Median SBP Research Articles

Drug adherence and psychosocial characteristics of patients presenting with hypertensive urgency at the emergency department.

To identify potentially targetable psychosocial factors associated with nonadherence to prescribed antihypertensive medications in patients presenting with hypertensive urgencies at an emergency department. This prospective study included patients treated with antihypertensive drugs who presented with hypertensive urgencies (SBP ≥180 mmHg and/or DBP ≥110 mmHg) at the emergency department of a tertiary referral clinic between April 2018 and April 2019. Health literacy was assessed using the Newest Vital Sign test. The Hospital Anxiety and Depression Scale (HADS) was used to quantify symptoms of anxiety and depression. Patients were classified nonadherent if less than 80% of the prescribed antihypertensive drugs were detectable in urine or plasma using liquid chromatography-high-resolution mass spectrometry. A total of 104 patients (62% women) presenting with hypertensive urgencies with a median SBP of 200 mmHg (IQR 190-212) and DBP of 97.5 mmHg (IQR 87-104) were included. Twenty-five patients (24%) were nonadherent to their antihypertensive medication. Nonadherent patients were more often men (66 versus 23%, P = 0.039), prescribed higher numbers of antihypertensive drugs (median 3, IQR 3-4 versus 2, IQR 1-3; P < 0.001), and more often treated with calcium channel blockers (76 versus 25%; P < 0.001) and/or diuretics (64 versus 40%; P = 0.030). There was no difference in health literacy (P = 0.904) or the scores on the HADS subscales for depression (P = 0.319) and anxiety (P = 0.529) between adherent and nonadherent patients. Male sex, higher numbers of antihypertensive drugs, and treatment with diuretics and/or calcium channel blockers were associated with nonadherence. We did not identify a specific psychosocial characteristic associated with nonadherence.

Physiological and Lifestyle Factors Associated With Abnormal Blood Pressure in Adolescents Before and After a School-Based Wellness Program in Michigan: A Report From Project Healthy Schools

PurposeHypertension (HTN) is associated with increased cardiovascular risk and unhealthy lifestyles in adults. However, data on both physiological and lifestyle factors associated with abnormal blood pressure (BP) in adolescents, as well as the effectiveness of interventions in improving these factors among adolescents with abnormal BP, is scarce. MethodsStudents enrolled in a middle-school-based wellness program, Project Healthy Schools (PHS), between 2005–2016 were eligible. Three systolic (SBP) and diastolic (DBP) BP measurements were taken pre-PHS and post-PHS; averages of the final two were analyzed. Students were grouped by baseline BP: abnormal BP (≥90th percentile for SBP and/or DBP, or ≥120/80 mmHg) or normal BP (<90th percentile for SBP and/or DBP, or <120/80 mmHg). Demographics, physiologic measures, and health behaviors were compared between groups pre- and post-PHS. ResultsOf 2,865 students, 812 (28.3%) had abnormal BP. Median SBP was 119 mmHg in abnormal BP students and 103 mmHg in normal BP students (p < .001). Females were less likely to have abnormal BP than males (48.4% vs. 51.6%, p < .01). Pre-PHS, abnormal BP students were more likely to be overweight (62.3% vs. 28.2%, p < .001) or obese (38.9% vs. 11.3%, p < .001) than normal BP students. Their total cholesterol, triglycerides, random glucose, resting, and recovery heart rates were also higher, and they had worse dietary and sedentary habits. Post-PHS, abnormal BP students demonstrated greater reduction in SBP (−4.0 vs. 2.8 mmHg, p < .001) and DBP (–3.3 vs. .8 mmHg, p < .001) than normal BP students. ConclusionsAbnormal BP was prevalent and associated with worse cardiometabolic health parameters and behaviors at baseline. Abnormal BP students demonstrated significant improvements in BP post-PHS, suggesting school-based programs may be effective as nonpharmacological lifestyle interventions in this population.

154-LB: Cardiac MRI Findings in Young Adults with Childhood-Onset Type 2 Diabetes

Left ventricular (LV) hypertrophy and left atrial dilation are present at echocardiography in youth with T2D, however limited cardiac MRI data exist. We compared cardiac MRI findings in young adults with childhood- onset T2D (n=10) age 19-24 years, with published controls. History, physical exam and HbA1c were obtained. Hemodynamics were evaluated from cine imaging. For myocardial fibrosis, extracellular volume (ECV) fraction and native T1 relaxation times were assessed using a Modified Look-Locker Imaging sequence. Subjects were 8 females and 2 males, 7 black, 1 white, 1 mixed race and 1 Hispanic. Median (interquartile range IQR) age, diabetes duration, SBP, BMI and HbA1c were 19.9 (1.39) years, 7.8 (4.7) years, 121.5 (25) mmHg, 32.7 (9.5) kg/m2 and 10.3 (3.04)%, respectively. Subjects had a higher median (IQR) end systolic volume (ESV) index than published mean (SD) for healthy 20-29 year olds: 40.81 (5.74) ml/m2 vs. 29 (5.1) ml/m2 (p=0.007). However, they had lower LV mass index: 54.61 (9.01) g/m2 vs. 69 (8.1) g/m2 (p=0.01) and ejection fraction (EF): 50 (2.8)% vs. 66 (4.6)% (p=0.0049). Higher median (IQR) myocardial T1 of 1030.35 (44.6) msec vs. 965.6 (30.2) msec (p=0.005) and ECV fraction of 27.5 (1.5)% vs. 25 (3)% (p=0.012) were present. LV mass index directly correlated with HbA1c (rs= 0.69, p=0.03). Females had a higher median (IQR) ESV index of 40.81 (4.08) ml/m2 than published mean (SD) for females age 16-20 years of 29 (7.5) ml/m2 (p= 0.01), but lower EF of 50 (2.65)% vs. 64.3 (7.3)% (p= 0.01) and cardiac index of 3.08 (0.425) L/min/m2 vs. 3.85 (0.86) L/min/m2 (p= 0.01). ESV index positively correlated with HbA1c (rs=0.762, p=0.03). Males had a median (IQR) ESV index of 39.94 (25.7) ml/m2, LV mass index of 67.46 (13.9) g/m2 and EF of 54.95 (9.9)%. In this pilot study, young adult subjects with youth-onset T2D had a different myocardial phenotype compared to published normal values, characterized by undersized hearts relative to larger body size, poorer systolic performance and evidence for early onset myocardial fibrosis. Disclosure S. Vazquez Diaz: None. L.E. Katz: None. S. Gidding: None. W. Witschey: None. C. Capella: None. H. Litt: None. Funding University of Pennsylvania; National Institutes of Health (3T32DK7314-39S1)

Delta Systolic Blood Pressure (SBP) Can be a Stronger Predictor of Mortality Than Pre-Aortic Occlusion SBP in Non-Compressible Torso Hemorrhage: An Abotrauma and Aorta Analysis.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is becoming a standardized adjunct for the management in patients with severe non-compressible torso hemorrhage (NCTH). Although guidelines have been developed to help with the best indications for REBOA utilization, no studies have addressed the significance of change in systolic blood pressure (ΔSBP) after REBOA insufflation. We hypothesized that ΔSBP would predict mortality in patients with NCTH and have utility as a surrogate marker for hemorrhage status. This was an international, multicenter retrospective review of all patients managed with REBOA from the ABOTrauma Registry and the AORTA database. ΔSBP was defined as the difference between pre- and post-REBOA insertion SBP. Based on post-insertion SBP, patient hemorrhage status was categorized as responder or non-responder. A non-responder was defined as a hypotensive patient with systolic blood pressure < 90 mm Hg after REBOA placement with full aortic occlusion. Significance was set at P < 0.05. A total of 524 patients with NCTH were included. Most (74%) were male, 77% blunt injured with a median age of 40 (27-58) years and Injury Severity Score 34 (25-45). Overall mortality was 51.0%. Twenty percent of patients were classified as non-responders. Demographic and injury descriptors did not differ between groups. Mortality was significantly higher in non-responders versus responders (64% versus 46%, respectively; P = 0.001). Non-responders had lower median pre-insertion SBP (50 mm Hg vs. 67 mm Hg; P < 0.001) and lower ΔSBP (20 mm Hg vs. 48 mm Hg; P < 0.001). REBOA non-responders present and remain persistently hypotensive and are more likely to die than responders, indicating a potential direct correlation between ΔSBP as a surrogate marker of hemorrhage volume status and mortality. Future prospective studies will need to further elucidate the impact of Damage Control Resuscitation efforts on ΔSBP and mortality.

Cross-sectional centiles of blood pressure by age and sex: a four-hospital database retrospective observational analysis

ObjectivesNational guidelines for identifying physiological deterioration and sepsis in hospitals depend on thresholds for blood pressure that do not account for age or sex. In populations outside hospital, differences in...

P252 The cardiovascular risk profile in patients with inflammatory bowel disease: A cross-sectional single-centre study (the CARE-IBD study)

Abstract Background Patients with inflammatory bowel disease (IBD) have an increased risk of cardiovascular diseases (CVD). The European Society of Cardiology guidelines recommend to use a 1.5 factor CVD risk multiplier in rheumatoid arthritis, but state a gap in evidence for other inflammatory diseases. The aim of this study was to assess the prevalence of CVD and traditional cardiovascular risk factors in IBD. Methods This is a single-centre cross-sectional study at the IBD outpatient clinic in September and October 2019. Patients ≥18 years underwent body measurements (systolic, diastolic blood pressure (SBP, DBP), length, weight, waist, hip circumference), biochemical analysis (plasma glucose, total cholesterol (TC), triglycerides, HDL, LDL) and completed an extensive cardiovascular questionnaire (history of CVD, thromboembolic events, medication use). To identify groups at risk of hypertension (SBP&amp;gt;140 or DBP&amp;gt;90 mmHg), overweight (&amp;gt;25 kg/m2), hyperlipidaemia (TC&amp;gt;5 mmol/l) and cardiovascular events, comparisons were made between gender, IBD subtype (Crohn’s disease (CD), ulcerative colitis (UC)) and disease activity (Harvey Bradshaw Index or Simple Clinical Colitis Activity Index&amp;gt;5). Results A total of 235 IBD patients were included (112 males (48%), median age 45 years (IQR 33–55): 143 CD (61%), 92 UC (39%)). Median SBP and DBP were 135 (IQR 122–145) and 84 mmHg (IQR 66–93); hypertension was present in 43% of patients. Median BMI was 24.5 kg/m2 (IQR 21.9–27.4); 41% of patients were overweight. Hyperlipidaemia was present in 19% of patients. The self-reported prevalence of hypertension was 13%, hyperlipidaemia 8%, diabetes 4%, cardiovascular disease (heart failure, myocardial infarction, transient ischaemic attack, cerebrovascular accident) 10% and thromboembolic events (deep venous thrombosis, pulmonary embolism) 8%. Male patients showed a higher prevalence of hypertension (61%), greater waist–hip ratio (0.93, all p &amp;lt; .001), higher triglyceride (1.6 mmol/l, p = .003) and lower HDL levels (1.2 mmol/l, p = .000) as compared with females. CD patients were more frequently smokers (16%) with disease activity (51%)(p &amp;lt; .001), but showed lower levels of triglycerides (1.6 mmol/l, p = .013), TC (4.0 mmol/l) and LDL (2.3 mmol/l) (p &amp;lt; .001) as compared with UC. During active disease lower levels of LDL were observed as compared with remission (2.4 vs. 2.7 mmol/l, p = .040). Conclusion CVD are considerably prevalent in IBD patients. Well-known CVD risk factors hypertension, obesity and hyperlipidaemia are highly prevalent and remain undiagnosed in a substantial proportion of patients. Although no significant association is observed between CVD and gender or IBD subtype, CVD risk profile is different. Screening and early treatment of CVD risk factors might be recommended in IBD.

Intraoperative Blood Pressure Variability Predicts Postoperative Mortality in Non-Cardiac Surgery-A Prospective Observational Cohort Study.

Little is known about the clinical importance of blood pressure variability (BPV) during anesthesia in non-cardiac surgery. We sought to investigate the impact of intraoperative BPV on postoperative mortality in non-cardiac surgery subjects, taking into account patient- and procedure-related variables. This prospective observational study covered 835 randomly selected patients who underwent gastrointestinal (n = 221), gynecological (n = 368) and neurosurgical (n = 246) procedures. Patient’s and procedure’s risks were assessed according to the validated tools and guidelines. Blood pressure (systolic, SBP, and diastolic, DBP) was recorded in five-minute intervals during anesthesia. Mean arterial pressure (MAP) was assessed. Individual coefficients of variation (Cv) were calculated. Postoperative 30-day mortality was considered the outcome. Median SBP_Cv was 11.2% (IQR 8.4–14.6), DBP_Cv was 12.7% (IQR 9.8–16.3) and MAP_Cv was 10.96% (IQR 8.26–13.86). Mortality was 2%. High SBP_Cv (i.e., ≥11.9%) was associated with increased mortality by 4.5 times (OR = 4.55; 95% CI 1.48–13.93; p = 0.008). High DBP_Cv (i.e., ≥22.4%) was associated with increased mortality by nearly 10 times (OR = 9.73; 95% CI 3.26–28.99; p < 0.001). High MAP_Cv (i.e., ≥13.6%) was associated with increased mortality by 3.5 times (OR = 3.44; 95% CI 1.34–8.83; p = 0.01). In logistic regression, it was confirmed that the outcome was dependent on both SBPV and DBPV, after adjustment for perioperative variables, with AUCSBP_Cv = 0.884 (95% CI 0.859–0.906; p < 0.001) and AUCDBP_Cv = 0.897 (95% CI 0.873–0.918; p < 0.001). Therefore, intraoperative BPV may be considered a prognostic factor for the postoperative mortality in non-cardiac surgery, and DBPV seems more accurate in outcome prediction than SBPV.

Reducing Unnecessary Treatment of Asymptomatic Elevated Blood Pressure with Intravenous Medications on the General Internal Medicine Wards: A Quality Improvement Initiative.

Asymptomatic elevated blood pressure (BP) is common in the hospital. There is no evidence supporting the use of intravenous (IV) antihypertensives in this setting. To determine the prevalence and effects of treating asymptomatic elevated BP with IV antihypertensives and to investigate the efficacy of a quality improvement (QI) initiative aimed at reducing utilization of these medications. Retrospective cohort study. Urban academic hospital. Patients admitted to the general medicine service, including the intensive care unit (ICU), with ≥1 episode of asymptomatic elevated BP (>160/90 mm Hg) during hospitalization. A two-tiered, QI initiative. The primary outcome was the monthly proportion of patients with asymptomatic elevated BP treated with IV labetalol or hydralazine. We also analyzed median BP and rates of balancing outcomes (ICU transfers, rapid responses, cardiopulmonary arrests). We identified 2,306 patients with ≥1 episode of asymptomatic elevated BP during the 10-month preintervention period, of which 251 (11%) received IV antihypertensives. In the four-month postintervention period, 70 of 934 (7%) were treated. The odds of being treated were 38% lower in the postintervention period after adjustment for baseline characteristics, including length of stay and illness severity (OR = 0.62; 95% CI 0.47-0.83; P = .001). Median SBP was similar between pre- and postintervention (167 vs 168 mm Hg; P = .78), as were the adjusted proportions of balancing outcomes. Hospitalized patients with asymptomatic elevated BP are commonly treated with IV antihypertensives, despite the lack of evidence. A QI initiative was successful at reducing utilization of these medications.

Abstract TP426: Description of Early Hematoma Expansion Trajectory and Rate of Expansion in Patients With Intracranial Hemorrhage

Introduction: Expansion of intracerebral hemorrhage (ICH) is associated with increased disability and mortality. The trajectory and rate of hematoma expansion (HE) have not been well described. We evaluated ultra-early baseline and follow up CT and MRI scans to describe the direction and rate of expansion. Methods: We analyzed consecutive ICH patients enrolled in the multicenter, NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) clinical trial with baseline and follow up imaging between 6 to 48 hours. HE was defined as growth more than 33% or more than 6mL. Topographic locations were determined using x-, y-, and z- coordinates on OsiriX software. Direction of HE was described by a change in coordinates and correlated with anatomic location. Hematoma growth (HG) rate was described as hematoma volume divided by symptoms onset to scan time in hours. HE rate was described as change in hematoma volume between initial and follow up imaging divided by the time lapse in hours. Results: There were 387 patients with intracerebral hemorrhage enrolled in the FAST-MAG clinical trial. 260 patients had initial and follow up imaging without undergoing hematoma evacuation. The median age was 64, 176 (66.7%) were male. 97 patients were on antiplatelets and 25 were on anticoagulation. Median SBP on admission was 178 and median DBP was 95. 80 (30.7%) patients demonstrated hematoma expansion. The most common location observed was the basal ganglia (69.6%). These hemorrhages tend to expand in all x-, y- and z- coordinates with the greatest change in z- expanding cortically through the corona radiata. There is a high rate of intraventricular hemorrhage (51.5%). Average HG rate was 18.09mL/hr (17.9) and the average HE rate was 1.37mL/hr (1.86). Interestingly, basal ganglia and thalamic hemorrhages had higher rates of expansion. Both HG rate and HE rate were influenced by changes in blood pressure and use of antiplatelets or anticoagulantion. Conclusion: Hematoma expansion location can be predicted based on the location of the initial hemorrhage location. Hematoma trajectory and HE rate can help predict poor outcomes in ICH.

Pre-hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for exsanguinating pelvic haemorrhage

AimTo report the initial experience and outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an adjunct to pre-hospital resuscitation of patients with exsanguinating pelvic haemorrhage. MethodsDescriptive case series of consecutive adult patients, treated with pre-hospital Zone III REBOA by a physician-led pre-hospital trauma service, between January 2014 and July 2018. ResultsREBOA was attempted in 19 trauma patients (13 successful, six failed attempts) and two non-trauma patients (both successful) with exsanguinating pelvic haemorrhage. Trauma patients were severely injured (median ISS 34, IQR: 27–43) and profoundly hypotensive (median systolic blood pressure [SBP] 57, IQR: 40–68 mmHg). REBOA significantly improved blood pressure (Pre-REBOA median SBP 57, IQR: 35–67 mmHg versus Post- REBOA SBP 114, IQR: 86–132 mmHg; Median of differences 66, 95% CI: 25–74 mmHg; P < 0.001). REBOA was associated with significantly lower risk of pre-hospital cardiac arrest (REBOA 0/13 [0%] versus no REBOA 3/6 [50%], P = 0.021) and death from exsanguination (REBOA 0/13 [0%] versus no REBOA 4/6 [67%], P = 0.004), when compared to patients with a failed attempt. Successful REBOA was associated with improved survival (REBOA 8/13 [62%] versus no REBOA 2/6 [33%]; P = 0.350). Distal arterial thrombus requiring thrombectomy was common in the REBOA group (10/13, 77%). ConclusionREBOA is a feasible pre-hospital resuscitation strategy for patients with exsanguinating pelvic haemorrhage. REBOA significantly improves blood pressure and may reduce the risk of pre-hospital hypovolaemic cardiac arrest and early death due to exsanguination. Distal arterial thrombus formation is common, and should be actively managed.

Cardiogenic shock in France: What and who are we talking about? A descriptive analysis of the FRENSHOCK multicenter prospective registry

Epidemiologic data about cardiogenic shock (CS) are still poor and focused on ischemic CS, forgetting all part of the CS encountered in clinical practice. FRENSHOCK registry (NCT02703038) was a large prospective multicenter registry of non-selected CS patients admitted in critical care units realized between April and October 2016 in France. Patients were included if they met the following three criteria: – low cardiac output defined by SBP < 90 mmHg and/or the need of amines, or a low cardiac output defined by CI < 2.2L/min/m 2 (TTE or Swan–Ganz); – elevation of left and/or right heart pressures defined by clinic/radiology/biology/echocardiography/Swan-Ganz; – clinical and/or biological hypoperfusion. In total, 772 patients were included in 48 centers (male 72%, mean age of 66y). Comorbidities associated previous coronary revascularization 26%, peripheral arterial disease 15%, renal failure 21%, COPD 6%, diabetes 28%, tobacco 28%, dyslipidemia 35% and hypertension 47%. 56% were known for previous cardiomyopathy (30% ischemic, 10% idiopathic, 8% valvular). CS etiology often associated several triggers: ischemic was retained for 36% (type 1 infarction 17%). Non-ischemic trigger factors were predominant (64%): supra-ventricular (13%) and ventricular arrythmia (13%), infection (12%), iatrogenic (6%), conductive disorders (2%), non-observance (4%), and others (14%). At admission median SBP was 101.2 mmHg. Right heart failure signs were present in 49% and left signs in 72% (Killip IV 49%). Biological analysis found high lactate (3.0 mmol/L), renal (eGFR 49.6 ml/min) and hepatic alteration (ASAT 90.0 UI/ml; PT 57.1%). Median LVEF was 26.3% and TAPSE 13.4 mm. When realized (52%) coronarography was pathological in 81% (monotroncular 31%, bitroncular 35% and tritroncular 34%). A culprit lesion (79%) concern LVA 48%, RCA 23% and left main 15%. CS presentation and etiology are heterogeneous with a predominance of non-ischemic CS in practice.

Cardiovascular disease prevalence and risk factor prevalence in Type 2 diabetes: a contemporary analysis.

AimsTo describe the prevalence of major cardiovascular disease (CVD) and risk factor control in a contemporary population with Type 2 diabetes.MethodsWe used data from the national registry in Scotland, Scottish Care Information‐Diabetes, linked to hospital admissions. Using descriptive statistics and logistic regression we described associations of risk factors with CVD. CVD was defined based on diagnostic codes in primary or secondary care data for ischaemic heart disease, cerebrovascular disease peripheral arterial disease, heart failure, cardiac arrhythmia, hypertensive heart disease and revascularization procedures.ResultsAmong 248 400 people with Type 2 diabetes with a median age of 67.5 years (IQR 58.2, 76.1) and median diabetes duration of 7.8 years (3.8, 13.0), 32% had prior CVD (35% of men, 29% of women). Median HbA1c overall was 55 mmol/mol (7.2%), median SBP was 132 mmHg, median total cholesterol was 4.1 mmol/l and mean BMI was 32 kg/m2 . Overall two‐thirds (65% of men, 68% of women) have two or more of the following CVD risk factor thresholds: HbA1c ≥ 53 mmol/mol (7%), SBP > 130 mmHg or DBP > 80 mmHg, total cholesterol ≥ 5 mmol/l or BMI ≥ 30 kg/m2, or were currently smoking. Overall 84% were taking anti‐hypertensives and 75% a statin. Use of metformin was common at 58%, but other diabetes drugs that reduce CVD were rarely used.ConclusionsThere continues to be a high prevalence of CVD among people with Type 2 diabetes and a high level of unmet need for risk factor control. This implies substantial scope for reducing the excess risk of CVD in diabetes through improved management of known risk factors.

A case series of perioperative variables in relation to short-term outcomes in pediatric renal transplant recipients.

Multiple perioperative variables have been shown in existing literature to influence long-term outcomes of pediatric RTx, such as allograft survival. Their impact on short-term outcomes is not as well-documented. This case series aims to investigate the effects of nine perioperative variables on two short-term outcomes in pRTR: 1-week post-operative eGFR and post-operative LOS. A total of 73 pRTR transplanted over 3years from 2012 to 2014 at a single center were studied retrospectively and statistical analyses were performed. There was higher 1-week post-operative eGFR in pRTR who received living donor transplants compared to those who received deceased donor transplants (P=.01), with mean eGFR of 135mL/min/1.73m2 and 82mL/min/1.73m2 , respectively. Aorta-IVC anastomosis was associated with longer LOS compared to iliac vessel anastomosis (P=.03), with median LOS of 19 and 13days, respectively. There were no significant effects on 1-week eGFR or LOS of the seven other variables: pRTR age and gender, donor age, preoperative donor SBP, intraoperative mean CVP before graft perfusion, intraoperative median SBP z score after graft perfusion, and intraoperative fluid volume. Living donor transplants were associated with higher 1-week post-operative eGFR compared to deceased donor transplants. Aorta-IVC anastomosis was significantly associated with longer LOS compared to iliac vessel anastomosis.

Is there any alternative to standard chest compression techniques in infants? A randomized manikin trial of the new "2-thumb-fist" option.

Background:Pediatric cardiac arrest is a fatal emergent condition that is associated with high mortality, permanent neurological injury, and is a socioeconomic burden at both the individual and national levels. The aim of this study was to test in an infant manikin a new chest compression (CC) technique (“2 thumbs-fist” or nTTT) in comparison with standard 2-finger (TFT) and 2-thumb-encircling hands techniques (TTEHT).Methods:This was prospective, randomized, crossover manikin study. Sixty-three nurses who performed a randomized sequence of 2-minute continuous CC with the 3 techniques in random order. Simulated systolic (SBP), diastolic (DBP), mean arterial pressure (MAP), and pulse pressures (PP, SBP–DBP) in mm Hg were measured.Results:The nTTT resulted in a higher median SBP value (69 [IQR, 63–74] mm Hg) than TTEHT (41.5 [IQR, 39–42] mm Hg), (P < .001) and TFT (26.5 [IQR, 25.5–29] mm Hg), (P <.001). The simulated median value of DBP was 20 (IQR, 19–20) mm Hg with nTTT, 18 (IQR, 17–19) mm Hg with TTEHT and 23.5 (IQR, 22–25.5) mm Hg with TFT. DBP was significantly higher with TFT than with TTEHT (P <.001), as well as with TTEHT than nTTT (P <.001). Median values of simulated MAP were 37 (IQR, 34.5–38) mm Hg with nTTT, 26 (IQR, 25–26) mm Hg with TTEHT and 24.5 (IQR,23.5–26.5) mm Hg with TFT. A statistically significant difference was noticed between nTTT and TFT (P <.001), nTTT and TTEHT (P <.001), and between TTEHT and TFT (P <.001). Sixty-one subjects (96.8%) preferred the nTTT over the 2 standard methods.Conclusions:The new nTTT technique achieved higher SBP and MAP compared to the standard CC techniques in our infant manikin model. nTTT appears to be a suitable alternative or complementary to the TFT and TTEHT.

Haemodynamically unstable pelvic trauma: initial validation of a dedicated protocol by a retrospective cohort study with historical controls

Background: We present our experience after the introduction of Advanced Trauma Life Support (ATLS)©, Trauma Team (TT) and Preperitoneal Pelvic Packing (PPP) protocols for the treatment of hemodynamically unstable pelvic blunt trauma.Methods: This is a retrospective study with historical controls: before (Control Group, CG) and after (Study Group SG) the introduction of the protocol. A single physician managed the CG and angiography was the emergency manoeuvre. A team with ATLS guidelines and PPP as an emergency manoeuvre managed the SG. Data were collected retrospectively. Patients were divided into two groups: before and after the introduction of protocols.Results: From January 2007 to October 2014, 36 patients were treated at our Centre. We consider patients from January 2007 to August 2011 (19 patients, CG) and from September 2011 to October 2014 (17 patients, SG). Median age was 54 years (43–69) in the CG vs. 47 (40–63) in the SG (p = 0.43), median initial SBP 90 mmHg (85–103) in the CG 94 (69–103) in the SG, (p = 0.60), heart rate was 90 (80–110) in the G and 110 (95–130) in the SG, (p = 0.09). Median Injury Severity Score was 33 (21–41) in the CG and 34 (26–41) in the SG (p = 0.29). Time from arrival in the Emergency Department to first therapeutic manoeuvre was 132 minutes (109–180) in the CG and 87 minutes (51–204) in the SG (p = 0.4). The difference in mortality was statistically significant: 64.7% (11/17) in the CG and 23.5% (4/17) in the SG (p = 0.02).Conclusions: The introduction of protocols changed our approach in hemodynamically unstable pelvic trauma, achieving a remarkable improvement in early mortality.

Associations between glycaemic deterioration and aortic stiffness and central blood pressure: the ADDITION-PRO Study.

In the context of screening for diabetes, we examined levels of central haemodynamics among individuals with different levels of diabetes risk and analysed the impact of glycated haemoglobin A (HbA1c) and HbA1c changes on central haemodynamics. A Danish population-based stepwise screening programme for diabetes including a diabetes risk score (DRS) questionnaire and glucose measurements identified seven groups of individuals at increasing levels of diabetes risk. After 7.8 years of follow-up, 2048 individuals underwent aortic stiffness assessment by carotid-femoral pulse wave velocity (aPWV) and assessment of central blood pressure (BP). We compared differences in central haemodynamics at follow-up between the diabetes risk groups and analysed the impact of HbA1c at screening and HbA1c change on central haemodynamics at follow-up adjusting for relevant confounders. At screening, median age was 59.0 years, and median HbA1c was 5.7%. At follow-up, median aPWV was 8.0 m/s, and median central SBP was 123.5 mmHg. Among individuals with high DRS, aPWV, central SBP and DBP, and pulse pressure were higher in individuals with impaired glucose tolerance than normal glucose tolerance. Per 1%-point higher HbA1c at screening, aPWV was 0.23 m/s (95% confidence interval: 0.00; 0.46) higher, and central DBP was 1.35 mmHg (95% confidence interval: 0.19; 2.51) lower, whereas HbA1c change was not associated with any of the central haemodynamics. Dysglycaemia is associated with future aortic stiffness. However, glycaemic deterioration over 7.8 years does not affect aortic stiffness or central BP independently of other cardiometabolic risk factors.

Management of suspected acute heart failure dyspnea in the emergency department: results from the French prospective multicenter DeFSSICA survey.

BackgroundAn appropriate diagnostic process is crucial for managing patients with acute heart failure (AHF) in emergency department (ED). Our study aims to describe the characteristics and therapeutic management of patients admitted to the ED for dyspnea suspected to have AHF, their in-hospital pathway of care and their in-hospital outcome.MethodsConsecutive patients admitted in 26 French ED for dyspnea suspected to be the consequence of AHF, prior to in hospital diagnostic test, were prospectively included at the time of their admission in the DeFSSICA Survey. Clinical characteristics at admission were recorded by the ED physicians. At discharge from ED, patients were categorized as AHF or non-AHF based on the final diagnosis reported in the discharge summary. The completeness of the data was controlled by the local investigator.ResultsFrom 16/6/2014 to 7/7/2014, 699 patients were included, of whom 537 (77 %) had a final diagnosis of AHF at discharge. Patients with AHF were older (median 83 vs 79 years, p = 0.0007), more likely to have hypertension (71 % vs 57 %, p = 0.002), chronic HF (54 % vs 37 %, p = 0.0004), atrial fibrillation (45 % vs 34 %, p = 0.02) and history of hospitalization for AHF in the previous year (40 % vs 18 %, p < 0.0001) when compared to patients without AHF. Furosemide and oxygen were used in approximately 2/3 of the patients in the ED (respectively 75 and 68 %) whereas nitrates were in 19 % of the patients. Diagnostic methods used to confirm AHF included biochemistry (100 %), pro-B-type natriuretic peptide (90 %), electrocardiography (98 %), chest X-ray (94 %), and echography (15 %) which only 18 % of lung ultrasound.After the ED visit, 13 % of AHF patients were transferred to the intensive care unit, 28 % in cardiology units and 12 % in geriatric units. In-hospital mortality was lower in AHF vs non-AHF patients (5.6 % vs 14 %, p = 0.003).DiscussionDeFSSICA, a large French observational survey of acute HF, provides information on HF presentation and the French pathway of care. Patients in DeFSSICA were elderly, with a median age of 83 years. Compared with the French OFICA study, patients in DeFSSICA were more likely to have hypertension (71 % vs 62 %) and atrial fibrillation (45 % vs 38 %). As atrial fibrillation and a rapid heart rate have been closely linked to mortality, detection of atrial fibrillation should be considered systematically.The limited use of nitrates in DeFSSICA may be related to the median SBP of 140 (121–160) mmHg. However, our use of nitrates was similar to those in the EAHFE (20.7 %) and OPTIMIZE-HF (14.3 %) registries. In line with guidelines, the proportions of patients who underwent ECG, biological analysis, or chest X-ray were all >90 % in DeFSSICA. Similarly, BNP or pro-BNP was measured in 93 % of patients, compared with 82 % of patients in the OFICA study. Although BNP may be helpful when the diagnosis of HF is in doubt, ultrasound remains the gold standard. The use of ultrasound in the ED has been reported to accelerate the diagnosis of HF and the initiation of treatment, and shorten the length of stay. In-hospital mortality of HF patients in DeFSSICA was 6.4 %, slightly lower than in the OFICA study (8.2 %). Improved interdisciplinary cooperation has been highlighted as a key factor for the improvement of HF patient care.ConclusionsDeFSSICA shows that patients admitted for dyspnea suspected to be the consequence of AHF are mostly elderly. The diagnosis of AHF is difficult to ascertain based on clinical presentation in patients with dyspnea. Novel diagnostic techniques such as thoracic ultrasound are warranted to provide the right treatment to the right patients in the ED as early as possible.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-016-0300-x) contains supplementary material, which is available to authorized users.

ICU sedation with dexmedetomidine after severe traumatic brain injury

Objective: To comprehensively describe the use of dexmedetomidine in a single institutional series of adult ICU patients with severe TBI. This study describes the dexmedetomidine dosage and infusion times, as well as the physiological parameters, neurological status and daily narcotic requirements before, during and after dexmedetomidine infusion.Methods: This study identified 85 adult patients with severe TBI who received dexmedetomidine infusions in the Trauma ICU at Vanderbilt University Medical Center between 2006–2010. Demographic, haemodynamic, narcotic use and sedative use data were systematically obtained from the medical record and analysed for changes associated with dexmedetomidine infusion.Results: During infusion with dexmedetomidine, narcotic and sedative use decreased significantly (p < 0.001 and p < 0.05). Median MAP, SBP, DBP and HR also decreased significantly during infusion when compared to pre-infusion values (p < 0.001). Despite the use of dexmedetomidine, RASS and GCS scores improved from pre-infusion to infusion time periods.Conclusions: The findings demonstrate that initiation of dexmedetomidine infusion is not associated with a decline in neurological functioning in adults with severe TBI. Although there was an observed decrease in haemodynamic parameters during infusion with dexmedetomidine, the change was not clinically significant and the requirements for narcotics and additional sedatives were minimized.

Abstract 15973: The Association Between Blood Pressure Control and Outcomes Among Black Participants in the Jackson Heart Study

Introduction: The 2014 hypertension (HTN) guidelines liberalized blood pressure (BP) goals for people ≥60 years. Hypothesis: Increased systolic and diastolic blood pressure (SBP/DBP) will be associated with a higher risk of mortality and heart failure hospitalization (HFH) across all age groups. Methods: We used age-adjusted Kaplan-Meier estimates to calculate the cumulative incidence of mortality and HFH across SBP/DBP categories (Figure) among 5280 participants of the Jackson Heart Study (JHS), an exclusively black population. We used Cox proportional hazards models to investigate associations between baseline visit SBP/DBP and both mortality and HFH. Linearity of associations and differential effects by age were assessed. Results: Median age was 56 years (IQR: 46-65); 63% were female; median SBP was 125 mmHg (IQR: 114-137); and median DBP was 79 mmHg (IQR: 72-86). There were 520 deaths over 9 years and 340 HFHs over 7 years. The age-adjusted cumulative incidence of both mortality and HFH increased with SBP, while rates of both outcomes were similar by DBP (Figure). After multivariable adjustment, every 10 mmHg increase in SBP was associated with increased mortality (HR 1.12 95% CI [1.06, 1.17]; p&lt;.001) and HFH (HR 1.07 95% CI [1.00, 1.14]; p=0.05). The mortality risk per 10mmHg increase in SBP was greater in participants &lt;60 years (HR 1.26 95% CI [1.13, 1.42]; p&lt;.001) than ≥ 60 years (HR 1.09 95% CI [1.03, 1.15]; p=.004). DBP was inversely associated with risk of mortality (HR 0.85 95% CI [0.77, 0.94]; p= .002) and not associated with HFH (p=.20). Conclusions: In this JHS cohort, SBP was associated with both mortality and HFH, while DBP was inversely associated with mortality. Adults across all age groups were at increased risk of mortality as SBP increased. In the context of new HTN guidelines, these findings have important implications and should be considered when determining BP treatment goals in Black patients.

Abstract 17098: Evaluation of a Non-laboratory-based Cardiovascular Disease Risk Score in Predicting Cardiovascular Mortality in the Southern Community Cohort Study

Introduction: Cardiovascular disease (CVD) risk prediction guides clinical recommendations regarding primary prevention strategies. Recently, a non-laboratory-based CVD risk score was derived and validated in several populations. We evaluated the performance of the non-laboratory CVD risk score among individuals of low socioeconomic status in the southeastern US, with high CVD incidence rates. Methods: The Southern Community Cohort Study (SCCS) is a prospective cohort study of black and white adults enrolled primarily from community health centers in the southeastern US between 2002-2009. We calculated c-statistics and 95% confidence intervals (CI) to assess the performance of the non-laboratory risk score in discriminating 5- year risk of CVD death (ICD-10 I00-I99) in 14,243 participants (median enrollment age 51 yrs; 74% black, 71% female, 61% income &lt; $15,000 yr) with no history of MI/CABG or stroke at baseline and with complete data on all input variables (age, sex, smoking, diabetes mellitus, reported hypertension (HTN), measured SBP, and BMI). Reported HTN was substituted for anti-HTN therapy, used in the original risk score, because the latter was available only for a subset of the SCCS population. However, among this subset, 82% of individuals who reported HTN also reported use of anti-HTN drugs. Results: CVD risk factors were common: HTN (66%), smoking (59%), diabetes (29%), median SBP 130 mmHg, and median BMI 31 kg/m2. CVD death occurred in 263 participants (1.8%). The non-laboratory CVD risk score demonstrated poor discrimination for CVD mortality, with c-statistics of 0.65 (95% CI: 0.61-0.68) overall and 0.64 (0.59-0.69), 0.65 (0.6-0.7), 0.67 (0.63-0.71) and 0.58 (0.51-0.65) for males, females, blacks and whites, respectively. In an additional logistic regression model fit to the SCCS data, the inclusion of education and income did not substantially improve model performance; overall c-statistic 0.70 (0.67-0.73). Conclusion: In this population of predominantly low-income blacks and whites, a non-laboratory CVD risk score did not perform well in predicting CVD death in any of the race and gender groups. Future studies are warranted to develop algorithms for identifying individuals at increased CVD risk in low resource populations.