Severe Cardiovascular Morbidity Research Articles

Prenatal methamphetamine use increases risk of adverse maternal and neonatal outcomes

Although methamphetamine use has been increasing in recent years and occurring within new populations and in broader geographical areas, there is limited research on its use and effect in pregnancy. This study aimed to examine the association between prenatal methamphetamine use and maternal and neonatal outcomes in a large, contemporary birth cohort. This was a retrospective cohort study using California-linked vital statistics and hospital discharge data from 2008 to 2019. Methamphetamine use was identified using the International Classification of Disease, Ninth Revision and Tenth Revision, codes. Chi-square tests and multivariable Poisson regression models were used to evaluate the associations between methamphetamine use and maternal and neonatal outcomes. A total of 4,775,463 pregnancies met the inclusion criteria, of which 18,473 (0.39%) had methamphetamine use. Compared with individuals without methamphetamine use, individuals with methamphetamine use had an increased risk of nonsevere hypertensive disorders (adjusted risk ratio, 1.81; 95% confidence interval, 1.71-1.90), preeclampsia with severe features (adjusted risk ratio, 3.38; 95% confidence interval, 3.14-3.63), placental abruption (adjusted risk ratio, 3.77; 95% confidence interval, 3.51-4.05), cardiovascular morbidity (adjusted risk ratio, 4.30; 95% confidence interval, 3.79-4.88), and severe maternal morbidity (adjusted risk ratio, 3.53; 95% confidence interval, 3.29-3.77). In addition, adverse neonatal outcomes were increased, including preterm birth at <37weeks of gestation (adjusted risk ratio, 2.85; 95% confidence interval, 2.77-2.94), neonatal intensive care unit admission (adjusted risk ratio, 2.46; 95% confidence interval, 2.39-2.53), and infant death (adjusted risk ratio, 2.73; 95% confidence interval, 2.35-3.16). Methamphetamine use in pregnancy is associated with an increased risk of adverse maternal and neonatal outcomes that persists after adjustment for confounding variables and sociodemographic factors. Our results can inform prenatal and postpartum care for this high-risk, socioeconomically vulnerable population.

Cardiac magnetic resonance reveals biventricular impairment in Cushing’s syndrome: a multicentre case-control study

PurposeCushing’s syndrome (CS) is associated with severe cardiovascular (CV) morbidity and mortality. Cardiac magnetic resonance (CMR) is the non-invasive gold standard for assessing cardiac structure and function; however, few CMR studies explore cardiac remodeling in patients exposed to chronic glucocorticoid (GC) excess. We aimed to describe the CMR features directly attributable to previous GC exposure in patients with cured or treated endogenous CS.MethodsThis was a prospective, multicentre, case-control study enrolling consecutive patients with cured or treated CS and patients harboring non-functioning adrenal incidentalomas (NFAI), comparable in terms of sex, age, CV risk factors, and BMI. All patients were in stable condition and had a minimum 24-month follow-up.ResultsSixteen patients with CS and 15 NFAI were enrolled. Indexed left ventricle (LV) end-systolic volume and LV mass were higher in patients with CS (p = 0.027; p = 0.013); similarly, indexed right ventricle (RV) end-diastolic and end-systolic volumes were higher in patients with CS compared to NFAI (p = 0.035; p = 0.006). Morphological alterations also affected cardiac function, as LV and RV ejection fractions decreased in patients with CS (p = 0.056; p = 0.044). CMR features were independent of metabolic status or other CV risk factors, with fasting glucose significantly lower in CS remission than NFAI (p < 0.001) and no differences in lipid levels or blood pressure.ConclusionCS is associated with biventricular cardiac structural and functional impairment at CMR, likely attributable to chronic exposure to cortisol excess independently of known traditional risk factors.

Clinical manifestations and outcomes associated with PICU admission in children with multisystem inflammatory syndrome in Taiwan: A retrospective cohort study.

Multisystem inflammatory syndrome in children (MIS-C) is a rare and serious systemic inflammatory disorder that occurs following a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. This study aims to investigate the clinical manifestations, risk factors associated with pediatric intensive care unit (PICU) admission, and outcome among children with MIS-C in Taiwan. A retrospective analysis was conducted among pediatric patients diagnosed with MIS-C between June 2022 and February 2023 at Chang Gung Memorial Hospital, Linkou, Taiwan. Data on demographics, clinical features, laboratory findings, treatment modalities, and outcomes were collected and analyzed. Twenty-eight MIS-C patients, including 9 boys and 19 girls, with an average age of 5.3 ± 3.8 years old, were enrolled. Most of the cases (78.6%) were diagnosed following the first pandemic wave of COVID-19 in Taiwan. The leading clinical manifestations observed were fever (100%), skin rash (64.3%), tachycardia (46.4%), and vomiting (46.4%). Nine patients (32.1%) were admitted to the PICU due to hypotension or neurological manifestations. Higher levels of band-form white blood cells, procalcitonin, ferritin, d-dimer, prothrombin time, NT-proBNP, and lower platelet levels on arrival were associated with PICU admission (p = 3.9 × 10-2 ,9 × 10-3 , 4 × 10-3 ,1 × 10-3 , 5 × 10-3 , 4.1 × 10-2 , and 3.4 × 10-2 , respectively). Arrhythmia in one case (3.5%) and coronary artery abnormalities, including dilatation in two cases (7.1%) and small aneurysms in one case (3.5%) were identified. Regardless of ICU admission, no patients experienced systolic dysfunction or mortality following treatment. MIS-C cases in Taiwan have a favorable outcome. Although one-third of the patients required PICU admission, none of the MIS-C cases resulted in severe cardiovascular morbidity or mortality. This study provides valuable insights into the clinical manifestations and outcomes associated with PICU admission in children with MIS-C in Taiwan.

Assessment of Non-Alcoholic Fatty Liver Disease as Risk Factor for Cardiovascular Disease

Objectives: Non-alcoholic fatty liver disease (NAFLD) is increasing in prevalence during present obesity pandemic. More than 25% of persons globally are believed to have non-alcoholic fatty liver disease. Many reports claim that there is an increased risk of atherosclerotic cardiovascular disease (ASCVD) among patients with non-alcoholic fatty liver disease. NAFLD is a silent disease in initial stages but progress to severe hepatic disease and increases cardiovascular morbidity in later stages, so identification and management of NAFLD are of paramount importance in preventive aspect of cardiovascular disease (CVD). Hence, the aim of this present study is to assess the risk of CVD in patients with non-alcoholic fatty liver disease in patients with and without diabetes and to evaluate usefulness of non-alcoholic fatty liver disease as a risk factor for CVD. Materials and Methods: The present study is a single-center observational study and it included 81 patients with non-alcoholic fatty liver disease. Results: In these patients, cardiovascular risk is assessed by ASCVD score, PROCAM score, QRISK 3 score, and atherogenic index of plasma and compared between diabetic and non-diabetic population. The difference has been found between diabetic and non-diabetic in Procom_score, ASCVD_score, and Q-risk_score but not found in AIP_score. Conclusion: The outcome of this study is that there is an increased risk of cardio vascular disease in patients with non-alcoholic fatty liver disease and risk is further increased in patients with coexisting diabetes mellitus and NAFLD.

Assisted Reproductive Technology and Cardiovascular Outcomes in Parents and Offspring

BackgroundThe impact of assisted reproductive technology (ART) on the cardiovascular system is unclear. MethodsWe conducted a retrospective longitudinal cohort study of 1,001,593 pregnancies conceived naturally or through ART from 2008 to 2019 in Québec to assess the association of ART with cardiovascular disease in families. The exposure measure was ART. The outcome included severe maternal cardiovascular morbidity, congenital heart defects in offspring, and long-term risk of cardiovascular hospitalisation in mothers, fathers, and offspring during 11 years of follow-up. We estimated the association between ART and cardiovascular outcomes with the use of adjusted log-binomial regression (risk ratio, 95% confidence interval [CI]) and Cox proportional hazards regression models (hazard ratio [HR]). ResultsCompared with natural conception, ART was associated with 2.04 times the risk of severe cardiovascular morbidity in mothers (95% CI 1.86-2.23) and 1.38 times the risk of congenital heart defects in offspring (95% CI 1.26-1.50). ART was not associated with the risk of maternal cardiovascular hospitalisation following pregnancy (HR 1.03, 95% CI 0.88-1.21). However, ART was associated with an increased risk of paternal cardiovascular hospitalisation (HR 1.24, 95% CI 1.11-1.38) and offspring cardiovascular hospitalisation (HR 1.27, 95% CI 1.01-1.61), mainly due to an increased risk of hypertension. ConclusionsART is associated with only a small increase in the risk of cardiovascular complications in families. Parents and offspring may be reassured that ART likely has no major impact on the cardiovascular system.

Sleep disordered breathing and the risk of severe maternal morbidity in women with preeclampsia: A population-based study.

Obstructive sleep apnea (OSA) may exacerbate the widespread endothelial dysfunction seen in preeclampsia, potentially worsening clinical outcomes. We aimed to assess whether OSA is associated with an increased risk of severe maternal morbidity, cardiovascular morbidity, and healthcare utilization among women with preeclampsia. We performed a retrospective cohort study utilizing data from the National Perinatal Information Center (2010-2014) in the United States.The cohort comprised women with preeclampsia. We estimated the association between OSA and the outcomes using logistic regression analyses and determined odds ratio adjusted for demographic factors and comorbidities (ORadj) and associated 95% confidence intervals (CI). The primary outcome was a composite of mortality and severe maternal morbidity comprising intensive care unit (ICU) admission, acute renal failure, pulmonary edema, pulmonary embolism, congestive heart failure, cardiomyopathy, and stroke. Secondary outcomes comprised the subset of cardiovascular events, as well as increased healthcare utilization (including Cesarean delivery, preterm birth, ICU admission, and prolonged length of hospital stay). In total, 71,159 women had preeclampsia, including 270 (0.4%) with OSA. Women with preeclampsia and OSA were more likely to experience severe maternal morbidity than women without OSA (ORadj 2.65, 95% CI [1.94-3.61]). Moreover, women with concomitant OSA had more severe cardiovascular morbidity than women without OSA (ORadj 5.05, 95% CI [2.28-11.17]). Accordingly, OSA was associated with increased healthcare utilization in women with preeclampsia (ORadj. 2.26, 95% CI [1.45-3.52]). In women with preeclampsia, OSA increases the risk for severe maternal morbidity, cardiovascular morbidity, and healthcare utilization.

Prevalence of familial hypercholesterolaemia in patients presenting with premature acute coronary syndrome

Familial hypercholesterolaemia (FH) is responsible for severe hypercholesterolaemia and premature cardiovascular morbidity and mortality. The first clinical event is typically an acute coronary syndrome. Unfortunately, FH is largely underdiagnosed in the general population. To assess the prevalence of clinical FH among patients with premature (aged≤50 years) acute myocardial infarction (MI) and compare it with FH prevalence in a control population. We reviewed in our database all patients with premature MI (aged≤50 years) referred to Ambroise Paré Hospital from 2014 to 2018. FH prevalence was estimated via the Dutch Lipid Clinic Network score, based on personal and family history of premature cardiovascular disease and low-density lipoprotein cholesterol concentrations. FH was "possible" with a score between 3 and 5 points, "probable" with a score between 6 and 8 and "definite" with a score above 8. FH prevalence in young patients with MI was then compared with FH prevalence in a general population of the same age from the CARVAR 92 prospective cohort. Of the 457 patients with premature MI, 29 (6%) had "probable" or "definite" FH. In the CARVAR 92 cohort, 16 (0.16%) of 9900 subjects aged≤50 years had "probable" or "definite" FH. FH prevalence was 39 times greater among patients with premature MI than in the control population (P<0.0001). In multivariable analysis, FH was strongly associated with MI (adjusted odds ratio 38.4, 95% confidence interval 19.1-79.4). FH is>30-fold more common in patients referred for premature MI than in the general population; this highlights the need for FH screening after a first MI to enhance lipid-lowering therapy and allow early identification of family members.

Prevalence of familial hypercholesterolemia in patients presenting with premature acute coronary syndrome

Abstract Background Familial hypercholesterolemia (FH) is a common genetic disorder responsible for premature and severe cardiovascular morbidity and mortality. The FH prevalence in patients who experienced a premature acute coronary syndrome (ACS) ranges from 5 to 50% according to previous studies and no comparison with FH prevalence in general population are available in those studies. Purpose We aimed to assess the prevalence of clinical FH among patients with premature acute myocardial infarction (MI) (age ≤50 years) and to compare it with FH prevalence in a control population (age ≤50 years), coming from the same population pool. Methods Patients with diagnosis of premature MI (age ≤50 years) referred to Ambroise Paré hospital from 2014 to 2018 were included. FH prevalence was estimated via the Dutch Lipid Clinic Network score, based on personal and familial history of premature cardiovascular disease, and LDL-cholesterol levels. FH was “possible” with a score between 3 and 5 points, “probable” with a score between 6 and 8 and “definite” with a score &amp;gt;8 and no FH was defined as a score &amp;lt;3. FH prevalence in patients with MI was compared to FH prevalence in a general population (age ≤50 years), coming from the prospective cohort CARVAR 92. Results Among the 457 patients with premature MI, 220 (48%) patients had no FH, 208 (46%) had a “possible” FH and 29 (6%) had a “probable” or “definite” FH. In the control population, 9900 subjects aged ≤50 years were identified: 9343 (94.37%) had no FH, 541 (5.46%) had a “possible” FH and 16 (0.16%) had a “probable” or “definite” FH. Considering subjects with “probable” or “definite” FH, FH prevalence was 37.5 times greater among patients with premature MI than in control population (p&amp;lt;0.0001). Conclusion Familial hypercholesterolemia is &amp;gt;30-fold more common in patients referred for premature MI than in general population of the same age, coming from the same population pool. This highlights the need for FH diagnosis after a first episode of MI to enhance lipid-lowering therapy and allow an early identification of family members. Funding Acknowledgement Type of funding sources: None.

Pathophysiological Mechanisms to Review Association of Atrial Fibrillation in Heart Failure With Obstructive Sleep Apnea.

Sleep-disordered breathing (SDB) comprising obstructive sleep apnea (OSA) is found in more than half of patients with heart failure (HF) and may have negative impacts on cardiovascular function. Increased atherosclerotic cardiovascular disease and the development of coronary events and congestive heart failure are associated with OSA. It is associated with a substandard quality of life, increased hospitalizations, and a poor prognosis. Despite its association with severe cardiovascular morbidity and mortality, the condition is frequently underdiagnosed. The substantial clinical evidence has established OSA as an independent risk factor for bradyarrhythmias and tachyarrhythmias in the last decade. The mechanisms which lead to such arrhythmias are uncertain. In short, OSA patients have a significantly elevated risk of HF and atrial fibrillation (AF). The direct correlation between HF, SDB, and cardiac arrhythmias has been poorly understood. The purpose of this study is to get a better understanding of the relation between AF, OSA, and HF by focusing on the pathophysiological mechanisms underlying these conditions. Therefore, we searched for articles to support our association in PubMed and Google Scholar databases.

Predicting severe cardiovascular morbidity in pregnancy and beyond.

Predicting severe cardiovascular morbidity in pregnancy and beyond.

Outcome analysis and risk factors for postoperative colonic ischaemia after aortic surgery

PurposeColonic ischaemia (CI) represents a serious complication after aortic surgery. This study aimed to analyse risk factors and outcome of patients suffering from postoperative CI.MethodsData of 1404 patients who underwent aortic surgery were retrospectively analysed regarding CI occurrence. Co-morbidities, procedural parameters, colon blood supply, procedure-related morbidity and mortality as well as survival during follow-up (FU) were compared with patients without CI using matched-pair analysis (1:3).ResultsThirty-five patients (2.4%) with CI were identified. Cardiovascular, pulmonary and renal comorbidity were more common in CI patients. Operation time was longer (283 ± 22 vs. 188 ± 7 min, p < 0.0001) and blood loss was higher (2174 ± 396 vs. 1319 ± 108 ml, p = 0.0049) in the CI group. Patients with ruptured abdominal aortic aneurysm (AAA) showed a higher rate of CI compared to patients with intact AAA (5.4 vs. 1.9%, p = 0.0177). CI was predominantly diagnosed by endoscopy (26/35), generally within the first 4 postoperative days (20/35). Twenty-eight patients underwent surgery, all finalised with stoma creation. Postoperative bilateral occlusion and/or relevant stenosis of hypogastric arteries were more frequent in CI patients (57.8 vs. 20.8%, p = 0.0273). In-hospital mortality was increased in the CI group (26.7 vs. 2.9%, p < 0.0001). Survival was significantly reduced in CI patients (median: 28.2 months vs. 104.1 months, p < 0.0001).ConclusionCI after aortic surgery is associated with considerable perioperative sequelae and reduced survival. Especially in patients at risk, such as those with rAAA, complicated intraoperative course, severe cardiovascular morbidity and/or perioperative deterioration of the hypogastric perfusion, vigilant postoperative multimodal monitoring is required in order to initiate diagnosis and treatment.

SAT-217 Paraganglioma in Two Unrelated Kinyarwanda-Speaking Patients in Anatomically Distinct Sites

Introduction: Capable of generating excess catecholamines, untreated extra-adrenal paragangliomas (PGL) result in severe cardiovascular morbidity and mortality. Increasingly, a hereditary basis can be identified to underlie PGLs, though such data is largely absent in non-Caucasian populations. Case 1: A 43 yr. old Kinyarwanda-speaking woman from DR Congo presented with left lower extremity edema and hypertension, with blood pressure of 154/86 while on spironolactone, HCTZ and furosemide. Ultrasound was negative for a DVT; abdominal CT revealed a 3 cm necrotic mass, inferior to the duodenum and abutting the IVC and aorta, as well as 2 bladder wall lesions. EUS-guided FNA revealed a keratin-negative neuroendocrine tumor. Urinary 24hr norepinephrine (NE) was high at 185 mcg [15–80]. Urinary 24hr normetanephrine (NM) was high at 1404 mcg [119-451; hypertensive <900]. MIBG scan confirmed avidity in the aortocaval mass. Despite lack of bladder uptake on MIBG, pathology similarly pointed to PGL. Surgery included excision of bladder, pelvic nodes, uterus, and aortocaval tumor. Post-op, urinary 24hr NE was 18 mcg and NM was 297 mcg, both normal. One year later, MIBG/SPECT and CT of the abdomen were negative for recurrence. A GeneDx panel of 12 PGL/PCC mutations was negative. Case 2: An unrelated 41 yr. old Kinyarwanda-speaking woman from Rwanda, with prior history of preeclampsia and multiple miscarriages, presented with palpitations, headaches and hypertension. Echo showed a 4 cm mass posterior to the left atrium; the mass was18F-FDG PET-avid. Video-assisted thoracoscopy was performed yet the tumor’s vascularity precluded a biopsy. Biopsy of mediastinal mass after performing thoracotomy was consistent with PGL. Plasma NM was high at 7.1 nmol/l (<0.90), consistent with PGL and she underwent complete removal of the tumor. Testing for SDHB mutation was negative. Symptoms resolved and antihypertensives were discontinued. Follow-up plasma NM was 0.55 nmol/l 1-year post op and remained normal for six years of follow-up. Discussion: Less than 10% of PGLs are known to involve the mediastinum or bladder (1). In familial PGL, the most commonly identified non-syndromic mutations involve SDHD, SDHAF2, SDHB, SDHD, SDHC, VHL, and MAX. Tumorigenesis in a sizable fraction of PGLs is not well understood. Conclusion: We present two cases of extra-adrenal PGL, both exhibiting similar age, sex and geographic ancestry. Our cases raise questions that require active investigation regarding additional environmental and/ or genetic factors which might predispose to PGLs in uncommon anatomic sites.

Severe Cardiovascular Morbidity in Women With Hypertensive Diseases During Delivery Hospitalization

(Am J Obstet Gynecol. 2019;220:582.e1–582.e11) The pregnancy-related mortality ratio in the United States has tripled between 1987 and 2014. Some studies have estimated 35% to 44% of cases of maternal mortality or severe maternal morbidity are preventable. Hypertensive disorders of pregnancy (HDP) affect 10% of pregnancies worldwide and are one of the main causes of maternal and perinatal morbidity. Cardiovascular (CV) disease is the leading cause of death in women in the United States and the leading cause of pregnancy-related death. HDP have been associated with an increased risk of CV disease 10 to 30 years after delivery, but there is a lack of data on the relationship between HDP and CV morbidity during hospitalization for delivery. This study aimed to identify the risk of CV morbidity during delivery hospitalization in pregnancies complicated by HDP.

Progressive Pulmonary Artery Dilatation is Associated with Type B Aortic Dissection in Patients with Marfan Syndrome.

Objective: Marfan syndrome (MFS) is a connective tissue disorder associated with severe cardiovascular morbidity and mortality. It is unknown if aorta complications in MFS are associated with progressive pulmonary artery (PA) dilatation. Methods: We measured the PA diameter on routine magnetic resonance imaging in a population of MFS patients seen in our specialised centre with follow up of diameters as well as the outcome. Results: PA dilatation was defined as an increase in diameter of 2 mm or more, and 71 patients (44%) of our total cohort (n = 162) met this criterion; mean follow up between two scans was 8.6 years (standard deviation (SD) ± 2.7 years). Furthermore, 28 patients suffered from dissections, of which 14 had a type A dissection, 10 had a type B dissection, and 4 patients suffered from both. Of those who suffered from dissection, 64% (18 out of 28) had a dilatation of the PA, versus 39% (53 out of 134) in the patient group without a dissection (p < 0.05). There was a significant association between type B dissection and descending aorta diameter (OR 1.14; 95% CI 1.05–1.24 p < 0.01) and PA dilatation (OR 1.69; 95% CI 1.03–2.77 p = 0.04). In the multivariable analysis the final model for type B dissection, only systolic blood pressure (OR 1.06; 95% CI 1.01–1.11 p = 0.02) and PA dilatation were statistically significant (OR 1.85; 95% CI 1.10–3.12 p = 0.02) while descending aorta diameter was not. Conclusions: We report an association between progressive PA dilatation and type B dissection. Our findings encourage a renewed interest in PA dimensions in MFS.

Dyslipidemia in type 2 diabetes mellitus (T2dm): Pathophysiology, pattern and management

Type 2 diabetes mellitus (T2DM) is related with severe cardiovascular morbidity and mortality throughout the worldwide. Dyslipidemia, high blood glucose level, and coronary artery diseases are well linked with each other in T2DM and it has been demonstrated that higher prevalence of cardiovascular disease (CVD) in T2DM is due to chronic uncontrolled hyperglycemia. Dyslipidemia, which affects almost 50% of patients with T2DM, is a cardiovascular risk factor and characteristic features of dyslipidemic diabetes are elevated plasma triglyceride level, decline in high density lipoprotein cholesterol (HDL-c) level, and raised level of small dense low density lipoprotein (LDL) particles. An adequate availability of many lipid-lowering agents and nutritional supplements provides novel and effective treatments in control of lipid levels in diabetes patients. Several hypolipidemics, such as statins, fibric acid derivatives, niacin, and bile acid sequestrants, are available to target normalization of the entire lipid profile in T2DM patients. This review highlights the prevalence, underlying pathogenesis, patterns and various management approaches of dyslipidemia in patients with T2DM. Keywords: Type 2 diabetes mellitus, Dyslipidemia, Cardiovascular disease, statins, Triglycerides.

SAT-606 Graves' Orbitopathy Treated with Kahaly's Protocol: IV High Dose Glucocorticoids

Graves’ Orbitopathy (GO) is present in approximately 25-50-% of patients with Graves’ hyperthyroidism. Treatment should rely on a thorough assessment of the clinical activity score (CAS), severity of GO and its impact on the patient’s quality of life. Most patients can be managed with non surgical treatments alone, and those requiring surgical intervention often benefit from concurrent medical therapy. We are presenting a case of active and moderate GO successfully treated with high dose glucocorticoids (GCs). 48 yo female presented with history of subclinical hyperthyroidism since age 40 with only complaint of excessive tearing and redness in both eyes for last 1 yr. Physical exam was remarkable for exophthalmos of bilateral eyes with minimal inferior scleral show with no evidence of goiter. Her labs showed TSH of 0.05 (0.27-4.2 microIU/ml), FT4 2.36(0.90-1.7 ng/dL), TPO 502(<9.0 IU/ml), TSI 132(<=122%) and TRAb 12.43(<=1.75IU/L). She was treated with methimazole, currently requiring 2.5 mg daily to maintain euthyroid status. Initially she was treated with artificial tears for 2 weeks followed by tapering dose of oral prednisone for 3 weeks. 3 months later patient presented with double, blurry vision while trying to read. On exam she had exophthalmos, mild lid lag, conjunctival injection, and early pannus formation on left cornea with CAS 3,TSH 1.41,FT4 0.83 and FT3 76.2. Patient was treated with dexamethasone/ neomycin/ polymyxin B eye drops at bedtime with doxycycline 50 mg BID PO for 3 months with improvement in her symptoms and remained symptom free for 2 yrs. 2 yrs later patient presented with bilateral eye pain, redness with tearing, left > right and diplopia with horizontal gaze with CAS of 6. She was again treated with oral prednisone taper over 3 weeks without any improvement. Then she was treated with IV methylprednisolone 500 mg weekly for 6 weeks, followed by 250 mg weekly for another 6 weeks with marked improvement in her symptoms of eye pain, redness of eyelid and conjunctiva and caruncle swelling and mild improvement in eyelid swelling 4 weeks after treatment. Our patient was successfully treated with high dose IV GCs. Corticosteroids activate transcription of anti inflammatory mediators and inhibit the transcription of proinflammatory mediators (ie. cytokines and prostaglandins). IV steroids suppress immune system through genomic pathway and non genomic pathway. IV GCs are more effective and have a lower side effects burden than oral steroids and thus are the preferred mode of administration. Patient should be screened for contraindications to IV GCs, including liver dysfunction, recent viral hepatitis, severe cardiovascular morbidity, uncontrolled HTN and diabetes. High dose IV GCs can be safely used for treatment of active, moderate to severe GO and should be used as firstline treatment in patients with active and moderate to severe GO.

Severe cardiovascular morbidity in women with hypertensive diseases during delivery hospitalization

Cardiovascular disease is the leading cause of pregnancy-related death in the United States. Identification of short-term indicators of cardiovascular morbidity has the potential to alter the course of this devastating disease among women. It has been established that hypertensive disorders of pregnancy are associated with increased risk of cardiovascular disease 10-30 years after delivery; however, little is known about the association of hypertensive disorders of pregnancy with cardiovascular morbidity during the delivery hospitalization. We aimed to identify the immediate risk of cardiovascular morbidity during the delivery hospitalization among women who experienced a hypertensive disorder of pregnancy. This retrospective cohort study of women, 15-55 years old with a singleton gestation between 2008 and 2012 in New York City, examined the risk of severe cardiovascular morbidity in women with hypertensive disorders of pregnancy compared with normotensive women during their delivery hospitalization. Women with a history of chronic hypertension, diabetes mellitus, or cardiovascular disease were excluded. Mortality and severe cardiovascular morbidity (myocardial infarction, cerebrovascular disease, acute heart failure, heart failure or arrest during labor or procedure, cardiomyopathy, cardiac arrest and ventricular fibrillation, or conversion of cardiac rhythm) during the delivery hospitalization were identified using birth certificates and discharge record coding. Using multivariable logistic regression, we assessed the association between hypertensive disorders of pregnancy and severe cardiovascular morbidity, adjusting for relevant sociodemographic and pregnancy-specific clinical risk factors. A total of 569,900 women met inclusion criteria. Of those women, 39,624 (6.9%) had a hypertensive disorder of pregnancy: 11,301 (1.9%) gestational hypertension; 16,117 (2.8%) preeclampsia without severe features; and 12,206 (2.1%) preeclampsia with severe features, of whom 319 (0.06%) had eclampsia. Among women with a hypertensive disorder of pregnancy, 431 experienced severe cardiovascular morbidity (10.9 per 1000 deliveries; 95% confidence interval, 9.9-11.9). Among normotensive women, 1780 women experienced severe cardiovascular morbidity (3.4 per 1000 deliveries; 95% confidence interval, 3.2-3.5). Compared with normotensive women, there was a progressively increased risk of cardiovascular morbidity with gestational hypertension (adjusted odds ratio, 1.18; 95% confidence interval, 0.92-1.52), preeclampsia without severe features (adjusted odds ratio, 1.96; 95% confidence interval, 1.66-2.32), preeclampsia with severe features (adjusted odds ratio, 3.46; 95% confidence interval, 2.99-4.00), and eclampsia (adjusted odds ratio, 12.46; 95% confidence interval, 7.69-20.22). Of the 39,624 women with hypertensive disorders of pregnancy, there were 15 maternal deaths, 14 of which involved 1 or more cases of severe cardiovascular morbidity. Hypertensive disorders of pregnancy, particularly preeclampsia with severe features and eclampsia, are significantly associated with cardiovascular morbidity during the delivery hospitalization. Increased vigilance, including diligent screening for cardiac pathology in patients with hypertensive disorders of pregnancy, may lead to decreased morbidity for mothers.

83 Can Pharmacists Effectively Manage Blood Pressure for Discharged Urban Emergency Department Patients With Uncontrolled Hypertension?

Uncontrolled hypertension (HTN) leads to severe cardiovascular morbidity, and is commonly encountered in emergency department (ED) practice. Linkage to primary care is elusive for many ED patients, specifically in underserved communities, and thus alternative modalities are needed. Pharmacist-led HTN medication management has proven effective for patients with uncontrolled BP. However, no studies to date have addressed the ability of pharmacists to manage HTN in ED patients post-discharge. The objective of this study is to assess the effectiveness of a pharmacist-led HTN management clinic in the ED population. This a prospective, single arm trial of an innovative healthcare delivery system, a pharmacist-led HTN clinic. We recruited 89 patients with uncontrolled HTN, and lack of access to primary care from our urban ED from May 24, 2017 to May 18, 2018. Per protocol, 5 follow-up visits were planned in an outpatient pharmacy clinic, where antihypertensive medications were initiated and titrated by a pharmacist, under a collaborative agreement with emergency physicians. Information regarding the patient demographics and medical history were collected. Descriptive statistics were applied with graphic display of blood pressure change. These data represent an ad hoc, interim analysis of an ongoing study. The mean age was 42.5 years old (SD=9.9); 51% were males; 94% were African American; 81% had 12th grade or more education; 53% reported full-time employment and 18% had no health insurance. The mean BMI was 34.5 and 51.2% were current smokers. The median BP at ED admission was 160/102 mmHg. Of 89 patients recruited, only 32 (35%) actually attended the first visit. Both systolic and diastolic BP declined throughout the follow-up pharmacy clinic visits with the most impact on systolic BP (Figure), which showed a mean decrease of 48 mmHg (95% confidence interval 20-77). The pharmacist made 47 medication interventions (initiation or titration) during 95 follow-up visits, for a rate of 0.49 interventions/visit. At protocol completion the mean number of antihypertensive medications per patient was 3. Preliminary results show pharmacist-led HTN management provided to ED patients post-discharge is effective at lowering BP in a clinically meaningful manner. The pharmacist was proactive in medication titration, and patients received evidence based care. Linkage between recruitment in the ED, and actual study participation was suboptimal. These data are encouraging, and provide the rationale for future larger scale studies. To better understand the potential for clinical implementation, an exploration of factors influencing the effectiveness of treatment and a comparison with usual care are needed, with special attention paid to improving ED to pharmacy transition.

315: Hypertensive disorders of pregnancy and severe cardiovascular morbidity in the immediate postpartum period

315: Hypertensive disorders of pregnancy and severe cardiovascular morbidity in the immediate postpartum period

Obstructive sleep apnea syndrome: coagulation anomalies and treatment with continuous positive airway pressure.

Obstructive sleep apnea syndrome (OSAS) is a highly prevalent sleep disorder associated with severe cardiovascular events, morbidity and mortality. Recent evidence has highlighted OSAS as an independent risk factor for an excessive platelet activation and arterial thrombosis, but the underlying mechanisms have not yet been determined. Studies in cell culture and animal models have significantly increased our understanding of the mechanisms of inflammation in OSAS. Hypoxia is a critical pathophysiological element that leads to an intense sympathetic activity, in association with systemic inflammation, oxidative stress and procoagulant activity. While platelet dysfunction and/or hypercoagulability play an important role in the pathogenesis of vascular disease, there are limited studies on the potential role of blood viscosity in the development of vascular disease in OSAS. Further studies are required to determine the precise role of hypercoagulability in the cardiovascular pathogenesis of OSAS, particularly its interaction with oxidative stress, thrombotic tendency and endothelial dysfunction. Nasal continuous positive airway pressure (nCPAP), the gold standard treatment for OSAS, not only significantly reduced apnea-hypopnoea indices but also markers of hypercoagulability, thus representing a potential mechanisms by which CPAP reduces the rate of cardiovascular morbidity and mortality in OSAS patients.