New and known predictors of the postthrombotic syndrome: A subanalysis of the ATTRACT trial.

Introduction: Postthrombotic syndrome (PTS) remains associated with significant clinical and economic burden. This study aimed to investigate known and novel predictors of the development of PTS in participants of the ATTRACT (Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis) trial. Methods: We used multivariable logistic regression to identify baseline and postbaseline factors that were predictive of the development of PTS during study follow-up, as defined by a Villalta score of 5 or greater or the development of a venous ulcer from 6 to 24 months after enrollment. Results: Among 691 patients in the study cohort (all had proximal deep vein thrombosis [DVT] that extended above the popliteal vein, of which 57% had iliofemoral DVT), 47% developed PTS. Further, we identified that Villalta score at baseline (odds ratio [OR], 1.09 [95% confidence interval [CI], 1.05-1.13] per one-unit increase) and employment status (unemployed due to disability: OR, 3.31 [95% CI, 1.72-6.35] vs. employed more than 35 hours per week) were predictive of PTS. In terms of postbaseline predictors, leg pain severity at day 10 (OR, 1.28 [95% CI, 1.13-1.45] per 1-point increase in a 7-point scale) predicted PTS. Also, patients receiving rivaroxaban on day 10 following randomization had lower rates of PTS (OR, 0.53 [95% CI, 0.33-0.86]) than patients on warfarin. Conclusions: Novel predictors for PTS identified in our study include baseline Villalta score, leg pain severity at 10 days, and unemployed due to disability. Our findings also suggest that the initial choice of anticoagulant to treat DVT may have an impact on the development of PTS.

Diagnostic precision of mentally estimated home blood pressure means.

CONTEXT: Paper home blood pressure (HBP) charts are commonly brought to physicians at office visits. The precision and accuracy of mental calculations of blood pressure (BP) means are not known. METHODS: A total of 109 hypertensive patients were instructed to measure and record their HBP for 1 week and to bring their paper charts to their office visit. Study section 1: HBP means were calculated electronically and compared to corresponding in-office BP estimates made by physicians. Study section 2: 100 randomly ordered HBP charts were re-examined repetitively by 11 evaluators. Each evaluator estimated BP means four times in 5, 15, 30, and 60 s (random order) allocated for the task. BP means and diagnostic performance (determination of therapeutic systolic and diastolic BP goals attained or not) were compared between physician estimates and electronically calculated results. RESULTS: Overall, electronically and mentally calculated BP means were not different. Individual analysis showed that 83% of in-office physician estimates were within a 5-mmHg systolic BP range. There was diagnostic disagreement in 15% of cases. Performance improved consistently when the time allocated for BP estimation was increased from 5 to 15 s and from 15 to 30 s, but not when it exceeded 30 s. CONCLUSION: Mentally calculating HBP means from paper charts can cause a number of diagnostic errors. Chart evaluation exceeding 30 s does not significantly improve accuracy. BP-measuring devices with modern analytical capacities could be useful to physicians.

Cross-Sectional Assessment of Achievement of Therapeutic Goals in a Canadian Multidisciplinary Clinic for Patients With Advanced Chronic Kidney Disease.

BACKGROUND: The implementation of advanced chronic kidney disease (CKD) multidisciplinary clinics has now demonstrated their effectiveness in delaying and even avoiding dialysis for patients with CKD. However, very little has been documented on the management and achievement of targets for a number of parameters in this context. OBJECTIVE: Our goal was to assess our multidisciplinary clinic therapy performance in relation to the targets for hypertension, anemia, and calcium phosphate assessment. DESIGN AND SETTING: A cross-sectional descriptive study was conducted with a cohort including all patients followed up in our multidisciplinary clinic in July 2014. MEASUREMENTS: Comorbidity, laboratory, and clinical data were collected and compared with the recommendations of scientific organizations. RESULTS: The cohort included 128 patients, 37.5% of whom were women. Mean follow-up time was 26.6 ± 25.1 months and mean estimated glomerular filtration rate (eGFR) was 14.0 ± 4.7 mL/min/1.73 m2. A total of 24.2% of patients with diabetes achieved blood pressure targets of <130/80 mm Hg, while 56.5% of patients without diabetes achieved targets of <140/90 mm Hg. Hemoglobin of patients treated with erythropoiesis-stimulating agents was 100 to 110 g/L in 36.2% of the patients, below 100 for 39.7% of them, and above 110 for 24.1%, whereas 67.2% were within the acceptable limits of 95 to 115 g/L. In addition, 63.4% of patients had a serum phosphate of <1.5 mmol/L, and 90.9% of patients had total serum calcium <2.5 mmol/L. LIMITATIONS: Our study is a single center study with the majority of our patients being Caucasian. This limits the generalizability of our findings. CONCLUSION: The control rates of various parameters were satisfactory given the difficult clinical context, but could be optimized. We publish these data in the hope that they are helpful to others engaged in quality improvement in their own programs or more generally.

CONTEXTE: L'implantation de cliniques multidisciplinaires spécialisées en néphropathie chronique de stade avancé a prouvé leur efficacité à retarder ­ voire à éviter ­ le recours à la dialyse chez les patients atteints d'insuffisance rénale chronique (IRC). Cependant, il existe peu de littérature sur la gestion et l'atteinte d'objectifs propres à un tel contexte en regard de certains paramètres. OBJECTIF DE L'ÉTUDE: Nous avons voulu évaluer l'efficacité thérapeutique de notre clinique multidisciplinaire par rapport aux paramètres suivants : l'hypertension, l'anémie et le taux de phosphate de calcium. CADRE ET TYPE D'ÉTUDE: Une étude descriptive transversale a été menée auprès d'une cohorte constituée de tous les patients suivis à notre clinique multidisciplinaire en juillet 2014. MESURES: On a colligé les comorbidités, les résultats de laboratoire et les données cliniques des patients. Ces données ont ensuite été comparées aux valeurs recommandées par la communauté scientifique. RÉSULTATS: La cohorte comptait 128 patients, 37,5 % étaient des femmes. La durée moyenne du suivi était de 26,6 ± 25,1 mois et le DFGe moyen des participants était de 14,0 ± 4,7 mL/min/1,73 m2. Seuls 24,2 % des patients diabétiques présentaient une tension artérielle inférieure à 130/80 mm Hg, soit la valeur cible pour ce groupe de patients, alors que 56,5 % des non-diabétiques ont maintenu leur tension artérielle sous la valeur cible de 140/90 mm Hg. Le taux d'hémoglobine des patients traités avec des agents stimulant l'érythropoïèse se situait entre 100 et 110 g/L dans 36,2 % des cas; 39,7 % présentaient un taux d'hémoglobine inférieur à 100 g/L, et 24,1 % présentaient un taux supérieur à 110 g/L. Dans la majorité des cas (67,2 %), le taux d'hémoglobine se situait dans les limites acceptables, soit entre 95 et 115 g/L. Enfin, 63,4 % des participants à l'étude présentaient des valeurs de phosphate sérique inférieures à 1,5 mmol/L et un total de 90,9 % des patients présentaient des valeurs de calcium sérique inférieures à 2,5 mmol/L. LIMITES DE L'ÉTUDE: Notre étude s'est tenue dans un seul établissement et auprès d'une population à majorité caucasienne, ce qui limite la généralisation de nos résultats. CONCLUSION: Compte tenu du contexte clinique difficile, nous considérons les taux de contrôle pathologique atteints pour les paramètres étudiés comme satisfaisants, quoiqu'ils puissent encore être améliorés. Nous publions ces résultats dans l'espoir qu'ils serviront notamment à l'amélioration de programmes mis sur pied par d'autres équipes.

The impact of unrecorded readings on the precision and diagnostic performance of home blood pressure monitoring: a statistical study.

Hypertension is a major cardiovascular risk factor. To address the disease adequately, most clinicians rely on home blood pressure monitoring (HBPM). However, the impact of unrecorded BP values on the precision and diagnostic performance of BP schedules is unknown. We obtained 103 HBP patients schedules from a previous study. Then, readings were randomly removed from each schedule in order to create new incomplete schedules using a resampling technique. We obtained 10,000 new incomplete schedules. For each number of randomly removed readings, the percentages of incomplete schedules outside a systolic/diastolic blood pressure (SBP/DBP) range of 5/3 mmHg were calculated from the same complete patient's schedule. The sensitivity and specificity of incomplete HBPM schedules regarding BP control were also assessed. One hundred three HBPM schedules were analyzed. Mean patients' age was 67.9 ± 9.9 years. In non-diabetic patients, the mean BP of complete schedules' means was 131.9 ± 12.4/75.5 ± 10.5. In diabetic patients, the mean BP of complete schedules' means was 135.5 ± 14.0/73.4 ± 8.2 mmHg. When schedules were composed of 14 and 21 random measures, differences over 5 mmHg were seen in 2.6% and 0.1% of non-diabetic patients' schedule and 3.7% and 0.1% of diabetic patients' schedule, respectively. At 21 measurements, sensitivity and specificity were approximately 95% and 98% in non-diabetic patients and 90% and 99% in non-diabetic patients, respectively. HBPM precision and diagnostic performance improve rapidly with accumulation of readings. Incomplete schedules composed of 21 readings can provide an almost perfect diagnostic tool compared with the complete schedule reference.

Comparison of Different Automated Office Blood Pressure Measurement Devices: Evidence of Nonequivalence and Clinical Implications.

BACKGROUND: Automated office blood pressure (AOBP) measuring devices are increasingly recommended as preferred blood pressure (BP) diagnostic tools, but it is unclear how they compare and how clinical environments impact their performance. METHODS: This prospective randomized factorial parallel 4-group study compared BP estimates by BpTRU (VSM MedTech, Vancouver, BC, Canada) and Omron HEM 907 (Omron Healthcare, Kyoto, Japan) devices in closed vs open areas. Patients diagnosed with hypertension were recruited during office visits. After baseline open-room AOBP measurement with the BpTRU, patients had a second BP measurement with either the BpTRU or HEM 907 in either open or closed areas. Absolute BP levels and differences between the first and second measurements were compared. Diagnostic performance was also assessed. RESULTS: Two hundred fifty-eight patients were studied. Their mean age was 66.2 ± 12.0 years, and 62% were men. The mean of first AOBP estimates was 127.4/73.3 mm Hg. Analyses of subsequent measurements revealed no influence of open or closed areas on BP means and diagnostic performance. Conversely, the Omron HEM 907 exceeded BpTRU systolic BP measurements by 4.6 mm Hg (< 0.01) in closed areas and by 3.9 mm Hg (< 0.01) in open areas. The discrepancy between devices was amplified at lower BP levels. CONCLUSIONS: Although different areas did not influence BP estimates, the Omron HEM 907 significantly exceeded BpTRU measurements on average and especially at lower BP levels. These differences should be considered when interchanging devices and could have clinical decision impacts in a population of patients treated for hypertension. Our results support the constant use of only 1 device type in a given clinic.

The Gap Between Manual and Automated Office Blood Pressure Measurements Results at a Hypertension Clinic.

BACKGROUND: Blood pressure (BP) readings taken in clinics are often higher than BP readings taken in a research setting. Recent guidelines and clinical trials have highlighted the necessity of using automated office blood pressure (AOBP) devices and standardizing measurement procedures. The goal of the present study was to compare AOBP vs manual BP measurement in both research and clinical environments in which operators and devices were the same and measurement procedures were standardized and optimal. METHODS: Clinical manual BP and AOBP measurement estimates were gathered from a retrospective cohort of patients followed in a hypertension clinic. Research AOBP and manual BP measurement data were obtained from past research studies. Descriptive statistics and agreement analyses with Cohen kappa coefficients were developed. The AOBP/manual BP measurement gap between clinical and research follow-up was compared using an unpaired t test. RESULTS: Two hundred eighty-eight patients were included in the clinical cohort, and 195 patients contributed to research-grade BP data. All patients had hypertension. AOBP averages were lower than manual measurement averages in both clinical (-3.6 ± 14.9 mm Hg / -3.0 ± 8.8 mm Hg) and research (-2.7 ± 10.0 / -2.4 ± 6.3 mm Hg) environments. The gap between measurement methods did not differ between research and clinical data. Cohen kappa coefficient was lower in the clinical context because of greater variability and more time between BP measurements (5.5 ± 2.9 months). CONCLUSIONS: Manual BP readings were slightly higher than AOBP estimates. The difference was not influenced by the real-world context of clinical practice. Office nonautomated BP measurements may still be valuable if measurement procedures are well standardized and performed by trained nurses.