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Correlation between Subclinical Heart Disease and Cardiovascular Risk Profiles in an Urban Emergency Department Population with Elevated Blood Pressures: A Pilot Study

https://doi.org/10.1016/j.jemermed.2014.12.026Get rights and content

Abstract

Background

Uncontrolled hypertension is a primary risk factor for development of cardiovascular complications.

Objective

Determine the point prevalence of left ventricular hypertrophy (LVH) and diastolic dysfunction in an urban emergency department (ED) population with elevated blood pressures (BP) and examine correlations between subclinical disease and patient cardiovascular risk profiles.

Methods

A convenience sample of patients with EBP (>140/90 on two measurements) had limited bedside echocardiograms (LBE). Subclinical hypertensive heart disease was classified as the presence of: LVH, abnormal ejection fraction (EF), or diastolic dysfunction.

Results

Thirty-nine patients with EBP were enrolled. The mean age was 46 years (SD = 10.9), 59% were women, 21% were smokers, and 92% had a history of hypertension. The average body mass index was 30.7 (SD = 8.7). Patients were 67% African American, 23% Latino, 5% Caucasian, 3% Asian, and 3% Native American. Subclinical disease was found in 39%: 31% had LVH, 15% had diastolic dysfunction, and 8% had abnormal EF. On bivariate analysis, elevated BP (p = 0.039) and blood urea nitrogen (p = 0.016) were correlated with subclinical heart disease. After adjusting for other covariates, receiving oral/intravenous antihypertensive medications in the ED (p = 0.005) was associated with subclinical heart disease.

Conclusions

We found a point prevalence of subclinical heart disease of 39% in this urban ED population, using LBE. Real-time identification of subclinical heart disease at early stages in the ED in conjunction with abnormal renal function can help emergency physicians identify those patients in need of more aggressive therapy and urgent follow-up.

Introduction

Emergency departments (EDs) serve a high-risk population, with many patients utilizing the ED as part of their primary care access 1, 2. Uncontrolled/untreated hypertension is a frequent condition among patients presenting to the ED and is a finding in up to 25% of ED patients 3, 4. Up to half of the patients presenting to the ED with elevated blood pressure (BP) are not currently under medical care, making the ED visit their only point of contact with health care providers (5). Among known hypertensives, approximately 42% report medication nonadherence (6).

Early identification of subclinical cardiac disease is an important component of cardiovascular disease prevention. Studies have estimated that the prevalence of subclinical diastolic dysfunction can be as high as 48% among high-risk groups with cardiovascular risk factors 7, 8. Levy et al., in a cohort of African American patients identified from an urban ED, found a 90% point prevalence of subclinical hypertensive heart disease (9). Left ventricular hypertrophy (LVH) is one of the strongest predictors of adverse cardiovascular outcomes in a hypertension population 10, 11, 12. Early recognition of LVH is important because it is reversible, and antihypertensive medications can decrease the associated cardiovascular morbidity and mortality 13, 14.

The study objectives were 1) to determine the point prevalence of subclinical heart disease (LVH and diastolic dysfunction) in an urban ED population with elevated blood pressures using real-time bedside ED echocardiograms, 2) to examine the correlation between subclinical disease and patient cardiovascular risk profiles, and 3) identify the utility for risk assessment/stratification in this population.

Section snippets

Methods

A convenience sample of ED patients with elevated blood pressures (blood pressure ≥ 140/90 mm Hg) with or without a history of hypertension were consented and enrolled from the University of Illinois Hospital and Health Sciences System Emergency Department. Patients were enrolled at various times of the day, including early mornings, weekends, and nights, to obtain a representative sampling of patients. Subjects were identified based upon their triage blood pressure but only consented and

Results

A total of 39 ED patients with evaluated blood pressures were enrolled. There was no predominance of cardiac symptoms among presenting chief complaints (multiple complaints 28%; musculoskeletal 26%; cardiac 21%; gastrointestinal 15%; ear, nose, and throat 2%; and pulmonary 2%). The mean age was 46 years (SD 10.9 years), 59% (n = 23) were women, 21% (n = 8) were smokers, and 92% had a past medical history of hypertension (n = 36). The average body mass index was 30.7 (SD = 8.7). Race/ethnicity

Discussion

We found a point prevalence of subclinical heart disease of 39% in this diverse urban ED population with elevated blood pressures, with the majority having evidence of LVH (31%). This represents a higher proportion compared to population studies such as the Multi-Ethnic Study of Atherosclerosis (MESA), which found a 9.8% prevalence of LVH among study participants and 13.1% prevalence among hypertensive participants 18, 19. The MESA study is an ongoing longitudinal cohort study of men and women

Conclusion

We demonstrated that patients with elevated blood pressures in the ED are at high risk for subclinical heart disease compared to the general population. Current published guidelines for the management of asymptomatic hypertension in the ED recommend future research related to the optimal screening for this patient population in the ED (28). Real-time identification of subclinical heart disease at earlier stages in patients with elevated blood pressures in the ED can help risk-stratify and

Acknowledgments

The project described was supported by the National Center for Advancing Translational Sciences (Grant UL1TR000050), National Institutes of Health (NIH), through Grant UL1TR000050. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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