Management and outcomes of chest pain telemedicine visits in a cardiology clinic during the COVID-19 pandemic.

Background: Beginning in March 2020, the COVID-19 pandemic forced many outpatient chest pain evaluations to be performed via telemedicine. The purpose of this study was to examine the impact of telemedicine on management and outcomes of patients who presented with chest pain. Methods: This retrospective chart review study included 771 unique patients, age >18 years, who were seen face-to-face in cardiology clinic visits from March 2019 through September 2019 with an encounter diagnosis of chest pain or angina, compared with 172 unique patients of age >18 who were seen via telehealth visit from March 2020 through September 2020. Data were extracted on patients' clinical outcomes up to 1 year after the initial visit, including emergency department visit or hospital admission for chest pain, any hospital admission, additional diagnostic testing, revascularization, and death (cardiovascular or any). Results: The telehealth group had higher rates of emergency department visits (19.2% vs 11.7%, P = 0.008), hospital admissions for chest pain (16.9% vs 10.5%, P = 0.019), as well as all hospital admissions (36.1% vs 28.2%, P = 0.04) compared with the face-to-face group. More patients in the face-to-face group received a stress test (41.1% vs 21.5% for the telehealth group; P < 0.001). There were no other statistically significant differences for diagnostic evaluations, revascularization, or death. Conclusion: Our findings suggest that in-person evaluation for chest pain may aid in reducing the number of emergency department visits and hospital admissions when compared to telehealth evaluation.

Effect of repeat manual blood pressure measurement on blood pressure and stage of hypertension.

Hypertension management guidelines are influenced by clinical trials that utilize automated office blood pressure (BP) to measure BP. Many primary care clinics still use manual office BP, which has been shown to produce significantly higher BP values than automated office BP. In a primary care office, a manual BP was obtained by nursing staff using an aneroid sphygmomanometer. Initial BPs ≥120/80 mm Hg were repeated during the clinical encounter by the physician. A total of 1012 encounters were analyzed, with 1000 meeting inclusion criteria. The median difference between nurse and provider BP was 4 mm Hg in systolic BP and 2 mm Hg in diastolic BP (P < 0.0001), with the greatest difference seen in patients with initial BPs >150 mm Hg systolic (10 mm Hg; P < 0.0001). Repeating BP measurements resulted in 34% of patients being reclassified to a lower hypertension stage. Patients with stage 1 and 2 hypertension initially were reclassified as controlled (systolic BP <130 mm Hg) in 40% and 8% of encounters, respectively, with repeat measurements. In clinics that use manual office BP, repeating a manual BP by the physician may provide a better reflection of adherence to standard hypertension performance measures used in the primary care setting.

Opening of the blood-brain barrier before cerebral pathology in mild hyperhomocysteinemia.

Hyperhomocysteinemia (HHcy) is a risk factor for cognitive impairment. The purpose of this study was to determine the temporal pattern of cerebral pathology in a mouse model of mild HHcy, because understanding this time course provides the basis for understanding the mechanisms involved. C57Bl/6 mice with heterozygous deletion cystathionine ß-synthase (cbs (+/-); Het) were used as a model of mild HHcy along with their wild-type littermates (cbs (+/+); WT). Mice were 'young' (5.3±0.2 months of age) and 'old' (16.6±0.9 months of age). Blood-brain barrier (BBB) permeability was quantified from Evans blue and sodium fluorescein extravasation. Microvascular architecture was assessed by z-stack confocal microscopy. Leukoaraiosis was measured from Luxol fast blue stained slides of paraffin brain sections. Inflammation was quantified using standard antibody-based immunohistochemical techniques. Cognitive function was assessed using the Morris water maze. BBB permeability was significantly greater in Het vs. WT mice at all ages (p<0.05). There were no differences in microvascular architecture among the groups. Compared with all other groups, old Het mice had significantly greater leukoaraiosis, inflammation in the fornix, and cognitive impairment (p<0.05). In mild HHcy, increased permeability of the BBB precedes the onset of cerebral pathology. This new paradigm may play a role in the progression of disease in HHcy.

Hyperhomocysteinemic mice show cognitive impairment without features of Alzheimer's disease phenotype.

Hyperhomocysteinemia (HHcy) is associated with cognitive impairment and Alzheimer's disease. Whether this association is mechanistic remains unclear. Here, we used a mouse model to test the hypothesis that HHcy increases levels of amyloid-ß (Aß) transporters in microvessels that form the blood-brain barrier, elevates Aß content (Aß40 and Aß42) in the brain, and impairs cognitive performance. Mice with HHcy and age-matched, non-HHcy controls (Ctrl) were studied in two age groups: adult (6.2 ± 0.4 months of age) and old (19 ± 2.0 months of age). Levels of Aß transporters, RAGE, LRP1, and Pgp, were not different between HHcy and Ctrl mice. Though there was an increase in overall brain Aß levels with age, there were no differences between HHcy and Ctrl groups in cortex, hippocampus, or midbrain/diencephalon. Despite the lack of difference in Aß, old mice with HHcy showed significant cognitive impairment on Morris water maze tests compared with Ctrl mice. We conclude that HHcy leads to cognitive impairment without many of the changes currently thought to be relevant to promoting the AD phenotype.