Outcomes associated with the high sensitivity cardiac troponin testing in patients presenting with non-cardiovascular disorders.

There are limited data regarding the utility of troponin testing in patients presenting with non-cardiovascular (CV) symptoms as the primary manifestation. The study population comprised 2057 patients who presented to the emergency department (ED) of a US healthcare system with non-CV symptoms as the primary manifestation between January and September 2018. We compared the effect of high-sensitivity cardiac troponin T (hs-cTnT) (n = 901) after its introduction vs. 4th generation cTnT (n = 1156) on the following outcomes measures: ED length of stay (LOS), coronary tests/procedures (angiography or stress test), and long-term mortality. Mean age was 64 ± 17 yrs., and 47% were female. Primary non-CV manifestations included pneumonia, obstructive pulmonary disease, infection, abdominal-complaint, and renal failure. Mean follow up was 9 ± 4 months. Patients' demographics and medical history were clinically similar between the two troponin groups. A second cTn test was obtained more frequently in the hs-cTnT than cTnT (84% vs. 32%; p < 0.001), possibly leading to a longer ED stay (8.1 ± 8.2 h vs 5.6 ± 3.4 h, respectively; p < 0.001). Coronary tests/procedures were performed at a significantly higher rate in the hs-cTnT than cTnT following the introduction of the hs-cTnT test (28% vs. 22%, p < 0.001). Multivariate analysis showed that following the introduction of hs-cTnT testing, there was a significant 27% lower risk of long-term mortality from ED admission through follow-up (HR = 0.73, 95%CI 0.54-0.98; p = 0.035). In conclusion, we show that in patients presenting primarily with non-CV disorders, the implementation of the hs-cTnT was associated with a higher rate of diagnostic coronary procedures/interventions, possibly leading to improved long-term survival rates.

Outcomes Associated with Introduction of the 5th Generation High-Sensitivity Cardiac Troponin in Patients Presenting with Cardiovascular Disorders.

BACKGROUND: The new high-sensitivity cardiac troponin T (hs-cTnT) is now widely used in the United States. OBJECTIVES: We aimed to examine outcomes associated with the introduction of the new 5th generation hs-cTnT assay among patients presenting to the emergency department (ED) with cardiovascular (CV) disorders. METHODS: The study comprised 5377 patients presenting to the ED with CV disorders between January and September 2018. Outcomes included rates of direct ED discharge, cardiac testing/procedures, and mortality. CV indications for troponin testing were categorized as rule-out acute coronary syndrome (RO-ACS) and other-CV (O-CV). RESULTS: Mean age was 62 ± 17 years, and 47% were female. Demographics and medical history did not differ significantly between the troponin groups. The use of hs-cTnT was associated with increased rates of direct discharge from the ED in the RO-ACS (48% vs. 37%; p < 0.01), but not in the O-CV (25% vs. 25%) cohort. Cardiac tests/procedures were more often performed after hs-cTnT vs. cTnT testing in both cohorts (45% vs. 41% for RO-ACS, and 33% vs. 28% for O-CV; p < 0.05 for both). Multivariate analysis demonstrated that hs-cTnT was not associated with a significant increase in postdischarge mortality in both cohorts (RO-ACS: hazard ratio = 1.47 [p = 0.13], O-CV: hazard ratio = 0.97 [p = 0.87]). CONCLUSIONS: Among patients with RO-ACS, hs-cTnT implementation resulted in increased rates of direct home discharge from the ED, without a significant increase in postdischarge mortality. Among patients presenting with O-CV indication, hs-cTnT implementation resulted in increased rates of cardiac testing procedures without an effect of ED discharge rates or long-term mortality.

Present and Future of Interventional Treatment of Resistant Hypertension.

The increasing prevalence of hypertension, a significant cause of disability and premature death throughout the world, is a major public health concern. This is especially true for the subset of patients who suffer from resistant hypertension, which is associated with a fourfold greater risk of cardiovascular events as compared to those hypertensive patients able to achieve target blood pressure. Though quite daunting in number and ill effect, hypertension remains the most common and the most important modifiable risk factor for coronary heart disease, congestive heart failure, peripheral vascular disease, stroke, and chronic kidney disease. Therefore, the ongoing development of novel therapies for the management of hypertension is of utmost importance. This review evaluates the present and future of interventional treatment of resistant hypertension, most of which remains investigational and warrants critical assessment.

Do clinicians recommend aspirin to patients for primary prevention of cardiovascular disease?

BACKGROUND: The United States Preventive Services Task Force (USPSTF) released updated guidelines in 2009 recommending aspirin to prevent myocardial infarction among at-risk men and stroke among at-risk women. OBJECTIVE: Our aim was to examine clinician aspirin recommendation among eligible persons based on cardiovascular risk scores and USPSTF cutoffs. DESIGN: We used across-sectional analysis of a current nationally representative sample. PARTICIPANTS: Participants were aged 40 years and older, and in the National Health and Nutrition Examination Survey (NHANES) (2011-2012). MAIN MEASURES: We determined aspirin eligibility for cardiovascular disease (CVD) prevention for each participant based on reported and assessed cardiovascular risk factors. We assessed men's risk using a published coronary heart disease risk calculator based on Framingham equations, and used a similar calculator for stroke to assess risk for women. We applied the USPSTF risk cutoffs for sex and age that account for offsetting risk for gastrointestinal hemorrhage. We assessed clinician recommendation for aspirin based on participant report. RESULTS: Among men 45-79 years and women 55-79 years, 87 % of men and 16 % of women were potentially eligible for primary CVD aspirin prevention. Clinician recommendation rates for aspirin among those eligible were low, 34 % for men and 42 % for women. Rates were highest among diabetics (63 %), those 65 to 79 years (52 %) or those in poor health (44 %). In contrast, aspirin recommendation rates were 76 % for CVD secondary prevention. After accounting for patient factors, particularly age, eligibility for aspirin prevention was not significantly associated with receiving a clinician's recommendation for aspirin (AOR 0.99 %; CI 0.7-1.4). CONCLUSIONS: Despite an "A recommendation" from the USPSTF for aspirin for primary prevention of CVD, the majority of men and women potentially eligible for aspirin did not recall a clinical recommendation from their clinician.

The role of obesity and obstructive sleep apnea in the pathogenesis and treatment of resistant hypertension.

The incidence of resistant hypertension, obesity, and obstructive sleep apnea (OSA), three highly prevalent conditions in the United States, is rising. Approximately one in three adults in the US has hypertension, and a significant proportion of these individuals have hypertension that is difficult to treat, or resistant. Obesity and OSA are well-established risk factors for resistant hypertension, a condition that portends significant cardiovascular risk. Awareness of the various mechanisms by which obesity and OSA impact systemic blood pressure is essential to better understand how best to effectively care for patients with resistant hypertension. In this review, we discuss the clinical and pathophysiologic associations between obesity, OSA, and resistant hypertension. Furthermore, we will explore the effect of continuous positive airway pressure therapy (CPAP) and other therapeutic interventions on blood pressure control in patients with resistant hypertension.Key Points• Obesity, obstructive sleep apnea, and resistant hypertension are highly prevalent conditions, with increasing overall incidence [1-3].• Both obesity and obstructive sleep apnea are independent risk factors for the development of resistant hypertension.• OSA is characterized by a physiologic cascade of collapse of the upper airway, which can lead to intermittent hypoxia, hypercapnia, significant negative intra-thoracic pressure, and increased SNS output.• Intermittent hypoxia leads to activation of the endothelin system [17, 18, 19•], which can lead to the development of resistant hypertension.• Intermittent hypoxia can lead to the over activation of the SNS, which can also contribute to the development of resistant hypertension [20, 21].• OSA leads to state of elevated adrenergic tone, which in turn may contribute to resistant hypertension [25-27].• OSA patients have a higher incidence of "non-dipping" of nocturnal systolic blood pressure, a marker of increased adrenergic tone. This potentially represents a risk factor for hypertensive end organ disease [31, 32].• The prevalence of OSA is significantly higher in patients predisposed to fluid accumulation: including kidney disease, heart failure and resistant hypertension [33].• Interventions (such as the daytime use of compression stocking) which reduce daytime lower extremity fluid accumulation can significantly reduce the severity of OSA, particularly in patients with comorbid resistant hypertension [35, 36].• CPAP therapy can significantly reduce blood pressure in patients with comorbid hypertension and OSA. The treatment effect is most pronounced in those with resistant hypertension and OSA [16••, 38-42].

Team-based home blood pressure monitoring for blood pressure equity a protocol for a stepped wedge cluster randomized trial.

BACKGROUND: Home Blood Pressure Monitoring (HBPM) that includes a team with a clinical pharmacist is an evidence-based intervention that improves blood pressure (BP). Yet, strategies for promoting its adoption in primary care are lacking. We developed potentially feasible and sustainable implementation strategies to improve hypertension control and BP equity. METHODS: We assessed barriers and facilitators to HBPM and iteratively adapted implementation strategies through key informative interviews and guidance from a multistakeholder stakeholder team involving investigators, clinicians, and practice administration. RESULTS: Strategies include: 1) pro-active outreach to patients; 2) provision of BP devices; 3) deployment of automated bidirectional texting to support patients through education messages for patients to transmit their readings to the clinical team; 3) a hypertension visit note template; 4) monthly audit and feedback reports on progress to the team; and 5) training to the patients and teams. We will use a stepped wedge randomized trial to assess RE-AIM outcomes. These are defined as follows Reach: the proportion of eligible patients who agree to participate in the BP texting; Effectiveness: the proportion of eligible patients with their last BP reading <140/90 (six months); Adoption: the proportion of patients invited to the BP texting; Implementation: patients who text their BP reading ≥10 of days per month; and Maintenance: sustained BP control post-intervention (twelve months). We will also examine RE-AIM metrics stratified by race and ethnicity. CONCLUSIONS: Findings will inform the impact of strategies for the adoption of team-based HPBM and the impact of the intervention on hypertension control and equity. REGISTRATION DETAILS: www. CLINICALTRIALS: gov Identifier: NCT05488795.

Interventional approaches for resistant hypertension.

PURPOSE OF REVIEW: The number of Americans with hypertension is growing, and within that group there remain a growing number of patients with resistant hypertension. This growth has occurred despite numerous pharmacologic advancements and innovative therapies. Resistant hypertension carries a significant risk of morbidity and mortality. An interventional approach to treating patients with resistant hypertension may provide a supplementary aid to those with difficult-to-control blood pressure on medications alone. RECENT FINDINGS: An interventional approach to patients with resistant hypertension is effective and likely well tolerated. Baroreceptor stimulation was shown to increase the likelihood of reaching a normal blood pressure in patients whose hypertension was previously uncontrolled using pharmacotherapy alone. Renal sympathetic denervation was likewise shown to successfully treat hypertension in a previously uncontrolled population. With both of these therapies, statistically significant endpoints were reached, and there were likely low risks of procedural complications, though further investigation continues to examine safety and effectiveness. SUMMARY: Interventional therapies may be an increasingly important adjunct therapy for patients with resistant hypertension that fails to be controlled with pharmacotherapy alone. Two exciting interventions that are under investigation and are likely effective are electrical stimulation of carotid baroreceptors and catheter denervation of renal sympathetic nerves.

Perioperative hypertension: defining at-risk patients and their management.

Hypertension is an extremely pervasive condition that affects a large percentage of the world population. Although guidelines exist for the treatment of the patient with elevated blood pressure, there remains a paucity of literature and accepted guidelines for the perioperative evaluation and care of the patient with hypertension who undergoes either cardiac or noncardiac surgery. Of particular importance is defining the patients most vulnerable to complications and the indications for immediate and rapid antihypertensive treatment and/or cancellation of surgery to reduce these risks in each of the three perioperative settings: preoperative, intraoperative, and postoperative. This review also examines the parenteral antihypertensive medications most commonly administered in the perioperative setting.

Low Blood Pressure Threshold for Adverse Outcomes During Left Ventricular Assist Device Support.

It has been suggested that maintaining low mean arterial pressure (MAP) in left ventricular assist device (LVAD) recipients is associated with a reduced risk of stroke/death. However, the lower limit of the optimal MAP range has not been established. We aimed to identify this lower limit in a contemporary cohort of LVAD recipients with frequent longitudinal MAP measurements. We analyzed 86,651 MAP measurements in 309 patients with an LVAD (32% LVADs with full magnetic levitation of the impeller) at a tertiary medical center during a mean follow-up of 1.7 ± 1.1 years. Cox proportional hazards regression modeling was used to study the association of serial MAP measurements with stroke/death within 3 years after index discharge. Multivariate analysis identified MAP ≤75 mm Hg, compared with MAP >75 mm Hg, as the low MAP threshold associated with increased risk of death (hazard ratio [HR] 4.74, 95% confidence interval [CI] 2.85 to 7.87, p <0.001), stroke (HR 2.72;, 95% CI 1.39 to 5.33, p = 0.01), and stroke/death (HR 4.45, 95% CI 2.83 to 6.99, p <0.001). The risk associated with MAP ≤75 mm Hg was consistent in subgroups categorized by age, gender, race, device type, renal function, right-sided heart failure, and blood pressure medications. In conclusion, our findings suggest that maintaining MAP ≤75 mm Hg during long-term follow-up in LVAD recipients is associated with increased risk of stroke/death regardless of risk factors or medical management.

Baroreflex stimulation in antihypertensive treatment.

Hypertension is a leading cause of morbidity and mortality worldwide. Despite the development of new medications, an alarmingly high proportion of patients are not reaching their target blood pressure goals, so nonpharmacologic therapies have been attracting more interest. Chronic baroreceptor stimulation of the carotid sinus has been shown to reduce blood pressure by inhibiting the sympathetic nervous system, particularly the renal sympathetic tone. This finding has led to the development of implantable carotid sinus stimulators, which have now been studied in both animals and humans, as a means for treating chronic hypertension. The enthusiasm for this modality has led to ongoing studies, which will provide more information on its safety and efficacy in patients with resistant hypertension. The early study results using baroreflex stimulation therapy are promising and suggest that it may play a significant role in controlling blood pressure in the future.

Renin inhibition for hypertension: selecting the right role for a new class of drug.

With the arrival of a new class of drugs for the management of hypertension comes the need to define its role. Aliskiren, an orally administered direct renin inhibitor, has been approved by the US Food and Drug Administration for the treatment of hypertension. Currently, the recommendation for choice of agent in the treatment of uncomplicated hypertension is a thiazide diuretic, and for patients with diabetic nephropathy, heart failure, or coronary artery disease, an angiotensin-converting enzyme inhibitor. Patients for whom an angiotensin-converting enzyme inhibitor is indicated who are intolerant as a result of side effects should take an angiotensin receptor blocker. A new class of medicines that specifically inhibits renin is an exciting addition to the armamentarium in the treatment of hypertension. This article explores the role of aliskiren in treating hypertension as well as its side effects and appropriate dosing.

An Evidence-Based Review of Elevated Blood Pressure for the Inpatient.

Elevated blood pressure is common in patients who are hospitalized. There are no guidelines and few recommendations to help inpatient providers manage patients with elevated blood pressure. There are no normal reported values for blood pressure in the inpatient and recording circumstances often widely vary. Many factors may influence blood pressure such as pain, anxiety, malaise, nicotine withdrawal, or withholding home medications. This review of available literature suggests potential harm and little to no potential benefit in treating asymptomatic patients with elevated blood pressure. This review also found no evidence that asymptomatic elevated blood pressure progresses to lead to end-organ damage. However, there are clear instances of hypertensive emergency where treatment is indicated. Conscientious adjustment of an anti-hypertensive regimen should be undertaken during episode of elevated blood pressure associated with end-organ damage.

Canceling dental procedures due to elevated blood pressure: Is it appropriate?

BACKGROUND: In 1974, the American Dental Association first considered recommending that dental offices measure blood pressure (BP) routinely, and it has been further encouraged since 2006. Investigators in several dental publications have recommended cancellation of dental procedures based solely on BP greater than 180/110 millimeters of mercury for urgent oral health care and greater than 160/100 mm Hg for elective oral health care, in the absence of prior medical consultation. METHODS: The authors reviewed the evidence for cancellation of any dental or surgical procedures by using an Ovid MEDLINE search for the terms dental, elevated blood pressure, and hypertension. In addition, the authors searched resources at ebd.ada.org using the same criteria. The authors collaborated to develop recommendations in view of 2017 guidelines on this subject. RESULTS: To the authors' knowledge, there are no professionally accepted criteria or study evidence indicating a specific BP elevation at which to prohibit oral health care. Researchers of a 2015 review on management of comorbidities in ambulatory anesthesia failed to find increased morbidity from hypertension in the outpatient setting. CONCLUSIONS: To the authors' knowledge, there are no prospective study investigators that have addressed whether or when to cancel dental procedures due to office-measured elevated BP. The authors recommend using current anesthesiology guidelines based on functional status and past BP measurements to prevent unnecessary cancellations. PRACTICAL IMPLICATIONS: It is seldom necessary to cancel dental procedures on the basis of BP measured before a planned procedure for patients under a physician's care.

Baroreflex device therapy in the treatment of hypertension.

Despite therapy with multiple optimally dosed medications, hypertension remains poorly controlled in a sizeable number of people worldwide. This has spurred interest in exploring other pharmacologic and nonpharmacologic options for treatment. The carotid baroreceptors are important in regulating blood pressure in chronic hypertension by centrally mediated sympathoinhibitory effects and other effects. This has led to renewed interest in treating hypertension by electrically stimulating the carotid baroreceptors. Although this concept was first studied several decades ago, modern technology and better understanding of physiology have finally allowed the development of a feasible treatment option. Ongoing trials are finding significant and sustained reductions in blood pressure, a good safety profile, and tolerable side-effects. These promising results indicate that this modality has the potential to become a useful tool in future treatment of hypertension.

Direct renin inhibition: an analysis of possible benefits.

The US Food and Drug Administration's approval in March 2007 of aliskiren, the first commercially available direct renin inhibitor, for the treatment of hypertension met with great enthusiasm. Clinical trials have demonstrated it to be as effective as other commonly prescribed antihypertensive agents with few side effects. Preclinical studies in genetically manipulated rats have shown it to be effective in reversing angiotensin II-induced cardiac and renal damage. Despite the notable absence of human clinical data for this agent, many clinicians have touted aliskiren as the ideal agent to achieve additional suppression of the renin-angiotensin-aldosterone system (RAAS) as a means to reduce the morbidity and mortality of chronic diseases of the cardiovascular and renal systems. Clinical studies are ongoing and future studies are planned to prove its effectiveness in several chronic diseases known to be related to RAAS activation.

Predictive value of admission electrocardiography in patients with heart failure.

Admission electrocardiography (ECG) in heart failure (HF) patients provides important diagnostic information; however, there are limited data regarding the prognostic significance of ECG parameters for predicting cardiac events (CEs). The ECGs of 246 patients admitted with acute HF were evaluated for heart rate, rhythm, QRS and ST-T wave abnormalities, QTc duration, QT peak corrected (QTpc), T amplitude, and axis. The end points included rehospitalization for a CE or death during 30-day follow-up. There were 71 (29%) patients with CEs. In patients with CEs, atrial fibrillation (AF) was observed more frequently (27% vs 13%, respectively; P=.009) and QTpc was shorter (370+/-43 vs 386+/-44 ms, respectively; P=.020). Multivariate logistic regression analysis revealed that QTpc

Comparison of prognostic significance of amino-terminal pro-brain natriuretic Peptide versus blood urea nitrogen for predicting events in patients hospitalized for heart failure.

N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and blood urea nitrogen (BUN) predict outcomes in patients with heart failure (HF). However, it is unknown whether NT-pro-BNP is a better prognostic marker than BUN in patients hospitalized with HF. Chart reviews were performed on 257 consecutively hospitalized patients with HF whose NT-pro-BNP levels were drawn at the time of admission. The ability of NT-pro-BNP and BUN to predict the primary end point (death or readmission <30 days after discharge) was determined. Seventy-three patients (28%) reached the primary end point. Patients who reached the primary end point had significantly higher NT-pro-BNP and BUN levels. On multivariate regression analysis, the predictive values of BUN and NT-pro-BNP were very similar: the hazard ratio for NT-pro-BNP greater than the median was 1.81 (p = 0.044), and the hazard ratio for BUN greater than the median was 1.83 (p = 0.039). Analysis of the associations between NT-pro-BNP, BUN, and 30-day death or readmission as end points showed that BUN is a better predictor of outcomes (hazard ratio 3.15, p = 0.012) than NT-pro-BNP (hazard ratio 1.44, p = 0.399). In conclusion, in patients admitted to hospitals with HF, BUN is at least an equal prognosticator of HF rehospitalization or death as NT-pro-BNP. BUN outperforms NT-pro-BNP in predicting mortality in patients with advanced HF. If admitting physicians are confident that the diagnosis of HF is correct, then admission NT-pro-BNP adds little to clinical management.

Improving care in resistant hypertension: medication trends and nonpharmacologic strategies in a specialty clinic.

OBJECTIVE: Resistant hypertension is an important clinical problem that is poorly studied and not well managed. The objective of this study was to identify factors associated with successful treatment of resistant hypertension in a specialty clinic. METHODS: This was a retrospective observational study examining the medical records of patients seen at a specialty hypertension clinic at the University of Rochester, Rochester, New York, USA, in the year 2005. The records of 68 patients were reviewed. Those presenting with resistant hypertension (defined as BP > or =140/90mm Hg and receiving at least three antihypertensive medications, including a diuretic) were identified. Change in medication type and dosage, BP reduction, and percentage of patients at Joint National Committee (JNC)-7 goal were noted. RESULTS: Twenty-eight patients were included in the analysis. Mean age was 62.5 +/- 11.6 years, 54% were women, and mean presenting BP was 175.4 +/- 23.5/87.5 +/- 14.6mm Hg. After an average of 6.2 +/- 3.2 visits over a mean of 13.9 +/- 13.5 months, mean BP was reduced to 145.3 +/- 27.7/73.9 +/- 13.6mm Hg (paired t-test: p = 0.001 SBP, p = 0.0001 DBP), and 44.8% of the patients were at their JNC-7 goal. Change in the mean number of antihypertensive medications was not significantly different between the initial and final clinic visits (4.1 +/- 1.2 vs 4.2 +/- 1.0; p = 0.627). Combination pill use increased from four patients (14%) at initial visit to 19 (68%) at final visit. Numbers of patients treated with diuretics, beta-adrenoceptor antagonists, calcium channel antagonists (CCB), and minoxidil increased at the final clinic visit. Significant dose-related changes included the up-titration of CCBs to high doses, and the initiation of moderate doses of thiazide diuretics; mainly chlorthalidone (67% final visit vs 0% at initial visit). CONCLUSIONS: Patients referred to a specialty clinic for the control of resistant hypertension achieved significant reductions in BP with frequent visits, combination pills, and greater use and higher doses of CCBs and thiazide diuretics.

Prevalence of comorbidities and their influence on blood pressure goal attainment in geriatric patients.

Hypertension in elderly patients is common and is associated with unique challenges. This study examines the prevalence of comorbidities in elderly hypertensive patients and evaluates the association between comorbidities and other covariates with blood pressure goal attainment. Data were collected through retrospective review of medical records and included patient characteristics, comorbidities, treatment-related variables, and blood pressure goal attainment. At least 1 comorbidity was present in 88% of patients, and 61% had multiple comorbidities. The most common comorbidity was isolated systolic hypertension. The presence of diabetes or isolated systolic hypertension at initial visit and treatment with a thiazide diuretic at the final clinic visit were associated with significantly higher odds of patients not achieving blood pressure goal. A diagnosis of heart failure was associated with lower odds of not achieving blood pressure goal. These issues should be given special consideration during the evaluation, treatment selection, and long-term monitoring of this population.