Prevalence of elevated blood pressure in 563,704 adult patients with stroke presenting to the ED in the United States

PURPOSE: The aim of this study was to estimate the prevalence of elevated blood pressure in adult patients with acute stroke in the United States (US). METHODS: Patients with stroke were classified by initial systolic blood pressure (SBP) into 4 categories using demographic, clinical, and treatment data from the National Hospital Ambulatory Medical Care Survey, the largest study of use and provision of emergency department (ED) services in the United States. We also compared the age-, sex-, and ethnicity-adjusted rates of elevated blood pressure strata, comparable with stages 1 and 2 hypertension in the US population. RESULTS: Of the 563704 patients with stroke evaluated, initial SBP was below 140 mm Hg in 173120 patients (31%), 140 to 184 mm Hg in 315207 (56%), 185 to 219 mm Hg in 74586 (13%), and 220 mm Hg or higher in 791 (0.1%). The mean time interval between presentation and evaluation was 40 +/- 55, 33 +/- 39, 25 +/- 27, and 5 +/- 1 minutes for increasing SBP strata (P = .009). A 3- and 8-fold higher rate of elevated blood pressure strata was observed in acute stroke than the existing rates of stages 1 and 2 hypertension in the US population. Labetalol and hydralazine were used in 6126 (1%) and 2262 (0.4%) patients, respectively. Thrombolytics were used in 1283 patients (0.4%), but only in those with SBP of 140 to 184 mm Hg. CONCLUSIONS: In a nationally representative large data set, elevated blood pressure was observed in over 60% of the patients presenting with stroke to the ED. Elevated blood pressure was associated with an earlier evaluation; however, the use of thrombolytics was restricted to patients with ischemic stroke with SBP below 185 mm Hg.     

Epidemiology of elevated blood pressure in the ED

ObjectivesTo determine the prevalence and demographics of elevated blood pressure (BP) in emergency department (ED) patients.MethodsRetrospective study at an academic ED. ED patients with any systolic blood pressure (SBP) ≥ 140 mm Hg or diastolic blood pressure (DBP) ≥ 90 mm Hg over a 1-year period were included. Data pertaining to frequency of elevated BP across different ethnic categories, age groups, days of the week, shifts, and gender were collected.ResultsA total of 44 435 patient records were accessed. Overall 47.6% (95% CI, 47.2%-48.1%) of patients had elevated BP (SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg). Fifty three percent (95% CI, 52%-54%) were women. Among patients with elevated BP, 18% (95% CI, 17.8%-18.9%) had severe BP elevation (SBP ≥ 180 or DBP ≥ 110). Overall, patients > 45 years old were more likely to have elevated BP in ED. Across all ethnic groups, BP increased with age. Significant differences were noted in the prevalence of elevated BP between whites (52%), and other ethnic groups (African Americans [45%] and Hispanics [31%]) (P < .01). Overall, 64% (95% CI, 63.3%-64.6%) of patients with elevated BP were discharged from the ED. Forty four percent (95% CI, 42.4%-45.5%) of patients with severe BP elevation were also discharged from the ED.ConclusionsThis study provides knowledge of distribution of elevated BP among different age, gender and ethnic groups in the ED which can be used to develop specific interventions to improve recognition, prevention, detection, and treatment of hypertension.     

Routine testing in patients with asymptomatic elevated blood pressure in the ED

Study Objective

There are no clear recommendations for the diagnostic evaluation of patients who present to the emergency department (ED) with asymptomatic elevated blood pressure. In patients presenting with asymptomatic elevated blood pressure in the ED, we measured the prevalence of abnormalities on a basic metabolic profile (BMP) that led to hospital admission as well as the prevalence of diminished renal function.

Methods

This is a cross-sectional study at 2 urban teaching EDs with a largely African American population. Adult patients (≥18 years) with a triage diastolic blood pressure (BP) 100 mm Hg or higher and without symptoms suggestive of acute end-organ damage were enrolled. All patients had a BMP sent. The primary outcome measured was abnormalities on the BMP that led to hospital admission. The secondary outcome measured was the prevalence of diminished renal function (glomerular filtration rate <60 mL min⁻¹ 1.73 m⁻²).

Results

One hundred sixty-seven patients with asymptomatic elevated BP were studied. Twelve (7.2%; 95% confidence interval, 3%-11%) patients were admitted due to abnormal results on the BMP. Twenty-seven (16.2%; 95% confidence interval, 11%-21%) patients met the secondary outcome measure of diminished renal function (glomerular filtration rate <60 mL min⁻¹ 1.73 m⁻²).

Conclusion

In a homogenous African American population presenting to the ED with asymptomatic elevated BP, there is a relatively high prevalence of abnormalities on the BMP that led to hospital admission. We suggest routine testing of a serum creatinine should be strongly considered in a largely African American patient population with asymptomatic elevated BP in the ED.     

The association between glycemic, lipids and blood pressure control among Israeli diabetic patients

Background: It is recommended that in diabetes mellitus patientsall risk factors for cardiovascular disease should be controlled. Aim: To evaluate the rate of reaching all glycemic, lipids andblood pressure target levels among diabetic patients in Israeland to analyze demographic and clinical parameters associatedwith it. Design: A cross-sectional study. Methods: The study was conducted in Maccabi Healthcare Services,Israel's second largest health maintenance organization. Allpatients (n = 41 936), older than 20 years, who were listedon Maccabi Healthcare Service's diabetes mellitus computerizeddatabase and had all three study parameters (HbA1c, LDL-C andblood pressure levels during 2005) were eligible for the study.The rate of reaching HbA1c <7.0%, LDL-C <100 mg/dl andblood pressure <130/85 mmHg, as well as its association withvarious demographic and clinical parameters were analyzed. Results: Only 13% of all study patients achieved all three targetlevels. The parameters which were significantly associated withgoal achievement were compliance to medical treatment for allthree parameters (OR 1.56, 95% CI 1.44–1.69, P = 0.0001),male gender (OR 1.42, 95% CI 1.31–1.54, P = 0.0001), comorbiditywith ischemic heart disease (OR 1.23, 95% CI 1.13–1.34,P = 0.0001), and >12 visits per year to family physician(OR 1.10, 95% CI 1.02–1.19, P = 0.012). Conclusion: Non-compliance with treatment and sub-optimal follow-upby family physicians are associated with increased risk of failureto control major risk factor among diabetic patients.     

The need for dental care among adults presenting to an urban ED

Objective

The study aimed to estimate the prevalence of need for dental care among patients in the ED and assess associated characteristics.

Methods

This was a cross-sectional study conducted in the emergency department (ED) of a level I trauma center between June 1 and August 31, 2009. All ED patients were prospectively screened during randomly selected 8-hour blocks of time; consenting patients completed a survey on sociodemographics and health. The treating clinician completed an oral health examination to determine the patient's need for dental care as none (continue usual care), early (need to be seen soon), or urgent (need to be seen immediately). Data were analyzed using logistic regression.

Results

There were 4670 patients who presented to the ED, 2787 (59.7%) were eligible, 1190 (63.2%) consented and enrolled, and 653 (54.9%) had a dental examination. Of these, 388 (59.4%; 95% confidence interval [CI], 56%-63%) had no need for dental care, 199 (30.5%; 95% CI, 27%-34%) had an “early need,” and 66 (10.1%; 95% CI, 8%-12%) had an “urgent need.” Logistic regression showed the need for dental care was associated with age, ethnicity, and having not had a routine checkup/cleaning in the last 3 years.

Conclusions

Of the patients presenting to the ED, 40.6% were in some need of dental care. This need was not associated with insurance or socioeconomic status as shown in previous studies. Age, ethnicity, and no routine oral care in the last 3 years were all associated with early/urgent need for oral health care.     

Differing prevalence estimates of elevated blood pressure in ED patients using 4 methods of categorization

Objective

This study examined the variability of blood pressure measurements and prevalence estimates of elevated blood pressure in emergency department (ED) patients using 4 different methods of categorization.

Methods

A prospective, observational study was conducted on adult ED patients with elevated triage blood pressures (systolic ≥140 or diastolic ≥90 mm Hg). Three blood pressure measurements were obtained on all subjects and categorized as follows: (1) triage measurement only, (2) the mean of the triage and second measurement, (3) the mean of the 3 measurements, and (4) the mean of the second and third measurements.

Results

Of 2192 screened patients, 326 were included in the final analysis with mean triage systolic and diastolic blood pressures of 160 and 90 mm Hg, respectively. Prevalence estimates of elevated blood pressure in this sample ranged from 100% (reference standard: mean triage blood pressure) to the most conservative estimate of 67% (fourth method).

Conclusion

Determination of elevated blood pressure in ED patients is largely dependent on the method of blood pressure categorization.     

No association between metoclopramide treatment in ED and reduced risk of post-concussion headache

Objective

There is a lack of definitive pediatric literature on effective pharmacotherapy for persistent post-concussion headache symptoms. This study assessed whether acute metoclopramide treatment in the Emergency Department (ED) was associated with a reduction in persistent headache in children at 1- and 4-weeks post-concussion.

Increased peak blood velocity in association with elevated blood pressure

To test the hypothesis that peak blood velocity in the common carotid artery is increased in association with elevated blood pressure, the authors measured peak common carotid blood velocity in 458 subjects by color Doppler ultrasonography. Blood pressure was measured at the time of ultrasound examination by automated sphygmomanometer. Peak blood velocity was increased in subjects with elevated blood pressure (right common carotid: 72.5 ± 2.0 cm/s vs. 62.7 ± 2.5 cm/s, left common carotid: 72.0 ± 1.8 cm/s vs. 63.9 ± 2.0 cm/s, p < 0.001). Peak blood velocity was significantly correlated with systolic blood pressures between 135 and 160 mmHg (r = 0.47 in right common carotid, 0.45 in left common carotid, n = 123, p < 0.001). No correlation was found between peak blood velocity and blood pressures less than 135 mmHg or greater than 160 mmHg. By increasing erythrocyte momentum, increased peak blood velocity may play a role in the pathogenesis of arterial diseases associated with hypertension.     

Lack of relationship between hypertension-associated symptoms and blood pressure in hypertensive ED patients

A number of cardiopulmonary and neurological symptoms are presumed to be associated with hypertension. We examined the prevalence of these symptoms in ED patients with elevated blood pressure (BP) and studied the relationship between symptom prevalence and BP value. We enrolled consecutive adult ED patients with sustained BP elevation (systolic BP>or=140 mm Hg, diastolic BP>or=90 mm Hg). BP values were categorized according to Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure, 6th Report criteria. Elevated BP was noted in 551 (29%) of 1908 patients. Unprompted complaints of hypertension-associated symptoms were noted in 26%, and there was no association between BP category and complaints other than dyspnea. Symptom interviews were conducted in 294 (56%) patients; 68% of this subset noted >or=1 current hypertension-associated symptom with no relationship between symptom prevalence and BP category. We conclude that symptoms putatively associated with hypertension are common among ED patients with elevated BP, and their prevalence appears unrelated to BP value.     

The ED is an efficient place to treat ED patients

The purpose of this study was to determine what percentage of ED patients would be more efficiently treated in an offsite clinic. A stratified sample consisting of 650 ED visits were reviewed. Patient care was classified as more efficiently delivered in ED or clinic using prospectively developed criteria. Five hundred fifty-three (85%; 95% confidence interval [CI], 82-88%) visits met the definition of efficient ED utilization. One (0.15%; 95% CI, 0.01-0.99%) met the criteria for efficient clinic utilization. The other 96 (15%; 95% CI, 12-18%) failed to meet the definition of efficient for either site; 92 of these failed 2 or more clinic criteria. Only 25 (3.9%; 95% CI, 2.6-5.7%) were seen for nonacute problems. Few ED patients would be more efficiently seen in a clinic.     

Health literacy of adults presenting to an urban ED

Objective

The aim of the study was to assess the prevalence of limited health literacy in an urban emergency department (ED) and its association with sociodemographic variables.

Methods

This was a cross-sectional study of patients presenting to the ED of an urban county hospital. For 3 months, we screened a convenience sample of patients presenting to the ED. Participants completed a brief demographic survey and a validated assessment of health literacy, the Short Test of Functional Health Literacy in Adults (S-TOFHLA). Multinomial logistic regression model was used to analyze data.

Results

Of the 15?930 patients presenting to the ED, 5601 met inclusion criteria. Of eligible patients, 65% (3639) agreed to complete demographic surveys and 26% (960) of them agreed to complete the S-TOFHLA. The most common exclusions were inability to contact the patient and age less than 18 years. Participating patients were younger than those who declined (mean age, 36.8 compared to 40.8 [t = 7.49; P < .001]). Sex and ethnicity were not significantly different across groups. Of all participants, 15.5% possessed limited health literacy. Inadequate health literacy was independently associated with increasing age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.05-1.10), non-English primary language (OR, 6.97; 95% CI, 2.76-17.6), male sex (OR, 1.82; 95% CI, 1.03-3.21), nonwhite ethnicity (OR, 2.66; 95% CI, 1.40-5.04), and years of education in the United States (OR, 0.63; 95% CI, 0.42-0.92). Marginal health literacy was associated with increasing age (OR, 1.03; 95% CI, 1.00-1.05); male sex (OR, 1.84; 95% CI, 1.04-3.24); ethnicity (OR, 2.08; 95% CI, 1.12-3.85); and a housing status of homelessness (OR, 9.66; 95% CI, 2.33-40.0), living with friends (OR, 4.59; 95% CI, 1.18-17.9), or renting (OR, 4.16; 95% CI, 1.21-14.3). Moderate to high correlation among housing variables was observed.

Conclusions

Of patients enrolled in the study, 15.5% have limited health literacy. Age, male sex, non-English first language, nonwhite ethnicity, limited education, and unstable housing were associated with limited health literacy.     

Prevalence of orthostatic hypotension among patients presenting with syncope in the ED

We sought to determine the prevalence of orthostatic hypotension as a cause of syncope in the emergency setting, and describe the characteristics of patients diagnosed with this condition. Blood pressure orthostatic changes were measured prospectively in a standardized fashion up to 10 minutes, or until symptoms occurred, in all consecutive patients with syncope as a chief complaint presenting in the emergency department (ED) of a primary and tertiary care hospital. Patients unable to stand-up were excluded. Hypotension was considered to be the cause of syncope when there was: (1) a decrease in systolic blood pressure (SBP) >or= 20 mm Hg with simultaneous symptoms; (2) a decrease in SBP between 10 and 20 mm Hg, but a SBP or= 20 mm Hg were found in 10% of patients with syncope attributed to other causes. Compared with patients with vasovagal disorder, those with orthostatic hypotension were older; had more comorbid conditions including hypertension, organic heart disease, and abnormal electrocardiogram; were taking more hypotensive medications; and required more frequently hospitalization (P <.01). We concluded that standardized blood pressure measurement in the ED enabled to strongly implicate orthostatic hypotension as a cause of syncope in 24% of patients with this symptom. Drug-related hypotension was the most frequent cause for this disorder.     

The association between an increased level of gamma-glutamyl transferase and systolic blood pressure in diabetic subjects

Gamma-glutamyl transferase (GGT) is an enzyme present in serum and on most cell surfaces and serves as an oxidative stress marker. Although serum GGT is associated with hypertension development, little data are available on the associations between GGT and hypertension among populations with diabetes mellitus (DM). Our aim was to investigate the potential association between the changes in systolic or diastolic blood pressure (SBP/DBP) and the GGT level in type 2 DM subjects, in comparison with non-DM subjects. In 179 non-DM and 177 DM subjects, SBP/DBP, body mass index (BMI), fasting plasma glucose, serum asparate aminotransferase, alanine aminotransferase and GGT were measured at the baseline and after a 1-year period. Between these 2-measurement points, in non-DM subjects, SBP and DBP levels were significantly increased, while GGT tended to increase. In contrast, in DM subjects, the mean levels of SBP, DBP and GGT remained unchanged. Multivariate analysis revealed that in non-DM subjects the degree of increase in SBP was significantly and positively correlated to that of GGT (beta = 0.165), along with age and BMI. Likewise, the increase in DBP was correlated to that of GGT in non-DM subjects (beta = 0.170). In contrast, in DM subjects, the degree of increase in SBP was significantly correlated to that of only GGT (beta = 0.166). These results suggest that the presence of DM may attenuate the effects of GGT on DBP.     

血液透析患者家庭自测血压与透析日血压的相关性研究

目的 调查家庭自测血压与血液透析中心测量血压的关联度,患者在透析中心测量的血压中,哪一个能更好反映非透析日血压的状态. 方法 有56名血液透析患者参与研究,分别采集患者家庭自测血压、上机前血压及上机后不同时间点血压情况,比较不同时间点血压测量值之间的相关性.结果 上机后1h血压判定为高血压组、正常血压组与家庭自测血压判定为高血压组、正常血压组的符合率最高,分别为81.8％、61.8％.将患者按照家庭自测血压状态分为高血压组和正常血压组后,可见高血压组上机前30min的收缩压、舒张压与家庭自测收缩压、舒张压的差值最小,而正常血压组,上机前30min的收缩压、舒张压与家庭自测收缩压、舒张压的差值最大. 结论 上机后1h血压判定为高血压组、正常血压组与家庭自测血压判定为高血压组、正常血压组的符合率最高,可以通过上机后1h血压状态估计患者透析间期的血压情况.     

Blood cocaine and metabolite concentrations, clinical findings, and outcome of patients presenting to an ED

The purpose was to determine if blood cocaine or metabolite concentrations would accurately reflect the severity of clinical findings in patients presenting to the emergency department, identifying those requiring therapeutic intervention or those at risk for poor outcome. Blood for determination of cocaine and metabolite concentrations was drawn from patients and were determined by an extractive alkylation/mass spectrometry procedure. The mean blood concentrations (mg/L) in 111 patients were as follows: cocaine, 0.26 +/- 0.5; ecgonine 0.42 +/- 0.47; ecgonine methyl ester 0.21 +/- 0.37, norcocaine 0.03 +/- 0.17; benzoylecgonine 1.28 +/- 1.29, cocaethylene 0.02 +/- 0.06. Two patients died, 23 required hospital admission, and 88 were discharged from the ED. There was no statistical correlation between cocaine or any metabolite concentration and the severity of clinical symptoms, disposition, need for treatment or outcome. Blood cocaine and metabolite concentrations should be interpreted with caution because they vary widely and do not predict the severity of clinical findings, the incidence of adverse effects, outcome, or need for interventional therapy.     

Correlation between capillary and arterial blood gas parameters in an ED

Background and aims

Sampling from arteries for the analysis of blood gases is a common procedure in emergency departments (ED). The procedure is painful for the patients and causes concern for the medical personnel due to possible complications, such as hematoma, infection, ischemia, and formation of fistula or aneurism. The present study compared the results of capillary and arterial blood gases analyses (CBG and ABG) to emphasizing a less aggressive technique with the fewest complications for this procedure.

Materials and methods

In the comparative/analytical study, the results of ABG and CBG for 187 patients referring to the ED of a teaching hospital were compared using SPSS 18 statistical software (SPSS, Chicago, IL) in relation to the mean partial pressure of oxygen (Po₂), partial pressure of carbon dioxide (Pco₂), base excess (BE), bicarbonate (HCO₃), serum acidity (pH), and saturation of hemoglobin oxygen (SaO₂).

Results

Saturation of hemoglobin oxygen, HCO₃, pH, Pco₂, Po₂, and BE exhibited significant statistical correlation between ABG and CBG (P = .001). The average correlations between capillary and arterial samples were 0.78 for pH, 0.73 for Pco₂, 0.71 for BE, 0.90 for HCO₃, 0.77 for Po₂, and 0.52 for SaO₂. Comparison of the parameters means did not exhibit significant differences between arterial and capillary samples except for Po₂ and SaO₂ (P > .05).

Conclusion

There appear to be strong correlation between samples collected from the finger tip capillaries with the arterial blood samples in relation to the analysis of blood gas.     

Comparison of men and women presenting to an ED with acute appendicitis

Appendicitis is a common problem presenting to the Emergency Department (ED). Missed or delayed diagnosis can result in increased morbidity and is a common cause of malpractice claims. Diagnosis in women is more difficult because of additional clinical considerations. The study hypothesis is that women with appendicitis presenting to an ED experience a longer delay to operative intervention resulting in an increased rate of perforated appendix. A retrospective chart review of 196 male and female patients between twelve and fifty years of age presenting to the ED with final discharge diagnosis of appendicitis was performed. Mean time from ED presentation to operative intervention was 477 minutes for men and 709 minutes for women (P = .02). Perforated appendix was present in 38.7% of men and 23.5% of women (P = .002). Women with appendicitis presenting to an ED experience significant delay to surgery, however, this is not associated with an increased rate of perforation.