to 2019. Continuous prehospital ETCO2 data were linked with patient care registries. We developed a novel analytic approach that allows for reflection of prehospital ETCO2 over the entire prehospital course of care. The primary outcome was hemorrhagic shock on emergency department (ED) presentation, defined as either initial ED systolic blood pressure of 90 mm Hg or less or initial Shock Index (SI) > 0.9, and transfusion of at least one unit of blood product during their ED stay. Prehospital ETCO2 less than 25 mm Hg was evaluated for predictive value of hemorrhagic shock. Three hundred and seven patients (82% men, 34% penetrating injury, 42% in hemorrhagic shock on ED arrival, 27% mortality) were included in the study. Patients in hemorrhagic shock had lower median ETCO2 values (26.5 mm Hg vs. 32.5 mm Hg; p < 0.001) than those not in hemorrhagic shock. Patients with prehospital ETCO2 less than 25 mm Hg were 3.0 times (adjusted odds ratio = 3.0; 95% confidence interval, 1.1-7.9) more likely to be in hemorrhagic shock upon ED arrival than patients with ETCO2 ≥ 25 mm Hg. Intubated patients with hemorrhagic shock upon ED arrival had significantly lower prehospital ETCO2 values. Incorporating ETCO2 assessment into prehospital care for trauma patients could support decisions regarding prehospital blood transfusion, and triage to higher-level trauma centers, and trauma team activation. Prognostic, level III.

Mortality in hypotensive trauma patients requiring laparotomy is related to degree of hypotension and provides evidence for focused interventions

BackgroundMortality in hypotensive patients requiring laparotomy is reported to be 46% and essentially unchanged in 20 years. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been incorporated into resuscitation...

Neurofibromatosis Type 1 Presenting With Adrenal Pheochromocytoma

Abstract Background: Pheochromocytomas &amp; Paragangliomas (PCC/PGL) are amongst the rare endocrine tumours, occurring with an incidence of 0.8 per 100,0001. Though most of them have a benign nature, they are usually hormonally active causing significant cardiovascular morbidity due to the catecholamine secretion. Approximately a third of PCC/PGL have underlying germline mutations including Neurofibromatosis type 1 (NF1). Clinical Case: A 49 year old man was reviewed for symptoms of palpitation, headache, sweating, and blurred vision. physical examination revealed signs of NF1. He had multiple neurofibromas over the skin of the back, chest and neck, café-au-lait spots on the trunk and limbs. Ophthalmology assessment revealed multiple Lisch nodules bilaterally. Urinary catecholamines were significantly elevated. His initial systolic blood pressure was 190/148 mmHg. The patient’s medical history included hypertension that used to be well-controlled with Amlodipine 10 mg and Bisoprolol 5mg. however his blood pressure was harder to control during the past year. Laboratory investigations testing included measurements of urinary fractionated metanephrines which revealed high normetanephrines with a value of 690 nmol/d (N &amp;lt; 240). metanephrines (485 nmol/d: N &amp;lt; 275) and norepinephrines (456 nmol/d: N &amp;lt; 440). Plasma free normetanephrines were 3.20 nmol/L (N &amp;lt;1.20) and free metanephrines 0.4 nmol/L (N &amp;lt; 0.48). CT scan of the abdomen showed a 1.3 x 2.4x 3.9 mass in the left suprarenal gland which showed showed moderate uptake on A meta-iodobenzylguanidine (MIBG) scan. And no evidence of metastases. The patient underwent laparoscopic adrenalectomy of the left suprarenal gland and histopathological examination was confirmatory of pheochromocytoma postoperatively. Conclusion:This is a case demonstrating the association between the germline mutation causing neurofibromatosis type 1 with the rare catecholamine secreting tumour (pheochromocytoma). Reference:1. Lefebvre M, Foulkes WD. Pheochromocytoma and paraganglioma syndromes: genetics and management update. Curr Oncol. 2014;21(1):e8-e17. doi: 10.3747/co.21.1579. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

High‐Resistance Inspiratory Muscle Strength Training Improves Cerebrovascular Function in Midlife/Older Adults

Background Advancing age is associated with increased risk for cardiovascular diseases (CVD), cognitive decline, Alzheimer's disease and related dementias. Part of this risk may be driven by age-related increases in systolic blood pressure (SBP) and subsequent cerebrovascular dysfunction. Habitual aerobic exercise lowers SBP and promotes cerebrovascular health; however, lack of time and other barriers limit adherence to physical activity guidelines in the majority of adults. High-resistance inspiratory muscle strength training (IMST; 30 inhalations/session against resistance), is a time-efficient, highly-adherable lifestyle intervention for lowering SBP and improving peripheral vascular function in midlife/older (ML/O; ≥50 years) adults with initial above-normal SBP (i.e., ≥120 mmHg). However, whether IMST improves cerebrovascular function in this at-risk population is unknown. Purpose: To determine if high-resistance IMST improves measures of cerebrovascular function in ML/O adults with initial above-normal SBP. We hypothesized 6 weeks of high-resistance IMST would improve cerebrovascular function vs. low-resistance Sham training. Methods: Cerebrovascular function was measured in 16 ML/O adults before and after 6 weeks of high-resistance IMST (30 breaths/day, 6 days/week, 75% maximal inspiratory pressure [PIMAX]) (n=9, 4F/5M, 65 ± 3 years) or Sham training (15% PIMAX, n=7, 2F/5M, 63 ± 2 years). Middle cerebral artery blood velocity (MCAv) was measured with a 2-MHz transcranial Doppler probe during 5 minutes each of normocapnia and hypercapnia (5% CO2, balanced nitrogen). Cerebrovascular reactivity (CVR), a measure of cerebrovascular responsiveness to a vasoactive stimulus, was determined as ΔMCAv/Δend-tidal CO2 between normocapnia and hypercapnia and interpreted as an index of cerebrovascular health. To account for potential changes in perfusion pressure, CVR was normalized to the change in mean arterial BP from normocapnia to hypercapnia and expressed as cerebrovascular conductance index (CVCi) reactivity. Pulsatility index, a marker of cerebrovascular stiffness, was calculated as (MCAvsystole – MCAvdiastole)/MCAvmean. Results: CVR was significantly increased after 6 weeks of IMST (pre: 1.38 ± 0.22 cm/s/mmHg, post: 2.31 ± 0.34 cm/s/mmHg; p=0.04), but not Sham training (pre: 1.20 ± 0.08 cm/s/mmHg, post: 1.48 ± 0.23 cm/s/mmHg; p=0.75). As a result, CVR was higher in the IMST group vs. Sham after the intervention period (p=0.06). CVCi reactivity also was significantly higher after IMST (pre: 0.009 ± 0.002 cm/s/mmHg2, post: 0.018 ± 0.004 cm/s/mmHg2; p=0.05), but not Sham training (pre: 0.009 ± 0.001 cm/s/mmHg2, post: 0.010 ± 0.002 cm/s/mmHg2; p=0.90). Pulsatility index did not change in either group (all p>0.05). Conclusion: These preliminary findings suggest high-resistance IMST is a promising, time-efficient intervention for improving select measures of cerebrovascular function in ML/O adults with initial above-normal SBP, a cohort at high risk for future CVD and cognitive decline.

Efectos del entrenamiento de fuerza domiciliario durante el confinamiento por COVID-19 en el síndrome coronario agudo

Introduction and objectiveCardiac rehabilitation has the highest level of recognition in medical guideline references. The rise of COVID-19 pandemic, particularly during the first months of strict containment, cause to temporally stop most of the ongoing programs. We studied the effects of an interdisciplinary phase II secondary prevention in patients diagnosed with a recent acute coronary syndrome with the use of new technologies, home-exercise and telemedicine. MethodsBetween the 2nd and 11th of March 2020, we included 37 patients with recent acute coronary syndrome (76.4%), low-risk and preserved systolic function and underwent a 12-week treatment. A dynamic muscle toning with overload domiciliary training program was applied, in addition to nutritional counselling, as well as psychological and educational therapy. ResultsOf the initial cohort, 30 patients finished. At the end of the program, we observed and increased functional capacity over the 6-min walking test (+47.13m; 95% CI: 32.82-61.45, P<.001), and improvement to the subjective feeling of dyspnoea on the modified Borg scale (−0.5 units; 95% CI: −0.76 to −0.24, P=.001), and an improvement over both initial and final training systolic blood pressure (−6.67mmHg; 95% CI: −10.98 to −2.35, P=.004) (−7mmHg; 95% CI: −12.86 to −1.14, P=.021). We also observed an increase in the level of physical activity during leisure time in the IPAQ questionnaire (+1162.93min/week; 95% CI: 237.36–2088.5, P=.016), and in the Mediterranean eating habits on the PREDIMED test (+2.1units; 95% CI: 1.32–2.28, P<.001). ConclusionsAfter three months of a domiciliary cardiac rehabilitation program, patients increased their functional capacity, feeling of dyspnoea, blood pressure and eating habits. Domiciliary telemedicine cardiac rehabilitation program produces an improvement in the patient after acute coronary syndrome.

Systemic Hemodynamic Changes in Low-Dose Ethanol Embolotherapy for Soft-Tissue Arteriovenous Malformations

Ethanol embolotherapy is considered an optimal choice for the treatment of arteriovenous malformations (AVMs); however, there are some complications associated with this treatment. This study aimed to prospectively investigate systemic hemodynamic changes in high-flow AVMs using ethanol embolotherapy. From September 2012 to September 2014, 34 male patients and 26 female patients with AVMs who underwent embolotherapy (100 sessions in total) with absolute ethanol were included in this study. Invasive systolic blood pressure (SBP) and heart rate (HR) were recorded before and after each injection and throughout the procedure. Differences between the initial and highest SBP (ΔmaxSP) and HR values (ΔmaxHR), as well as the initial and final SBP (ΔSP) and HR (ΔHR) values, were analyzed. We aimed to explore the potential association between these values and the amount of ethanol that was used. The total ethanol used was variable (0.01–0.40 mL/kg; mean, 0.20 mL/kg). SBP and HR increased after ethanol injection in most sessions (91 in 100 sessions). SBP decreased in 9 sessions (9 in 100 sessions), while HR, oxygen saturation, and end-tidal CO2 decreased in one of the 9 sessions. ΔmaxSP and ΔmaxHR averaged 38.4 mmHg and 27.8 bpm, respectively (both P<0.05), while ΔSP and ΔHR averaged 3.4 mmHg and 4.0 bpm, respectively (both P<0.05). ΔmaxSP and ΔmaxHR were positively correlated with the total dose of ethanol injected. Elevations in SBP and HR during ethanol embolotherapy are common, temporary, and most likely pain-mediated; these increases tend to be positively correlated with ethanol dose. Hypotension may be regarded as an acute complication of ethanol embolotherapy. Hypotension combined with bradycardia, oxygen desaturation, and decreased end-tidal CO2 may be a potential predictor of cardiovascular collapse.

Venous ligation versus venous repair: does the procedure impact venous thromboembolism risk?

BackgroundTraumatic lower extremity venous injuries are most commonly managed with either a vein ligation or repair procedure. Venous injuries are associated with an increased risk of developing venous thromboembolisms (VTE),...

Synergistic Impact of Systolic Blood Pressure and Perfusion Status on Mortality in Acute Heart Failure.

Physical examination remains the cornerstone in the assessment of acute heart failure. There is a lack of adequately powered studies assessing the combined impact of both systolic blood pressure (SBP) and hypoperfusion on short-term mortality. Patients with acute heart failure from 41 Spanish emergency departments were recruited consecutively in 3 time periods between 2011 and 2016. Logistic regression models were used to assess the association of 30-day mortality with SBP (<90, 90-109, 110-129, and ≥130 mm Hg) and with manifestations of hypoperfusion (cold skin, cutaneous pallor, delayed capillary refill, livedo reticularis, and mental confusion) at admission. Among 10 979 patients, 1143 died within the first 30 days (10.2%). There was an inverse association between 30-day mortality and initial SBP (35.4%, 18.9%, 12.4%, and 7.5% for SBP<90, SBP 90-109, SBP 110-129, and SBP≥130 mm Hg, respectively; P<0.001) and a positive association with hypoperfusion (8.0%, 14.8%, and 27.6% for those with none, 1, ≥2 signs/symptoms of hypoperfusion, respectively; P<0.001). After adjustment for 11 risk factors, the prognostic impact of hypoperfusion on 30-day mortality varied across SBP categories: SBP≥130 mm Hg (odds ratio [OR]=1.03 [95% CI, 0.77-1.36] and OR=1.18 [95% CI, 0.86-1.62] for 1 and ≥2 compared with 0 manifestations of hypoperfusion), SBP 110 to 129 mm Hg (OR=1.23 [95% CI, 0.86-1.77] and OR=2.18 [95% CI, 1.44-3.31], respectively), SBP 90 to 109 mm Hg (OR=1.29 [95% CI, 0.79-2.10] and OR=2.24 [95% CI, 1.36-3.66], respectively), and SBP<90 mm Hg (OR=1.34 [95% CI, 0.45-4.01] and OR=3.22 [95% CI, 1.30-7.97], respectively); P-for-interaction =0.043. Hypoperfusion confers an incremental risk of 30-day all-cause mortality not only in patients with low SBP but also in normotensive patients. On admission, physical examination plays a major role in determining prognosis in patients with acute heart failure.

Outcomes of Intensive Systolic Blood Pressure Reduction in Patients with Intracerebral Hemorrhage and Excessively High Initial Systolic Blood Pressure: Post Hoc Analysis of a Randomized Clinical Trial

Current guidelines from the American Heart Association and American Stroke Association call for intensive and aggressive blood pressure control in patients presenting with spontaneous intracerebral hemorrhage (ICH). In patients with systolic blood pressure (SBP) between 150 and 220 mmHg, lowering SBP to 140 mmHg is considered safe and is associated with improved functional outcomes. For patient with systolic blood pressures greater than 220mmHg, it is recommended to use continuous intravenous medications and frequent blood pressure monitoring to aggressively lower blood pressures, though there are no specific goal parameters recommended and inadequate data to evaluate the safety of such intensive blood pressure control.

Dietary Approaches to Stop Hypertension Dietary Intervention Improves Blood Pressure and Vascular Health in Youth With Elevated Blood Pressure.

This randomized control trial assessed the post-intervention and 18-month follow-up effects of a 6-month dietary approaches to stop hypertension (DASH)-focused behavioral nutrition intervention, initiated in clinic with subsequent telephone and mail contact, on blood pressure (BP) and endothelial function in adolescents with elevated BP. Adolescents (n=159) 11 to 18 years of age with newly diagnosed elevated BP or stage 1 hypertension treated at a hospital-based clinic were randomized. DASH participants received a take-home manual plus 2 face-to-face counseling sessions at baseline and 3 months with a dietitian regarding the DASH diet, 6 monthly mailings, and 8 weekly and then 7 biweekly telephone calls focused on behavioral strategies to promote DASH adherence. Routine care participants received nutrition counseling with a dietitian consistent with pediatric guidelines established by the National High Blood Pressure Education Program. Outcomes, measured pre- and post-intervention and at 18-months follow-up, included change in BP, change in brachial artery flow-mediated dilation, and change in DASH score based on 3-day diet recalls. Adolescents in DASH versus routine care had a greater improvement in systolic BP (-2.7 mm Hg, P= 0.03, -0.3 z-score, P=0.03), flow-mediated dilation (2.5%, P=0.05), and DASH score (13.3 points, P<0.0001) from baseline to post-treatment and a greater improvement in flow-mediated dilation (3.1%, P=0.03) and DASH score (7.4 points, P=0.01) to 18 months. The DASH intervention proved more effective than routine care in initial systolic BP improvement and longer term improvement in endothelial function and diet quality in adolescents with elevated BP and hypertension. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00585832.

Treatment variables associated with outcome in emergency department patients with suspected sepsis

BackgroundEarly treatment is advocated in the management of patients with suspected sepsis in the emergency department (ED). We sought to understand the association between the ED treatments and outcome in patients admitted with suspected sepsis. The treatments studied were: (i) the time to antibiotics, where time zero is the time the patient was booked in which is also the triage time; (ii) the volume of intravenous fluid (IVF); (iii) mean arterial pressure (MAP) after 2000 ml of IVF and (iv) the final MAP in the ED.MethodsWe performed a retrospective analysis of the ED database of patients aged ≥ 18 year who met two SIRS criteria or one red flag sepsis criteria on arrival, received intravenous antibiotics for a suspected infection and admitted between 8th February 2016 and 31st August 2017. The primary outcome measure was all-cause in-hospital mortality. The four treatments stated above were controlled for severity of illness and subject to multivariate logistic regression and Cox proportional-hazard regression to identify independent predictors of mortality.ResultsOf the 2,066 patients studied 272 (13.2%) died in hospital. The median time to antibiotics was 48 (interquartile range 30–82) minutes. The time to antibiotics was an independent predictor of mortality only in those who developed refractory hypotension (RH); antibiotics administered more than 55 mins after arrival was associated with an odds ratio (OR) for mortality of 2.75 [95% confidence interval (CI) 1.22–6.14]. The number-needed-to-treat was 4. IVF > 2000 ml (95% CI > 500– > 2100), except in RH, and a MAP ≤ 66 mmHg after 2000 ml of IVF were also independent predictors of mortality. The OR for mortality of IVF > 2,000 ml in non-RH was 1.80 (95% CI 1.15–2.82); Number-needed-to-harm was 14. The OR for morality for a MAP ≤ 66 mmHg after 2000 ml of IVF was 3.42 (95% CI 2.10–5.57). A final MAP < 75 mmHg in the ED was associated with, but not an independent predictor of mortality. An initial systolic blood pressure of < 100 mmHg has a sensitivity of 63.3% and specificity of 88.4% for the development of RH.ConclusionIn this study, antibiotics were found to be time-critical in RH. Intravenous fluids > 2000 ml (except in RH) and a MAP ≤ 66 mmHg after 2000 ml of IVF were also independent predictors of mortality.

Association Between Pain, Blood Pressure, and Medication Intensification in Primary Care: an Observational Study.

Treating hypertension is important but physicians often do not intensify blood pressure (BP) treatment in the setting of pain. To identify whether reporting pain is associated with (1) elevated BP at the same visit, (2) medication intensification, and (3) elevated BP at the subsequent visit. Retrospective cohort SETTING: Integrated health system PARTICIPANTS: Adults seen in primary care EXPOSURE: Pain status based on numerical scale: mild (1-3), moderate (4-6), or severe (≥ 7). We defined elevated BP as ≥ 140/80mmHg and medication intensification as increasing the dose or adding a new antihypertensive medication. Multilevel regression models were used to find the association between pain and (1) elevated BP at the index visit; (2) medication intensification at the index visit; and (3) elevated BP at the subsequent visit. Models adjusted for demographics, chronic conditions, and clustering within physician. In the third model, we adjusted for initial systolic BP as well. Our population included 56,322 patients; 3155 (6%) reported mild pain, 5050 (9%) reported moderate pain, and 4647 (8%) reported severe pain at the index visit. Compared with no pain, the adjusted odds ratios of elevated BP were 1.38 (95% CI: 1.28-1.48) for severe pain, 1.06 (95% CI: 0.99-1.14) for moderate pain, and 1.02 (95% CI: 0.93-1.12) for mild pain. Adjusted odds ratios of medication intensification at the index visit were 0.65 (95% CI: 0.54-0.80) for mild pain, 0.61 (95% CI: 0.52-0.72) for moderate pain, and 0.55 (95% CI: 0.47-0.64) for severe pain. Among patients with elevated BP at the index visit, reporting pain at the index visit was not associated with elevated BP at the subsequent visit. When patients reported pain, physicians were less likely to intensify antihypertensive treatment; nevertheless, patients reporting pain were not more likely to have elevated BP at the subsequent visit.

Hypocapnia, ischemic lesions, and outcomes after intracerebral hemorrhage

BackgroundAn association between spontaneous hyperventilation, delayed cerebral ischemia, and poor clinical outcomes has been reported in subarachnoid hemorrhage. We evaluated the relationship between early pCO2 changes, ischemic lesions and outcomes in patients with intracerebral hemorrhage (ICH). MethodsConsecutive patients with spontaneous ICH were enrolled in an observational cohort study conducted between 2006 and 2019. Patient characteristics and discharge outcome were prospectively recorded. Arterial blood gas (ABG) measurements and mechanical ventilation settings in the first 72 h of admission were retrospectively collected. MRI images were adjudicated for diffusion-restricted lesions consistent with ischemia and distant from the hematoma. We examined the associations between pCO2 changes, ischemic lesions, and discharge outcomes by univariate and adjusted analyses. ResultsABG data were available for 220 patients. Hyperventilation occurred in 52 (28%) cases and was not associated with clinical severity. Lower initial pCO2 was associated with greater risk of in-hospital death (OR 0.94 per mmHg, 95%CI [0.89, 0.996], p = 0.042) after adjustment for ICH Score, pneumonia and mechanical ventilation requirements. MRI data were available for 33 patients. Lower pCO2 was associated with a higher risk of ischemic lesions, except in patients with low initial systolic blood pressure (p < 0.05 for main and blood pressure interaction effects), after adjustment for other predictors. ConclusionsIn ICH patients with spontaneous ventilation, lower pCO2 was independently associated with greater risk of in-hospital death. In patients with elevated initial blood pressure, who undergo blood pressure reduction per guideline recommendations, lower pCO2 was associated with increased risk to develop ischemic lesions.

Outcomes of Intensive Systolic Blood Pressure Reduction in Patients With Intracerebral Hemorrhage and Excessively High Initial Systolic Blood Pressure

The safety and efficacy of intensive systolic blood pressure reduction in patients with intracerebral hemorrhage who present with systolic blood pressure greater than 220 mm Hg appears to be unknown. To evaluate the differential outcomes of intensive (goal, 110-139 mm Hg) vs standard (goal, 140-179 mm Hg) systolic blood pressure reduction in patients with intracerebral hemorrhage and initial systolic blood pressure of 220 mm Hg or more vs less than 220 mm Hg. This post hoc analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage-II trial was performed in November 2019 on data from the multicenter randomized clinical trial, which was conducted between May 2011 to September 2015. Patients with intracerebral hemorrhage and initial systolic blood pressure of 180 mm Hg or more, randomized within 4.5 hours after symptom onset, were included. Intravenous nicardipine infusion titrated to goals. Neurological deterioration and hematoma expansion within 24 hours and death or severe disability at 90 days, plus kidney adverse events and serious adverse events until day 7 or hospital discharge. A total of 8532 patients were screened, and 999 individuals (mean [SD] age, 62.0 [13.1] years; 620 men [62.0%]) underwent randomization and had an initial SBP value. Among 228 participants with initial systolic blood pressures of 220 mm Hg or more, the rate of neurological deterioration within 24 hours was higher in those who underwent intensive (vs standard) systolic blood pressure reduction (15.5% vs 6.8%; relative risk, 2.28 [95% CI, 1.03-5.07]; P = .04). The rate of death and severe disability (39.0% vs 38.4%; relative risk, 1.02 [95% CI, 0.73-1.78]; P = .92) was not significantly different between the 2 groups. There was a significantly higher rate of kidney adverse events in participants randomized to intensive systolic blood pressure reduction (13.6% vs 4.2%; relative risk, 3.22 [95% CI, 1.21-8.56]; P = .01), but no difference was observed in the rate of kidney serious adverse events. The higher rate of neurological deterioration within 24 hours associated with intensive treatment in patients with intracerebral hemorrhage and initial systolic blood pressure of 220 mm Hg or more, without any benefit in reducing hematoma expansion at 24 hours or death or severe disability at 90 days, warrants caution against generalization of recommendations for intensive systolic blood pressure reduction.

Systolic Blood Pressure Reduction and Acute Kidney Injury in Intracerebral Hemorrhage.

We determined the rates and predictors of acute kidney injury (AKI) and renal adverse events (AEs), and effects of AKI and renal AEs on death or disability in patients with intracerebral hemorrhage. We analyzed data from a multicenter trial which randomized 1000 intracerebral hemorrhage patients with initial systolic blood pressure ≥180 mm Hg to intensive (goal 110-139 mm Hg) over standard (goal 140-179 mm Hg) systolic blood pressure reduction within 4.5 hours of symptom onset. AKI was identified by serial assessment of daily serum creatinine for 3 days post randomization. AKI and renal AEs were observed in 149 patients (14.9%) and 65 patients (6.5%) among 1000 patients, respectively. In multivariate analysis, the higher baseline serum creatinine (≥110 μmol/L) was associated with AKI (odds ratio 2.4 [95% CI, 1.2-4.5]) and renal AEs (odds ratio 3.1 [95% CI, 1.2-8.1]). Higher area under the curve for intravenous nicardipine dose was associated with AKI (odds ratio 1.003 [95% CI, 1.001-1.005]) and renal AEs (odds ratio 1.003 [95% CI, 1.001-1.006]). There was a higher risk to death (relative risk 2.6 [95% CI, 1.6-4.2]) and death or disability (relative risk 1.5 [95% CI, 1.3-1.8]) at 90 days in patients with AKI but not in those with renal AEs. Intracerebral hemorrhage patients with higher baseline serum creatinine and those receiving higher doses of nicardipine were at higher risk for AKI and renal AEs. Occurrence of AKI was associated higher rates of death or disability at 3 months. Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT01176565.

Retinal Arteriolar Occlusions and Exudative Retinal Detachments in Malignant Hypertension: More Than Meets the Eye

Malignant hypertension is macrovascular and microvascular endothelial injury responsible for multiple organ damage. Considering the anatomical and functional homologies between the posterior pole of the eye and the kidney, ophthalmological explorations may inform clinicians on the mechanisms underpinning concurrent kidney injury in this condition. More specifically, we investigated whether the wall-to-lumen ratio (WLR) of retinal arterioles measured by adaptive optics ophthalmoscopy could be correlated to WLR of kidney arterioles as determined by pathology. We sought to estimate the incidence of retinal arteriole occlusion a supposedly uncommon complication of malignant hypertension. All patients hospitalized in our renal Intensive Care Unit for malignant hypertension between 2016 and 2019 were referred to ophthalmological examinations. Twenty-seven patients were included. Median retinal WLR was 0.39 [0.31-0.47] and was correlated with initial systolic (r = 0.56, P = 0.003) and mean blood pressure (r = 0.46, P = 0.02) upon admission. The retinal WLR was not correlated to renal pathological findings, as assessed by juxtaglomerular WLR (r = 0.38, P = 0.2), ratio of glomerulosclerosis (r = -0.39, P = 0.2), or tubulointerstitial fibrosis (r = -0.45, P = 0.08). Retinal WLR was not associated with neurological or cardiovascular end-organ damage. Branch retinal artery occlusion was detected in 18.5% of patients and exudative retinal detachment (ERD) in 29.6% of patients, without any significant correlation with canonical signs of retinal hypertension including optic disc swelling. In the setting of malignant hypertension, we failed to demonstrate a significant relationship between WLR and other meaningful end-organ injuries. However, branch retinal artery occlusion and ERD may have been hitherto underestimated.

Evaluation of Adrenal Vein Sampling Use and Outcomes in Patients With Primary Aldosteronism

BackgroundPrimary aldosteronism (PA) occurs in 10%-20% of patients with resistant hypertension. Guidelines recommend adrenal vein sampling (AVS) to identify patients for surgical management. We evaluate the use of AVS in managing PA to better understand the selection and outcomes of medical versus surgical treatment. MethodsA retrospective review was performed, and patients were divided into those who did (AVS) and did not have AVS (non-AVS). Demographics, aldosterone and renin levels, blood pressure, comorbidities, and antihypertensive medications were recorded. Reasons to defer AVS and medical versus surgical decision-making were examined and groups were compared. ResultsWe included 113 patients; 39.8% (45/113) had AVS, whereas 60.2% (68/113) did not. Groups were similar in age, body mass index, and initial systolic blood pressure (SBP).In patients who underwent AVS, 31 of 45 (68.9%) had unilateral secretion and were referred for surgery, whereas 13 of 45 (28.9%) had bilateral secretion. Of the 31 referred for surgery, 26 underwent laparoscopic adrenalectomy, all cured; four refused surgery; and one counseled toward medical management by their physician.In 68 non-AVS patients, 6 (8.8%) underwent adrenalectomy without sampling and 2 with no clinical improvement. The remaining deferrals were because of normal or bilateral adrenal nodules on imaging (8/68, 11.8%); medical management due to poor surgical candidacy (12/68, 17.6%); patient refusal of intervention (13/68, 19.1%); or reasons not stated (28/68, 41.1%). At the follow-up, patients who underwent AVS had lower median SBP (135.4 mmHg versus 144.7 mmHg, P = 0.0241) and shorter follow-up (17.7 mo versus 54.0 mo, P < 0.0001). Surgically managed patients had biochemical resolution of PA with normalization of potassium levels (3.6 to 4.7mEq/L, P < 0.00001). ConclusionsAVS correctly selects patients for surgical management avoiding unnecessary surgery. However, despite guidelines, AVS is not always pursued as part of PA treatment, potentially excluding surgical candidates.

Early Detection of Deep Venous Thrombosis in Trauma Patients.

BackgroundThis study was performed to determine whether trauma patients are at an increased risk of developing deep venous thrombosis (DVT) within the first 48 hours of hospitalization.Materials and methodsA retrospective review was performed using a prospectively maintained database of patients admitted to a trauma center during a five-year time period. Patients hospitalized for greater than 48 hours who received a screening venous duplex for DVT were included in the study.ResultsThere were 1067 venous duplex scans obtained, 689 (64.5%) within the first 48 hours of admission (early DVT group), 378 (35.4%) after the first 48 hours (late DVT group). Only 142 (13.2%) patients had a positive duplex scan for DVT, 55 (early group), 87 (late group). Comorbid conditions of congestive heart failure (P = 0.02), pelvic fractures (P = 0.04), and a lower initial systolic blood pressure on presentation (p = 0.04) were associated with early DVT. Head trauma (P < 0.01), mechanical ventilation (P < 0.001), and transfusion of blood products (P < 0.001), were predictors of DVT in the late group.ConclusionsTrauma patients are at an increased risk of developing venous thrombosis early in the hospital course due to comorbidities associated with trauma. Whereas, venous thrombosis in trauma patients diagnosed after the first 48 hours of hospitalization appears to be associated with prolonged patient immobility.

Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport.

The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency. This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement <90mmHg. A dose of 20mcg every two minutes, as needed, was allowed per protocol. The primary data source was the EMS electronic medical record. Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals. These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.

3-9SYSTOLIC BLOOD PRESSURE, MEAN ARTERIAL BLOOD PRESSURE RELATED TO CLINICAL OUTCOMES IN HEMORRHAGIC STROKE WITH EMERGENCY HYPERTENSION

Introduction: Stroke is a leading cause of mortality and disability in Indonesia. According to classification, 15–20% are hemorrhagic stroke, and 80% are due to hypertension. Many of them with emergency hypertension. Several studies have demonstrated a strong association between an increased level of blood pressure (BP) with poor outcomes. Comprehensive management of emergency hypertension could decrease mortality and disability. Objective: To study about the relationship of initial systolic blood pressure (SBP) and initial mean arterial pressure (MAP) with outcome in the patient having a hemorrhagic stroke and emergency hypertension. Method: This is an analytic observational study using medical records.The study investigated the association between SBP and MAP with clinical outcome based on The National Institutes of Health Stroke Scale (NIHSS) in living patients and deceased Result: We collected 60 subjects. Mean SBP initial 191.22 mmHg, MAP initial 134.26. We found a decrease in BP. Mean SBP at discharge 140.56 mmHg and MAP at discharge 103.0 mmHg. We observed decreasing in NIHSS from 12.89 at initial to 9.5 at discharge. Statistical analysis using Pearson's for delta SBP and MAP with NIHSS initial and discharge was not significant. The average of SBP and MAP of the patient who died is higher than the survived patient; however, it was not statistically significant. Conclusion: We could not find the relationship between initial systolic blood pressure, initial mean arterial pressure, and NIHSS in survived and deceased patients.