Reaching the Hard-to-Reach: Outcomes of the Severe Hypertension Outreach Intervention.

INTRODUCTION: Severe hypertension (≥180 mmHg systolic or ≥110 mmHg diastolic) is associated with a twofold increase in the relative risk of death. At the authors' Federally Qualified Health Center in the Southeast, 39% of adults (n=8,695) had hypertension, and 3% (n=235) were severe. The purpose of this project was to lower blood pressure and improve the proportion of patients achieving the Agency for Healthcare Research and Quality goal for blood pressure. METHODS: This quality improvement project was performed in 2017 in three 3-month Plan, Do, Study, Act cycles using a multidisciplinary outreach model in a community-based primary care setting. A clinical team including physicians, nurses, patient navigators, behavioral health counselors, and pharmacists contacted adult patients with severe hypertension (≥180/110 mmHg), scheduled visits, and established blood pressure and medication management goals. The data review and analysis concluded in 2019. RESULTS: Among patients with blood pressure ≥180/110 mmHg (n=235), the average age was 57 years (SD=12 years), 37% (n=87) were male, 82% (n=193) were Black, and 46% (n=108) were uninsured. The majority of those contacted attended a follow-up appointment within the 9-month project (77%, n=181) and achieved an improved systolic blood pressure (87%, n=167) and diastolic blood pressure (76%, n=146). Target blood pressure of <140/90 mmHg was achieved in 29% of patients (n=53). Medication possession ratio improved from 23% to 40% among patients reached by pharmacists (n=30). Fewer deaths occurred in those reached by the intervention than in those not reached (n=1 vs n=3). CONCLUSIONS: Multidisciplinary outreach and use of evidence-based guidelines (Eighth Joint National Committee) were associated with lower blood pressure in patients with severe hypertension.

Peripheral blood metabolite profiles associated with new onset atrial fibrillation.

BACKGROUND: Peripheral blood metabolite profiles have yielded mechanistic insights into various cardiovascular disease states. We hypothesized that peripheral blood metabolite profiles would be associated with new onset atrial fibrillation (AF). METHODS AND RESULTS: The study population comprised 1892 patients without AF at baseline, who, as part the MURDOCK Cardiovascular Disease Study molecular profiling cohort (n = 2023), had previously had determination of levels of 69 metabolites from frozen, fasting plasma specimens obtained during coronary angiography. We used Cox proportional hazards models to examine the association of 13 uncorrelated metabolite factors created from these data using principal components analysis (PCA) with new occurrences of AF during a median follow up of 2.8 (0.1-4.9) years. A total of 233 patients developed new AF (12.3%) during follow up. Patients with new onset AF were older (median 67 vs. 60 years); more often white (82 vs. 71%) and male (68 vs. 60%), and had more comorbidities than those who did not develop AF. After adjustment, PCA factor 1 (medium chain acylcarnitines; hazard ratio [HR]: 1.11 [1.01-1.22]), factor 2 (short chain dicarboxylacylcarnitines; HR: 1.21 [1.09-1.34]) and factor 5 (long chain acylcarnitines; HR: 1.19 [1.06-1.34]) were associated with new onset AF. CONCLUSION: Metabolite profiles were associated with new onset AF among patients referred for coronary angiography. Validation of these observations in broader patient populations may provide better mechanistic insight into the development of AF, and may provide new opportunities for prevention and treatment.