93 results on '"Lama Ghazi"'
Search Results
2. A randomized clinical trial assessing the effect of automated medication-targeted alerts on acute kidney injury outcomes
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F. Perry Wilson, Yu Yamamoto, Melissa Martin, Claudia Coronel-Moreno, Fan Li, Chao Cheng, Abinet Aklilu, Lama Ghazi, Jason H. Greenberg, Stephen Latham, Hannah Melchinger, Sherry G. Mansour, Dennis G. Moledina, Chirag R. Parikh, Caitlin Partridge, Jeffrey M. Testani, and Ugochukwu Ugwuowo
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Science - Abstract
Abstract Acute kidney injury is common among hospitalized individuals, particularly those exposed to certain medications, and is associated with substantial morbidity and mortality. In a pragmatic, open-label, National Institutes of Health-funded, parallel group randomized controlled trial (clinicaltrials.gov NCT02771977), we investigate whether an automated clinical decision support system affects discontinuation rates of potentially nephrotoxic medications and improves outcomes in patients with AKI. Participants included 5060 hospitalized adults with AKI and an active order for any of three classes of medications of interest: non-steroidal anti-inflammatory drugs, renin-angiotensin-aldosterone system inhibitors, or proton pump inhibitors. Within 24 hours of randomization, a medication of interest was discontinued in 61.1% of the alert group versus 55.9% of the usual care group (relative risk 1.08, 1.04 – 1.14, p = 0.0003). The primary outcome – a composite of progression of acute kidney injury, dialysis, or death within 14 days - occurred in 585 (23.1%) of individuals in the alert group and 639 (25.3%) of patients in the usual care group (RR 0.92, 0.83 – 1.01, p = 0.09). Trial Registration Clinicaltrials.gov NCT02771977.
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- 2023
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3. Multimorbidity is associated with lower total 24-hour movement activity among US adults
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Erin E. Dooley, Ligong Chen, Lama Ghazi, Bjoern Hornikel, Pablo Martinez-Amezcua, Priya Palta, C. Barrett Bowling, Paul Muntner, Cora E. Lewis, and Kelley Pettee Gabriel
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NHANES ,Accelerometry ,Chronic disease ,Physical activity ,Epidemiology ,MIMS-units ,Medicine - Abstract
Objective: Having chronic conditions may result in reduced physical and cognitive function but less is known about multimorbidity with daily movement. We examined the association of multimorbidity and device-measured total daily movement in a nationally representative sample of US adults aged ≥ 30 years from the 2011–2014 National Health and Nutrition Examination Surveys. Methods: Any multimorbidity (≥2 conditions) and complex multimorbidity (≥3 conditions across ≥ 3 body systems) were quantified using 16 chronic conditions via self-report and/or clinical thresholds. Total movement over 24-hours (Monitor-Independent Movement Summary units [MIMS-units]) was measured using a wrist-worn device (ActiGraph GT3X). Multivariable linear regression examined the association of 1) each chronic condition, 2) number of conditions, 3) any multimorbidity, and 4) complex multimorbidity with total movement. Covariates included age, gender, race/ethnicity, educational attainment, and smoking status. Results: Among US adults (N = 7304, mean age: 53.2 ± 0.34 years, 53.2% female, 69.4% Non-Hispanic White), 62.2% had any multimorbidity with 34.2% having complex multimorbidity. After adjustment, a higher number of chronic conditions was associated with incrementally lower total movement (β MIMS-units [95% CI] compared to those with no chronic conditions; one: −419 [−772, −66], two: −605 [−933, −278], three: −1201 [−1506, −895], four: −1908 [−2351, −1465], 5+: −2972 [−3384, −2560]). Complex multimorbidity presence was associated with −1709 (95% CI: −2062, −1357) and −1269 (−1620, −918) lower total movement compared to those without multimorbidity and multimorbidity but not complex, respectively. Conclusions: Multimorbidity was associated with lower 24-h movement among US adults and may be helpful for identifying adults at risk for low movement.
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- 2023
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4. Critical illness myopathy and trajectory of recovery in acute kidney injury requiring continuous renal replacement therapy: a prospective observational trial protocol
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Javier A Neyra, Felipe González-Seguel, J Pedro Teixeira, Benjamin R Griffin, Chaitanya Anil Pal, Nathanial Jenkins, Beth M Jones, Yuri Yoshida, Naomi George, Hayley Puffer Israel, Lama Ghazi, and Kirby P Mayer
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Medicine - Abstract
Introduction Acute kidney injury requiring renal replacement therapy (AKI-RRT) is common in the intensive care unit (ICU) and is associated with significant morbidity and mortality. Continuous RRT (CRRT) non-selectively removes large amounts of amino acids from plasma, lowering serum amino acid concentrations and potentially depleting total-body amino acid stores. Therefore, the morbidity and mortality associated with AKI-RRT may be partly mediated through accelerated skeletal muscle atrophy and resulting muscle weakness. However, the impact of AKI-RRT on skeletal muscle mass and function during and following critical illness remains unknown. We hypothesise that patients with AKI-RRT have higher degrees of acute muscle loss than patients without AKI-RRT and that AKI-RRT survivors are less likely to recover muscle mass and function when compared with other ICU survivors.Methods and analysis This protocol describes a prospective, multicentre, observational trial assessing skeletal muscle size, quality and function in ICU patients with AKI-RRT. We will perform musculoskeletal ultrasound to longitudinally evaluate rectus femoris size and quality at baseline (within 48 hours of CRRT initiation), day 3, day 7 or at ICU discharge, at hospital discharge, and 1–3 months postdischarge. Additional skeletal muscle and physical function tests will be performed at hospital discharge and postdischarge follow-up. We will analyse the effect of AKI-RRT by comparing the findings in enrolled subjects to historical controls of critically ill patients without AKI-RRT using multivariable modelling.Ethics and dissemination We anticipate our study will reveal that AKI-RRT is associated with greater degrees of muscle loss and dysfunction along with impaired postdischarge recovery of physical function. These findings could impact the in-hospital and postdischarge treatment plan for these patients to include focused attention on muscle strength and function. We intend to disseminate findings to participants, healthcare professionals, the public and other relevant groups via conference presentation and publication without any publication restrictions.Trial registration number NCT05287204.
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- 2023
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5. Hypertension, Blood Pressure Variability, and Acute Kidney Injury in Hospitalized Children
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James T. Nugent, Lama Ghazi, Yu Yamamoto, Christine Bakhoum, F. Perry Wilson, and Jason H. Greenberg
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acute kidney injury ,blood pressure variability ,hypertension ,pediatrics ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background Although hypertensive blood pressure measurements are common in hospitalized children, the degree of inpatient hypertension and blood pressure variability (BPV) associated with end organ complications like acute kidney injury (AKI) is unknown. Methods and Results All analyses are based on a retrospective cohort of children aged 1 to 17 years with ≥2 creatinine measurements during admission from 2014 to 2018. We used time‐updated Cox models to evaluate the association between BPV and hypertension with AKI. Time‐varying BPV and hypertension were based on blood pressure in the preceding 72 hours. For the analysis of hypertension and AKI, we excluded patients on vasopressors to ensure comparison between hypertensive and normotensive patients. During 5425 pediatric encounters, 258 430 blood pressure measurements were recorded (median [interquartile range] 22 [11–47] readings per encounter). Among all measurements, 32.7% were ≥95th percentile and 18.9% were ≥99th percentile for age, sex, and height. AKI occurred in 389 (7.2%) encounters. We observed a U‐shaped relationship between mean blood pressure and incident AKI. BPV was associated with AKI, with the largest effect sizes in the systolic and mean arterial pressure variability measures. Multiple hypertension thresholds were associated with AKI after controlling for confounders. In an additional multivariable model adjusted for BPV, the association between hypertension and AKI was attenuated but remained significant for hypertension defined as three stage 2 measurements in 1 day (hazard ratio, 1.43 [95% CI, 1.01–2.01]). Conclusions Hypertension and BPV are associated with AKI in hospitalized children. Future studies are needed to determine how pharmacologic and nonpharmacologic interventions modify AKI risk in pediatric inpatients with hypertension.
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- 2023
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6. Severe inpatient hypertension prevalence and blood pressure response to antihypertensive treatment
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Lama Ghazi, Fan Li, Xinyuan Chen, Michael Simonov, Yu Yamamoto, Aditya Biswas, Jonathan Hanna, Tayyab Shah, Raymond Townsend, Aldo Peixoto, and F. Perry Wilson
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antihypertensive therapy ,blood pressure response ,electronic health records ,hypertension ,inpatient ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Abstract Severe hypertension (HTN) that develops during hospitalization is more common than admission for HTN; however, it is poorly studied, and treatment guidelines are lacking. Our goal is to characterize hospitalized patients who develop severe HTN and assess blood pressure (BP) response to treatment. This is a multi‐hospital retrospective cohort study of adults admitted for reasons other than HTN who developed severe HTN. The authors defined severe inpatient HTN as the first documented BP elevation (systolic BP > 180 or diastolic BP > 110) at least 1 hour after admission. Treatment was defined as receiving antihypertensives (intravenous [IV] or oral) within 6h of BP elevation. As a measure of possible overtreatment, the authors studied the association between treatment and time to mean arterial pressure (MAP) drop ≥ 30% using the Cox proportional hazards model. Among 224 265 hospitalized adults, 10% developed severe HTN of which 40% were treated. Compared to patients who did not develop severe HTN, those who did were older, more commonly women and black, and had more comorbidities. Incident MAP drop ≥ 30% among treated and untreated patients with severe HTN was 2.2 versus 5.7/1000 person‐hours. After adjustment, treated versus. untreated patients had lower rates of MAP drop ≥ 30% (hazard rate [HR]: 0.9 [0.8, 0.99]). However, those receiving only IV treatment versus untreated had greater rates of MAP drop ≥ 30% (1.4 [1.2, 1.7]). Overall, the authors found that clinically significant MAP drop is observed among inpatients with severe HTN irrespective of treatment, with greater rates observed among patients treated only with IV antihypertensives. Further research is needed to phenotype inpatients with severe HTN.
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- 2022
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7. Kidney Function Decline in Young Adulthood and Subsequent 24-Hour Ambulatory Blood Pressure in Midlife: The CARDIA Study
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Lama Ghazi, MD, PhD, Daichi Shimbo, MD, David R. Jacobs, Jr., PhD, Holly Kramer, MD, MPH, Jordana B. Cohen, MD, MSCE, Paul Muntner, PhD, Yuichiro Yano, MD, PhD, and Paul E. Drawz, MD, MS
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Diseases of the genitourinary system. Urology ,RC870-923 - Published
- 2022
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8. Blood pressure response to commonly administered antihypertensives for severe inpatient hypertension.
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Lama Ghazi, Fan Li, Xinyuan Chen, Michael Simonov, Yu Yamamoto, Aditya Biswas, Jonathan Hanna, Tayyab Shah, Aldo J Peixoto, and F Perry Wilson
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Medicine ,Science - Abstract
BackgroundBlood pressure (BP) elevations are commonly treated in hospitalized patients; however, treatment is not guideline directed. Our objective was to assess BP response to commonly prescribed antihypertensives after the development of severe inpatient hypertension (HTN).MethodsThis is a cohort study of adults, excluding intensive care unit patients, within a single healthcare system admitted for reasons other than HTN who developed severe HTN (systolic BP>180 or diastolic BP >110 mmHg at least 1 hour after admission). We identified the most commonly administered antihypertensives given within 6 hours of severe HTN (given to >10% of treated patients). We studied the association of treatment with each antihypertensive vs. no treatment on BP change in the 6 hours following severe HTN development using mixed-effects model after adjusting for demographics and clinical characteristics.ResultsAmong 23,147 patients who developed severe HTN, 9,166 received antihypertensive treatment. The most common antihypertensives given were oral metoprolol (n = 1991), oral amlodipine (n = 1812), oral carvedilol (n = 1116), IV hydralazine (n = 1069) and oral hydralazine (n = 953). In the fully adjusted model, treatment with IV hydralazine led to 13 [-15.9, -10.1], 18 [-22.2, -14] and 11 [-14.1, -8.3] mmHg lower MAP, SBP, and DBP in the 6 hours following severe HTN development compared to no treatment. Treatment with oral hydralazine and oral carvedilol also resulted in significantly lower BPs in the 6 hours following severe HTN development (6 [-9.1, -2.1 and -7 [-9.1, -4.2] lower MAP, respectively) compared to no treatment. Receiving metoprolol and amlodipine did not result in a drop in BP compared to no treatment.ConclusionAmong commonly used antihypertensives, IV hydralazine resulted in the most significant drop in BP following severe HTN, while metoprolol and amlodipine did not lower BP. Further research to assess the effect of treatment on clinical outcomes and if needed which antihypertensives to administer are necessary.
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- 2022
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9. Neighborhood Socioeconomic Status and Quality of Kidney Care: Data From Electronic Health RecordsPlain-Language Summary
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Lama Ghazi, Theresa L. Osypuk, Richard F. MacLehose, Russell V. Luepker, and Paul E. Drawz
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Chronic kidney disease ,quality of care ,electronic health records ,neighborhood socioeconomic status ,healthcare system ,Diseases of the genitourinary system. Urology ,RC870-923 - Abstract
Rational & Objective: Electronic health records can be leveraged to assess quality-of-care measures in patients with chronic kidney disease (CKD). Neighborhood socioeconomic status could be a potential barrier to receiving appropriate evidence-based therapy and follow-up. We examined whether neighborhood socioeconomic status is independently associated with quality of care received by patients with CKD. Study Design: Observational study using electronic health record data. Setting & Participants: Retrospective study of patients seen at a health care system in the 7-county Minneapolis/St Paul area. Exposures: Census tract socioeconomic status measures (wealth, income, and education). Outcomes: Indicators of CKD quality of care: (1) prescription for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in patients with stage ≥ 3 CKD or stage 1 or 2 CKD with urinary albumin-creatinine ratio (UACR) > 300 mg/d, (2) UACR measurement among patients with laboratory-based CKD (estimated glomerular filtration rate < 60 mL/min/1.72 m2), and (3) CKD identified on the problem list or coded for at an encounter among patients with laboratory-based CKD. Analytic Approach: Multilevel Poisson regression with robust error variance with a random intercept at the census tract level. Results: Of the 16,776 patients who should be receiving an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 65% were prescribed these medications. Among patients with laboratory-based CKD (n = 25,097), UACR was measured in 27% and CKD was identified in the electronic health record in 55%. We found no independent association between any neighborhood socioeconomic status measures and CKD quality-of-care indicators. Limitations: 1 health care system and selection bias. Conclusions: We found no association of neighborhood socioeconomic status with quality of CKD care in our cohort. However, adherence to CKD guidelines is low, indicating an opportunity to improve care for all patients regardless of neighborhood socioeconomic status.
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- 2021
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10. Neighborhood Socioeconomic Status, Health Insurance, and CKD Prevalence: Findings From a Large Health Care SystemPlain-Language Summary
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Lama Ghazi, Theresa L. Osypuk, Richard F. MacLehose, Russell V. Luepker, and Paul E. Drawz
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Chronic kidney disease ,Medicaid ,prevalence ,socioeconomic status ,electronic health records ,Diseases of the genitourinary system. Urology ,RC870-923 - Abstract
Rational & Objective: Neighborhood socioeconomic status (SES) and health insurance status may be important upstream social determinants of chronic kidney disease (CKD), but their relationship remains unclear. The aim of this study was to determine whether neighborhood SES and individual-level health insurance status were independently associated with CKD prevalence. Study Design: Observational study using electronic health records (EHRs). Setting & Participants: EHRs of patients (n = 185,269) seen at a health care system in the 7-county Minneapolis/St Paul area (2017-2018). Exposures: Census tract neighborhood SES measures (median value of owner-occupied housing units [wealth], percentage of residents aged >25 years with bachelor’s degree or higher [education]) and individual-level health insurance status (aged
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- 2021
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11. Predicting patients with false negative SARS-CoV-2 testing at hospital admission: A retrospective multi-center study.
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Lama Ghazi, Michael Simonov, Sherry G Mansour, Dennis G Moledina, Jason H Greenberg, Yu Yamamoto, Aditya Biswas, and F Perry Wilson
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Medicine ,Science - Abstract
ImportanceFalse negative SARS-CoV-2 tests can lead to spread of infection in the inpatient setting to other patients and healthcare workers. However, the population of patients with COVID who are admitted with false negative testing is unstudied.ObjectiveTo characterize and develop a model to predict true SARS-CoV-2 infection among patients who initially test negative for COVID by PCR.DesignRetrospective cohort study.SettingFive hospitals within the Yale New Haven Health System between 3/10/2020 and 9/1/2020.ParticipantsAdult patients who received diagnostic testing for SARS-CoV-2 virus within the first 96 hours of hospitalization.ExposureWe developed a logistic regression model from readily available electronic health record data to predict SARS-CoV-2 positivity in patients who were positive for COVID and those who were negative and never retested.Main outcomes and measuresThis model was applied to patients testing negative for SARS-CoV-2 who were retested within the first 96 hours of hospitalization. We evaluated the ability of the model to discriminate between patients who would subsequently retest negative and those who would subsequently retest positive.ResultsWe included 31,459 hospitalized adult patients; 2,666 of these patients tested positive for COVID and 3,511 initially tested negative for COVID and were retested. Of the patients who were retested, 61 (1.7%) had a subsequent positive COVID test. The model showed that higher age, vital sign abnormalities, and lower white blood cell count served as strong predictors for COVID positivity in these patients. The model had moderate performance to predict which patients would retest positive with a test set area under the receiver-operator characteristic (ROC) of 0.76 (95% CI 0.70-0.83). Using a cutpoint for our risk prediction model at the 90th percentile for probability, we were able to capture 35/61 (57%) of the patients who would retest positive. This cutpoint amounts to a number-needed-to-retest range between 15 and 77 patients.Conclusion and relevanceWe show that a pragmatic model can predict which patients should be retested for COVID. Further research is required to determine if this risk model can be applied prospectively in hospitalized patients to prevent the spread of SARS-CoV-2 infections.
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- 2021
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12. Effect of Intensive and Standard Clinic‐Based Hypertension Management on the Concordance Between Clinic and Ambulatory Blood Pressure and Blood Pressure Variability in SPRINT
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Lama Ghazi, Nicholas M. Pajewski, Dena E. Rifkin, Jeffrey T. Bates, Tara I. Chang, William C. Cushman, Stephen P. Glasser, William E. Haley, Karen C. Johnson, William J. Kostis, Vasilios Papademetriou, Mahboob Rahman, Debra L. Simmons, Addison Taylor, Paul K. Whelton, Jackson T. Wright, Udayan Y. Bhatt, and Paul E. Drawz
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ambulatory blood pressure monitoring ,circadian rhythm ,concordance ,variability ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background Blood pressure (BP) varies over time within individual patients and across different BP measurement techniques. The effect of different BP targets on concordance between BP measurements is unknown. The goals of this analysis are to evaluate concordance between (1) clinic and ambulatory BP, (2) clinic visit‐to‐visit variability and ambulatory BP variability, and (3) first and second ambulatory BP and to evaluate whether different clinic targets affect these relationships. Methods and Results The SPRINT (Systolic Blood Pressure Intervention Trial) ambulatory BP monitoring ancillary study obtained ambulatory BP readings in 897 participants at the 27‐month follow‐up visit and obtained a second reading in 203 participants 293±84 days afterward. There was considerable lack of agreement between clinic and daytime ambulatory systolic BP with wide limits of agreement in Bland‐Altman plots of −21 to 34 mm Hg in the intensive‐treatment group and −26 to 32 mm Hg in the standard‐treatment group. Overall, there was poor agreement between clinic visit‐to‐visit variability and ambulatory BP variability with correlation coefficients for systolic and diastolic BP all
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- 2019
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13. Advances in understanding the renin-angiotensin-aldosterone system (RAAS) in blood pressure control and recent pivotal trials of RAAS blockade in heart failure and diabetic nephropathy [version 1; referees: 3 approved]
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Lama Ghazi and Paul Drawz
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Cardiovascular Pharmacology ,Cardiovascular Physiology/Circulation ,Drug Discovery & Design ,Endocrinology ,Heart Failure ,Hemodynamics, Vasc. Biology & Hypertension Sec. to Kidney Dis. ,Hypertension ,Pathophysiology of Chronic Kidney Disease (CKD) ,Pharmacogenomics ,Physiogenomics ,Renal Pharmacology ,Medicine ,Science - Abstract
The renin-angiotensin-aldosterone system (RAAS) plays a fundamental role in the physiology of blood pressure control and the pathophysiology of hypertension (HTN) with effects on vascular tone, sodium retention, oxidative stress, fibrosis, sympathetic tone, and inflammation. Fortunately, RAAS blocking agents have been available to treat HTN since the 1970s and newer medications are being developed. In this review, we will (1) examine new anti-hypertensive medications affecting the RAAS, (2) evaluate recent studies that help provide a better understanding of which patients may be more likely to benefit from RAAS blockade, and (3) review three recent pivotal randomized trials that involve newer RAAS blocking agents and inform clinical practice.
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- 2017
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14. Pragmatic trial of messaging to providers about treatment of acute heart failure: The PROMPT-AHF trial
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Lama Ghazi, Kyle O'Connor, Yu Yamamoto, Michael Fuery, Sounok Sen, Marc Samsky, Ralph J. Riello, Joanna Huang, Temitope Olufade, James McDermott, Silvio E. Inzucchi, Eric J. Velazquez, Francis Perry Wilson, Nihar R. Desai, and Tariq Ahmad
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Cardiology and Cardiovascular Medicine - Abstract
Acute Heart failure (AHF) is among the most frequent causes of hospitalization in the United States, contributing to substantial health care costs, morbidity, and mortality. Inpatient initiation of guideline-directed medical therapy (GDMT) is recommended for patients with heart failure with reduced ejection fraction (HFrEF) to reduce the risk of cardiovascular death or HF hospitalization. However, underutilization of GDMT prior to discharge is pervasive, representing a valuable missed opportunity to optimize evidence-based care. The PRagmatic Trial Of Messaging to Providers about Treatment of Acute Heart Failure tests the effectiveness of an electronic health record embedded clinical decision support system that informs providers during hospital management about indicated but not yet prescribed GDMT for eligible AHF patients with HFrEF. PRagmatic Trial Of Messaging to Providers about Treatment of Acute Heart Failureis an open-label, multicenter, pragmatic randomized controlled trial of 1,012 patients hospitalized with HFrEF. Eligible patients randomized to the intervention group are exposed to a tailored best practice advisory embedded within the electronic health record that alerts providers to prescribe omitted GDMT. The primary outcome is an increase in the proportion of additional GDMT medication classes prescribed at the time of discharge compared to those in the usual care arm.
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- 2023
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15. Is it Time to Personalize Digital Health Interventions?
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Lama Ghazi and Adam D Devore
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Cardiology and Cardiovascular Medicine - Published
- 2023
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16. Hypertension Across a Woman’s Life Cycle
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Lama Ghazi, Rahul V. Annabathula, Natalie A. Bello, Li Zhou, Richard Brandon Stacey, and Bharathi Upadhya
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Internal Medicine - Published
- 2022
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17. Electronic Alerts to Improve Heart Failure Therapy in Outpatient Practice
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Lama Ghazi, Yu Yamamoto, Ralph J. Riello, Claudia Coronel-Moreno, Melissa Martin, Kyle D. O’Connor, Michael Simonov, Joanna Huang, Temitope Olufade, James McDermott, Ravi Dhar, Silvio E. Inzucchi, Eric J. Velazquez, F. Perry Wilson, Nihar R. Desai, and Tariq Ahmad
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Cardiology and Cardiovascular Medicine - Published
- 2022
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18. Excessive Blood Pressure Response to Clonidine in Hospitalized Patients With Asymptomatic Severe Hypertension
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Jonathan Hanna, Lama Ghazi, Yu Yamamoto, Michael Simonov, Tayyab Shah, Francis P Wilson, and Aldo J Peixoto
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Male ,Incidence ,Hypertension ,Internal Medicine ,Humans ,Blood Pressure ,Female ,Middle Aged ,Clonidine - Abstract
Background There are limited and nonconcordant data on the rapidity and safety of blood pressure response to clonidine in the setting of asymptomatic severe hypertension. We evaluated the blood pressure response to clonidine in hospitalized patients with asymptomatic severe hypertension. Methods We performed a review of hospitalized, noncritically ill patients receiving clonidine within 6 hours of developing asymptomatic severe hypertension (systolic blood pressure [SBP] >180 or diastolic blood pressure [DBP] >110 mm Hg in the absence of acute hypertension-mediated target organ damage). The incidence of mean arterial pressure (MAP) reduction by ≥30% at 4 hours after clonidine was the primary endpoint. Results We identified 200 relevant patient encounters (median age 63 years, 48.5% women). Median time to clonidine following asymptomatic severe hypertension was 2.8 hours. A total of 20 (10%) patients had ≥30% MAP reduction within 4 hours after clonidine, and 32 (16%) patients had ≥30% reduction in either SBP, DBP, or MAP. Older age, female sex, and preexisting vascular disease were associated with ≥30% MAP reductions (P < 0.05). Only patient sex and clonidine dose of 0.3 mg were significant in multivariable models. There were 14 adverse events observed within 24 hours of administration of clonidine; most (9) were acute kidney injury. There were no ischemic (myocardial, cerebrovascular) events. Conclusions A substantial minority of hospitalized patients with asymptomatic severe hypertension experience precipitous blood pressure decline with clonidine, and though blood pressure declines more precipitously in women and those receiving higher doses (0.3 mg specifically), the response to clonidine is generally not predictable on clinical grounds.
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- 2022
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19. Abstract P383: Trends in Multimorbidity Among U.S. Adults With and Without Hypertension, 1999-2000 to 2017-2020
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Chibuike J Alanaeme, Oluwasegun P Akinyelure, Ying Wen, Ashley Christenson, Bharat Poudel, Shakia T Hardy, Kathryn Foti, Lama Ghazi, Christopher B Bowling, Michelle Long, Lisandro Colantonio, and Paul Muntner
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Physiology (medical) ,Cardiology and Cardiovascular Medicine - Abstract
Background: Most adults with hypertension have other chronic conditions. As obesity and diabetes are increasing among US adults, the prevalence of multimorbidity may have increased among US adults with hypertension. Methods: We used data from the National Health and Nutrition Examination Survey (NHANES) to assess the trend in multimorbidity among US adults (ages ≥ 20 years) with (n = 24,646) and without (n = 24,189) hypertension from 1999-2000 through 2017-March 2020. Hypertension was defined as systolic blood pressure ≥130 mm Hg, diastolic blood pressure ≥80 mm Hg, or use of antihypertensive medication. Multimorbidity was defined as the co-occurrence of ≥ 3 chronic conditions, not including hypertension. Chronic conditions were selected based on a framework from a US Health and Human Services report and data available in NHANES and included dyslipidemia, coronary heart disease, stroke, heart failure, diabetes, obesity, liver fibrosis, chronic kidney disease, asthma, lung disease (chronic obstructive pulmonary disease, emphysema, or chronic bronchitis), arthritis, hepatitis-C, cancer, and depression. Results: From 1999-2000 to 2017-2020, the age-adjusted mean number of chronic conditions increased from 2.4 to 3.0 among US adults with hypertension and from 1.9 to 2.2 among US adults without hypertension (Figure, top panel). During this period, the age-adjusted prevalence of multimorbidity increased from 42% to 56% among US adults with hypertension and from 32% to 34% among US adults without hypertension (Figure, bottom panel). In 2017-2020, after age, race/ethnicity, and sex adjustment, the mean difference in the number of chronic conditions among US adults with versus without hypertension was 0.70 (95% CI: 0.56 - 0.84). Multimorbidity was 1.50 (95% CI: 1.34 - 1.68) times more common among US adults with versus without hypertension. Conclusion: Multimorbidity has increased among US adults, and its prevalence is higher among adults with versus without hypertension.
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- 2023
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20. A Clinical Framework for Evaluating Machine Learning Studies
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Lama, Ghazi, Tariq, Ahmad, and Francis Perry, Wilson
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Heart Failure ,Machine Learning ,Humans ,Cardiology and Cardiovascular Medicine ,Algorithms - Published
- 2022
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21. Effect of intravenous antihypertensives on outcomes of severe hypertension in hospitalized patients without acute target organ damage
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Lama Ghazi, Fan Li, Michael Simonov, Yu Yamamoto, James T. Nugent, Jason H. Greenberg, Christine Y. Bakhoum, Aldo J. Peixoto, and F. Perry Wilson
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Adult ,Physiology ,Hypertension ,Internal Medicine ,Humans ,Blood Pressure ,Hypotension ,Cardiology and Cardiovascular Medicine ,Antihypertensive Agents ,Retrospective Studies - Abstract
Treatment of severe inpatient hypertension (HTN) that develops during hospitalization is not informed by guidelines. Intravenous (i.v.) antihypertensives are used to manage severe HTN even in the absence of acute target organ damage; however they may result in unpredictable blood pressure (BP) reduction and cardiovascular events. Our goal was to assess the association between i.v. antihypertensives and clinical outcomes in this population.This is a multihospital retrospective study of adults admitted for reasons other than HTN who develop severe HTN during hospitalization without acute target end organ damage. We defined severe HTN as BP elevation of systolic180 or diastolic110 mmHg. Treatment was defined as receiving i.v. antihypertensives within 3 h of BP elevation. We used overlap propensity score weighted Cox models to study the association between treatment and clinical outcomes during index hospitalization.Of 224 265 unique, nonintensive care unit hospitalizations, 20 383 (9%) developed severe HTN, of which 5% received i.v. antihypertensives and 79% were untreated within 3 h of severe BP elevation. In the overlap propensity weighted population, patients who received i.v. antihypertensives were more likely to develop myocardial injury (5.9% in treated versus 3.6% in untreated; hazard ratio [HR]: 1.6 [1.13, 2.24]). Treatment was not associated with increased risk of stroke (HR: 0.7 [0.3, 1.62]), acute kidney injury (HR: 0.97 [0.81, 1.17]), or death (HR: 0.86 [0.49, 1.51]).Intravenous antihypertensives were associated with increased risk of myocardial injury in patients who develop severe HTN during hospitalization. These results suggest that i.v. antihypertensives should be used with caution in patients without acute target organ damage.
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- 2022
22. Risk of Mild Cognitive Impairment or Probable Dementia in New Users of Angiotensin II Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors: A Secondary Analysis of Data From the Systolic Blood Pressure Intervention Trial (SPRINT)
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Jordana B, Cohen, Zachary A, Marcum, Chong, Zhang, Catherine G, Derington, Tom H, Greene, Lama, Ghazi, Jennifer S, Herrick, Jordan B, King, Alfred K, Cheung, Nick, Bryan, Mark A, Supiano, Joshua A, Sonnen, William S, Weintraub, Daniel, Scharfstein, Jeff, Williamson, Nicholas M, Pajewski, and Adam P, Bress
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Adult ,Male ,Angiotensin Receptor Antagonists ,Humans ,Angiotensin-Converting Enzyme Inhibitors ,Blood Pressure ,Cognitive Dysfunction ,Dementia ,Female ,General Medicine ,Aged ,Proportional Hazards Models - Abstract
The cardiovascular and renal outcomes of angiotensin-II receptor blocker (ARB) and angiotensin-converting enzyme inhibitor (ACEI) treatment are well-known; however, few studies have evaluated initiation of these agents and cognitive impairment.To emulate a target trial to evaluate the cognitive outcomes of initiating an ARB- vs ACEI-based antihypertensive regimen in individuals at risk for mild cognitive impairment (MCI) and probable dementia (PD).Active comparator, new-user observational cohort study design using data from the Systolic Blood Pressure Intervention Trial (SPRINT), conducted November 2010 through July 2018. Marginal cause-specific hazard ratios (HRs) and treatment-specific cumulative incidence functions were estimated with inverse probability (IP) weighting to account for confounding. Participants were using neither an ARB nor ACEI at baseline. Data analysis was conducted from April 7, 2021, to April 26, 2022.New users of ARB vs ACEI during the first 12 months of trial follow-up.Composite of adjudicated amnestic MCI or PD.Of 9361 participants, 727 and 1313 new users of an ARB or ACEI, respectively, with well-balanced baseline characteristics between medication exposure groups after inverse probability weighting (mean [SD] age, 67 [9.5] years; 1291 ]63%] male; 240 [33%] Black; 89 [12%] Hispanic; 383 [53%] White; and 15 [2%] other race or ethnicity. In the primary analysis, during a median follow-up of 4.9 years, the inverse probability-weighted rate of amnestic MCI or PD was 4.3 vs 4.6 per 100 person-years among participants initiating ARB vs ACEI (HR, 0.93; 95% CI, 0.76-1.13). In subgroup analyses, new users of an ARB vs ACEI had a lower rate of amnestic MCI or PD among those in the standard systolic blood pressure treatment arm (HR, 0.61; 95% CI, 0.41-0.91) but not in the intensive arm (HR, 1.17; 95% CI, 0.90-1.52) (P = .007 for interaction).In this observational cohort study of US adults at high cardiovascular disease risk, there was no difference in the rate of amnestic MCI or PD among new users of an ARB compared with ACEI, although 95% CIs were wide.
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- 2022
23. The association between fine particulate matter (PM2.5) and chronic kidney disease using electronic health record data in urban Minnesota
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Jesse D. Berman, Paul E. Drawz, and Lama Ghazi
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medicine.medical_specialty ,Fine particulate ,Epidemiology ,Minnesota ,Renal function ,urologic and male genital diseases ,Toxicology ,complex mixtures ,Article ,chemistry.chemical_compound ,Environmental health ,Air Pollution ,medicine ,Electronic Health Records ,Humans ,Renal Insufficiency, Chronic ,Creatinine ,Air Pollutants ,Proportional hazards model ,business.industry ,Incidence (epidemiology) ,Public Health, Environmental and Occupational Health ,Environmental Exposure ,Health studies ,medicine.disease ,Pollution ,female genital diseases and pregnancy complications ,chemistry ,Relative risk ,Particulate Matter ,business ,Kidney disease - Abstract
Background Recent evidence has shown that fine particulate matter (PM2.5) may be an important environmental risk factor for chronic kidney disease (CKD), but few studies have examined this association for individual patients using fine spatial data. Objective To investigate the association between PM2.5 and CKD (estimated glomerular filtration rate [eGFR] 10.4), third (10.3
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- 2021
24. REVeAL-HF
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F. Perry Wilson, Tariq Ahmad, Eric J. Velazquez, Yu Yamamoto, Nihar R. Desai, Allen L. Hsiao, Nitu Kashyap, Aditya Biswas, Michael Simonov, Melissa Martin, and Lama Ghazi
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medicine.medical_specialty ,Palliative care ,Referral ,business.industry ,Psychological intervention ,030204 cardiovascular system & hematology ,medicine.disease ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Heart failure ,Intervention (counseling) ,Risk of mortality ,medicine ,030212 general & internal medicine ,Cardiology and Cardiovascular Medicine ,Intensive care medicine ,Risk assessment ,business - Abstract
Heart failure (HF) is one of the most common causes of hospitalization in the United States and carries a significant risk of morbidity and mortality. Use of evidence-based interventions may improve outcomes, but their use is encumbered in part by limitations in accurate prognostication. The REVeAL-HF (Risk EValuation And its Impact on ClinicAL Decision Making and Outcomes in Heart Failure) trial is the first to definitively evaluate the impact of knowledge about prognosis on clinical decision making and patient outcomes. The REVeAL-HF trial is a pragmatic, completely electronic, randomized controlled trial that has completed enrollment of 3,124 adults hospitalized for HF, defined as having an N-terminal pro–B-type natriuretic peptide level of >500 pg/ml and receiving intravenous diuretic agents within 24 h of admission. Patients randomized to the intervention had their risk of 1-year mortality generated with information in the electronic health record and presented to their providers, who had the option to give feedback on their impression of this risk assessment. The authors are examining the impact of this information on clinical decision-making (use of HF pharmacotherapies, referral to electrophysiology, palliative care referral, and referral for advanced therapies like heart transplantation or mechanical circulatory support) and patient outcomes (length of stay, post-discharge 30-day rehospitalizations, and 1-year mortality). The REVeAL-HF trial will definitively examine whether knowledge about prognosis in HF has an impact on clinical decision making and patient outcomes. It will also examine the relationship between calculated, perceived, and real risk of mortality in this patient population. (Risk EValuation And Its Impact on ClinicAL Decision Making and Outcomes in Heart Failure [REVeAL-HF]; NCT03845660 ).
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- 2021
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25. The Association of Orthostatic Hypotension With Ambulatory Blood Pressure Phenotypes in SPRINT
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Paul E. Drawz, Stephen P. Juraschek, Nicholas M. Pajewski, and Lama Ghazi
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Male ,medicine.medical_specialty ,Ambulatory blood pressure ,Supine position ,Original Contributions ,law.invention ,Hypotension, Orthostatic ,Orthostatic vital signs ,Trial number ,Randomized controlled trial ,law ,Internal medicine ,Internal Medicine ,Humans ,Medicine ,Aged ,Aged, 80 and over ,business.industry ,Blood Pressure Monitoring, Ambulatory ,Middle Aged ,Phenotype ,Blood pressure ,Sprint ,Ambulatory ,Cardiology ,Female ,business - Abstract
Background Clinic blood pressure (BP) when measured in the seated position, can miss meaningful BP phenotypes, including low ambulatory BP (white coat effects [WCE]) or high supine BP (nocturnal non-dipping). Orthostatic hypotension (OH) measured using both seated (or supine) and standing BP, could identify phenotypes poorly captured by seated clinic BP alone. Methods We examined the association of OH with WCE and night-to-daytime systolic BP (SBP) in a subpopulation of SPRINT, a randomized trial testing the effects of intensive or standard (1. Results Of 897 adults (mean age 71.5±9.5 years, 29% female, 28% black), 128 had OH at least once. Among those with OH, 15% had WCE (vs. 7% without OH). Moreover, 25% of those with OH demonstrated a non-dipping pattern (vs. 14% without OH). OH was positively associated with both WCE (OR=2.24; 95%CI: 1.28, 4.27) and reverse dipping (OR=2.29; 95% CI: 1.31, 3.99). Conclusions The identification of OH in clinic was associated with two BP phenotypes often missed with traditional seated BP assessments. Further studies on mechanisms of these relationships are needed. Clinical trials registration Trial Number NCT03569020.
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- 2021
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26. Identifying Patients for Intensive Blood Pressure Treatment Based on Cognitive Benefit
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Lama Ghazi, Jincheng Shen, Jian Ying, Catherine G. Derington, Jordana B. Cohen, Zachary A. Marcum, Jennifer S. Herrick, Jordan B. King, Alfred K. Cheung, Jeff D. Williamson, Nicholas M. Pajewski, Nick Bryan, Mark Supiano, Josh Sonnen, William S. Weintraub, Tom H. Greene, and Adam P. Bress
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General Medicine - Abstract
ImportanceIntensive vs standard treatment to lower systolic blood pressure (SBP) reduces risk of mild cognitive impairment (MCI) or dementia; however, the magnitude of cognitive benefit likely varies among patients.ObjectiveTo estimate the magnitude of cognitive benefit of intensive vs standard systolic BP (SBP) treatment.Design, Setting, and ParticipantsIn this ad hoc secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT), 9361 randomized clinical trial participants 50 years or older with high cardiovascular risk but without a history of diabetes, stroke, or dementia were followed up. The SPRINT trial was conducted between November 1, 2010, and August 31, 2016, and the present analysis was completed on October 31, 2022.InterventionSystolic blood pressure treatment to an intensive (Main Outcomes and MeasuresThe primary outcome was a composite of adjudicated probable dementia or amnestic MCI.ResultsA total of 7918 SPRINT participants were included in the analysis; 3989 were in the intensive treatment group (mean [SD] age, 67.9 [9.2] years; 2570 [64.4%] men; 1212 [30.4%] non-Hispanic Black) and 3929 were in the standard treatment group (mean [SD] age, 67.9 [9.4] years; 2570 [65.4%] men; 1249 [31.8%] non-Hispanic Black). Over a median follow-up of 4.13 (IQR, 3.50-5.88) years, there were 765 and 828 primary outcome events in the intensive treatment group and standard treatment group, respectively. Older age (hazard ratio [HR] per 1 SD, 1.87 [95% CI, 1.78-1.96]), Medicare enrollment (HR per 1 SD, 1.42 [95% CI, 1.35-1.49]), and higher baseline serum creatinine level (HR per 1 SD, 1.24 [95% CI, 1.19-1.29]) were associated with higher risk of the primary outcome, while better baseline cognitive functioning (HR per 1 SD, 0.43 [95% CI, 0.41-0.44]) and active employment status (HR per 1 SD, 0.44 [95% CI, 0.42-0.46]) were associated with lower risk of the primary outcome. Risk of the primary outcome by treatment goal was estimated accurately based on similar projected and observed absolute risk differences (C statistic = 0.79). Higher baseline risk for the primary outcome was associated with greater benefit (ie, larger absolute reduction of probable dementia or amnestic MCI) of intensive vs standard treatment across the full range of estimated baseline risk.Conclusions and RelevanceIn this secondary analysis of the SPRINT trial, participants with higher baseline projected risk of probable dementia or amnestic MCI gained greater absolute cognitive benefit from intensive vs standard SBP treatment in a monotonic fashion.Trial RegistrationClinicalTrials.gov Identifier: NCT01206062
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- 2023
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27. Critical illness myopathy and trajectory of recovery in acute kidney injury requiring continuous renal replacement therapy: a prospective observational trial protocol
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J Pedro Teixeira, Benjamin R Griffin, Chaitanya Anil Pal, Felipe González-Seguel, Nathanial Jenkins, Beth M Jones, Yuri Yoshida, Naomi George, Hayley Puffer Israel, Lama Ghazi, Javier A Neyra, and Kirby P Mayer
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General Medicine - Abstract
IntroductionAcute kidney injury requiring renal replacement therapy (AKI-RRT) is common in the intensive care unit (ICU) and is associated with significant morbidity and mortality. Continuous RRT (CRRT) non-selectively removes large amounts of amino acids from plasma, lowering serum amino acid concentrations and potentially depleting total-body amino acid stores. Therefore, the morbidity and mortality associated with AKI-RRT may be partly mediated through accelerated skeletal muscle atrophy and resulting muscle weakness. However, the impact of AKI-RRT on skeletal muscle mass and function during and following critical illness remains unknown. We hypothesise that patients with AKI-RRT have higher degrees of acute muscle loss than patients without AKI-RRT and that AKI-RRT survivors are less likely to recover muscle mass and function when compared with other ICU survivors.Methods and analysisThis protocol describes a prospective, multicentre, observational trial assessing skeletal muscle size, quality and function in ICU patients with AKI-RRT. We will perform musculoskeletal ultrasound to longitudinally evaluate rectus femoris size and quality at baseline (within 48 hours of CRRT initiation), day 3, day 7 or at ICU discharge, at hospital discharge, and 1–3 months postdischarge. Additional skeletal muscle and physical function tests will be performed at hospital discharge and postdischarge follow-up. We will analyse the effect of AKI-RRT by comparing the findings in enrolled subjects to historical controls of critically ill patients without AKI-RRT using multivariable modelling.Ethics and disseminationWe anticipate our study will reveal that AKI-RRT is associated with greater degrees of muscle loss and dysfunction along with impaired postdischarge recovery of physical function. These findings could impact the in-hospital and postdischarge treatment plan for these patients to include focused attention on muscle strength and function. We intend to disseminate findings to participants, healthcare professionals, the public and other relevant groups via conference presentation and publication without any publication restrictions.Trial registration numberNCT05287204.
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- 2023
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28. Prognostic Significance of Ambulatory BP Monitoring in CKD: A Report from the Chronic Renal Insufficiency Cohort (CRIC) Study
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Matthew R. Weir, Paul E. Drawz, Joshua D. Bundy, James P. Lash, Jeanne Charleston, Raymond R. Townsend, Mahboob Rahman, Xue Wang, Edward Horowitz, Jordana B. Cohen, Sarah J. Schrauben, Cric Study Investigators, Lama Ghazi, Dawei Xie, and Debbie L. Cohen
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medicine.medical_specialty ,Ambulatory blood pressure ,biology ,business.industry ,Dipper ,030232 urology & nephrology ,General Medicine ,Disease ,030204 cardiovascular system & hematology ,medicine.disease ,biology.organism_classification ,03 medical and health sciences ,0302 clinical medicine ,Nephrology ,Heart failure ,Internal medicine ,Cohort ,medicine ,Myocardial infarction ,business ,Stroke ,Kidney disease - Abstract
Background Whether ambulatory BP monitoring is of value in evaluating risk for outcomes in patients with CKD is not clear. Methods We followed 1502 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study for a mean of 6.72 years. We evaluated, as exposures, ambulatory BP monitoring profiles (masked uncontrolled hypertension, white-coat effect, sustained hypertension, and controlled BP), mean ambulatory BP monitoring and clinic BPs, and diurnal variation in BP-reverse dipper (higher at nighttime), nondipper, and dipper (lower at nighttime). Outcomes included cardiovascular disease (a composite of myocardial infarction, cerebrovascular accident, heart failure, and peripheral arterial disease), kidney disease (a composite of ESKD or halving of the eGFR), and mortality. Results Compared with having controlled BP, the presence of masked uncontrolled hypertension independently associated with higher risk of the cardiovascular outcome and the kidney outcome, but not with all-cause mortality. Higher mean 24-hour systolic BP associated with higher risk of cardiovascular outcome, kidney outcome, and mortality, independent of clinic BP. Participants with the reverse-dipper profile of diurnal BP variation were at higher risk of the kidney outcome. Conclusions In this cohort of participants with CKD, BP metrics derived from ambulatory BP monitoring are associated with cardiovascular outcomes, kidney outcomes, and mortality, independent of clinic BP. Masked uncontrolled hypertension and mean 24-hour BP associated with high risk of cardiovascular disease and progression of kidney disease. Alterations of diurnal variation in BP are associated with high risk of progression of kidney disease, stroke, and peripheral arterial disease. These data support the wider use of ambulatory BP monitoring in the evaluation of hypertension in patients with CKD. Podcast This article contains a podcast at https://www.asn-online.org/media/podcast/JASN/2020_09_24_JASN2020030236.mp3.
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- 2020
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29. Effect of Intensive Blood Pressure Lowering on the Risk of Atrial Fibrillation
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Akm Fazlur Rahman, Lawrence J. Fine, Joseph L. Blackshear, Lama Ghazi, Elsayed Z. Soliman, Walter T. Ambrosius, Jeffrey T. Bates, Michel Chonchol, Tara I. Chang, Zhu Ming Zhang, Carlos J. Rodriguez, and Cora E. Lewis
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Male ,medicine.medical_specialty ,Aftercare ,Blood Pressure ,030204 cardiovascular system & hematology ,Lower risk ,Article ,Patient Care Planning ,Electrocardiography ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,Atrial Fibrillation ,Internal Medicine ,Humans ,Medicine ,In patient ,030212 general & internal medicine ,Antihypertensive Agents ,Aged ,business.industry ,Incidence ,Blood Pressure Determination ,Atrial fibrillation ,Middle Aged ,Prognosis ,medicine.disease ,Outcome and Process Assessment, Health Care ,Blood pressure ,Sprint ,Heart Disease Risk Factors ,Hypertension ,Cardiology ,Female ,Blood pressure lowering ,business - Abstract
It remains uncertain whether intensive control of blood pressure (BP) results in a lower risk of atrial fibrillation (AF) in patients with hypertension. Using data from SPRINT (Systolic Blood Pressure Intervention Trial), which enrolled participants with hypertension at increased risk of cardiovascular disease, we examined whether intensive BP lowering (target systolic BP [SBP] P =0.037). This effect was consistent among prespecified subgroups of SPRINT participants stratified by age, sex, race, SBP tertiles, prior cardiovascular disease, and prior chronic kidney disease when interactions between treatment effect and these subgroups were assessed using Hommel adjusted P values. In conclusion, intensive treatment to a target of SBP Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01206062.
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- 2020
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30. Rationale and design of a pragmatic trial aimed at improving treatment of hyperlipidemia in outpatients with very high risk atherosclerotic cardiovascular disease: A pragmatic trial of messaging to providers about treatment of hyperlipidemia (PROMPT-LIPID)
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Nimish N. Shah, Lama Ghazi, Yu Yamamoto, Melissa Martin, Michael Simonov, Ralph J. Riello, Kamil F. Faridi, Tariq Ahmad, F. Perry Wilson, and Nihar R. Desai
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Male ,Anticholesteremic Agents ,Hyperlipidemias ,Cholesterol, LDL ,Atherosclerosis ,Article ,Cardiovascular Diseases ,Outpatients ,Pragmatic Clinical Trials as Topic ,Humans ,Multicenter Studies as Topic ,Female ,Single-Blind Method ,Hydroxymethylglutaryl-CoA Reductase Inhibitors ,Cardiology and Cardiovascular Medicine ,Aged - Abstract
BACKGROUND: Despite guideline recommendations to optimize low-density lipoprotein cholesterol (LDL-C) reduction with intensification of lipid-lowering therapy (LLT) in patients with atherosclerotic cardiovascular disease (ASCVD), few of these patients achieve LDL-C < 70 mg/dL in practice. PURPOSE: We developed a real-time, targeted electronic health record (EHR) alert with embedded ordering capability to promote intensification of evidence based LLT in outpatients with very high risk ASCVD. METHODS: We designed a pragmatic, multicenter, single-blind, cluster randomized trial to test the effectiveness of an EHR-based LLT intensification alert. The study will enroll about 100 providers who will be randomized to either receive the alert or undergo usual care for outpatients with high risk ASCVD with LDL-C > 70 mg/dL. Total enrollment will include 2,500 patients. The primary outcome will be the proportion of patients with LLT intensification at 90 days. Secondary outcomes include achieved LDL-C at 6 months and the proportion of patients with LDL-C < 70 mg/dL or < 55 mg/dL at 6 months. RESULTS: Enrollment of 1,250 patients (50% of goal) was reached within 47 days (50% women, mean age 72, median LDL-C 91). At baseline, 71%, 9%, and 3% were on statins, ezetimibe, or proprotein convertase subtilisin/kexin type 9 inhibitors, respectively. CONCLUSIONS: PRagmatic Trial of Messaging to Providers about Treatment of HyperLIPIDemia has rapidly reached 50% enrollment of patients with very high risk ASCVD, demonstrating low baseline LLT utilization. This pragmatic, EHR-based trial will determine the effectiveness of a real-time, targeted EHR alert with embedded ordering capability to promote LLT intensification. Findings from this low-cost, widely scalable intervention to improve LDL-C may have important public health implications.
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- 2022
31. Prevalence of Secondary Hypertension in Otherwise Healthy Youth with a New Diagnosis of Hypertension: A Meta-Analysis
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James T. Nugent, Chelsea Young, Melissa C. Funaro, Kuan Jiang, Ishan Saran, Lama Ghazi, F. Perry Wilson, and Jason H. Greenberg
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Adolescent ,Pediatrics, Perinatology and Child Health ,Hypertension ,Prevalence ,Humans ,Mass Screening ,Prospective Studies ,Child ,Article ,Retrospective Studies - Abstract
OBJECTIVE: To estimate the prevalence of secondary hypertension among otherwise healthy children with hypertension diagnosed in the outpatient setting. STUDY DESIGN: MEDLINE, PubMed Central, Embase, Web of Science, and Cochrane Library were systematically searched for observational studies reporting the prevalence of secondary hypertension in children who underwent evaluation for hypertension and had no known comorbidities associated with hypertension at the time of diagnosis. Two authors independently extracted the study-specific prevalence of secondary hypertension in children evaluated for hypertension. Prevalence estimates for secondary hypertension were pooled in a random effects meta-analysis. RESULTS: Nineteen prospective and 7 retrospective studies including 2575 children with hypertension were analyzed, with a median of 65 (min-max range, 9–486) participants in each study. Studies conducted in primary care or school settings reported a lower prevalence of secondary hypertension (3.7% [95% CI: 1.2–7.2%]) than studies conducted in referral clinics (20.1% [95% CI: 11.5–30.3%]). When stratified by study setting, there were no significant subgroup differences according to study design, country, participant age range, hypertension definition, blood pressure device, or study quality. Although studies applied different approaches to diagnose secondary hypertension, diagnostic evaluations were at least as involved as the limited testing recommended by current guidelines. CONCLUSIONS: The low prevalence of secondary hypertension among children with a new diagnosis of hypertension identified on screening reinforces clinical practice guidelines to avoid extensive testing in the primary care setting for secondary causes in most children with hypertension.
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- 2022
32. Association of Antihypertensives That Stimulate vs Inhibit Types 2 and 4 Angiotensin II Receptors With Cognitive Impairment
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Zachary A, Marcum, Jordana B, Cohen, Chong, Zhang, Catherine G, Derington, Tom H, Greene, Lama, Ghazi, Jennifer S, Herrick, Jordan B, King, Alfred K, Cheung, Nick, Bryan, Mark A, Supiano, Joshua A, Sonnen, William S, Weintraub, Jeff, Williamson, Nicholas M, Pajewski, and Adam P, Bress
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Male ,Incidence ,Research ,General Medicine ,Middle Aged ,Receptor, Angiotensin, Type 2 ,Receptor, Angiotensin, Type 1 ,Angiotensin Receptor Antagonists ,Online Only ,Heart Disease Risk Factors ,Geriatrics ,Hypertension ,Prevalence ,Humans ,Cognitive Dysfunction ,Dementia ,Female ,Antihypertensive Agents ,Aged ,Follow-Up Studies ,Proportional Hazards Models ,Randomized Controlled Trials as Topic ,Original Investigation - Abstract
Key Points Question Are antihypertensive medications that stimulate type 2 and 4 angiotensin II receptors, compared with those that do not stimulate these receptors, associated with a lower risk of incident cognitive impairment? Findings In a secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT), this cohort study of 8685 patients found that prevalent use of medication regimens that contain exclusively angiotensin II receptor type 2 and 4–stimulating antihypertensives was associated with an approximately 25% lower risk of incident amnestic mild cognitive impairment or probable dementia during 4.8 years of follow-up. Meaning These results, if replicated in randomized clinical trials, suggest that certain antihypertensive medications could be used to prevent the development of cognitive decline., Importance Use of antihypertensive medications that stimulate type 2 and 4 angiotensin II receptors, compared with those that do not stimulate these receptors, has been associated with a lower risk of dementia. However, this association with cognitive outcomes in hypertension trials, with blood pressure levels in the range of current guidelines, has not been evaluated. Objective To examine the association between use of exclusively antihypertensive medication regimens that stimulate vs inhibit type 2 and 4 angiotensin II receptors on mild cognitive impairment (MCI) or dementia. Design, Setting, and Participants This cohort study is a secondary analysis (April 2011 to July 2018) of participants in the randomized Systolic Blood Pressure Intervention Trial (SPRINT), which recruited individuals 50 years or older with hypertension and increased cardiovascular risk but without a history of diabetes, stroke, or dementia. Data analysis was conducted from March 16 to July 6, 2021. Exposures Prevalent use of angiotensin II receptor type 2 and 4–stimulating or –inhibiting antihypertensive medication regimens at the 6-month study visit. Main Outcomes and Measures The primary outcome was a composite of adjudicated amnestic MCI or probable dementia. Results Of the 8685 SPRINT participants who were prevalent users of antihypertensive medication regimens at the 6-month study visit (mean [SD] age, 67.7 [11.2] years; 5586 [64.3%] male; and 935 [10.8%] Hispanic, 2605 [30.0%] non-Hispanic Black, 4983 [57.4%] non-Hispanic White, and 162 [1.9%] who responded as other race or ethnicity), 2644 (30.4%) were users of exclusively stimulating, 1536 (17.7%) inhibiting, and 4505 (51.9%) mixed antihypertensive medication regimens. During a median of 4.8 years of follow-up (95% CI, 4.7-4.8 years), there were 45 vs 59 cases per 1000 person-years of amnestic MCI or probable dementia among prevalent users of regimens that contained exclusively stimulating vs inhibiting antihypertensive medications (hazard ratio [HR], 0.76; 95% CI, 0.66-0.87). When comparing stimulating-only vs inhibiting-only users, amnestic MCI occurred at rates of 40 vs 54 cases per 1000 person-years (HR, 0.74; 95% CI, 0.64-0.87) and probable dementia at rates of 8 vs 10 cases per 1000 person-years (HR, 0.80; 95% CI, 0.57-1.14). Negative control outcome analyses suggested the presence of residual confounding. Conclusions and Relevance In this secondary analysis of SPRINT, prevalent users of regimens that contain exclusively antihypertensive medications that stimulate vs inhibit type 2 and 4 angiotensin II receptors had lower rates of incident cognitive impairment. Residual confounding cannot be ruled out. If these results are replicated in randomized clinical trials, certain antihypertensive medications could be prioritized to prevent cognitive decline., This secondary analysis cohort study of Systolic Blood Pressure Intervention Trial (SPRINT) participants assesses the association between antihypertensive medications that stimulate type 2 and 4 angiotensin II receptors with the risk of incident cognitive impairment.
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- 2022
33. Does This Child With High Blood Pressure Have Secondary Hypertension?
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James T. Nugent, Kuan Jiang, Melissa C. Funaro, Ishan Saran, Chelsea Young, Lama Ghazi, Christine Y. Bakhoum, F. Perry Wilson, and Jason H. Greenberg
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General Medicine - Abstract
ImportanceGuidelines recommend that all children and adolescents with hypertension undergo evaluation for secondary causes. Identifying clinical factors associated with secondary hypertension may decrease unnecessary testing for those with primary hypertension.ObjectiveTo determine the utility of the clinical history, physical examination, and 24-hour ambulatory blood pressure monitoring for differentiating primary hypertension from secondary hypertension in children and adolescents (aged ≤21 years).Data Sources and Study SelectionThe databases of MEDLINE, PubMed Central, Embase, Web of Science, and Cochrane Library were searched from inception to January 2022 without language limits. Two authors identified studies describing clinical characteristics in children and adolescents with primary and secondary hypertension.Data Extraction and SynthesisFor each clinical finding in each study, a 2 × 2 table was created that included the number of patients with and without the finding who had primary vs secondary hypertension. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool.Main Outcomes and MeasuresRandom-effects modeling was used to calculate sensitivity, specificity, and likelihood ratios (LRs).ResultsOf 3254 unique titles and abstracts screened, 30 studies met inclusion criteria for the meta-analysis and 23 (N = 4210 children and adolescents) were used for pooling in the meta-analysis. In the 3 studies conducted at primary care clinics or school-based screening clinics, the prevalence of secondary hypertension was 9.0% (95% CI, 4.5%-15.0%). In the 20 studies conducted at subspecialty clinics, the prevalence of secondary hypertension was 44% (95% CI, 36%-53%). The demographic findings most strongly associated with secondary hypertension were family history of secondary hypertension (sensitivity, 0.46; specificity, 0.90; LR, 4.7 [95% CI, 2.9-7.6]), weight in the 10th percentile or lower for age and sex (sensitivity, 0.27; specificity, 0.94; LR, 4.5 [95% CI, 1.2-18]), history of prematurity (sensitivity range, 0.17-0.33; specificity range, 0.86-0.94; LR range, 2.3-2.8), and age of 6 years or younger (sensitivity range, 0.25-0.36; specificity range, 0.86-0.88; LR range, 2.2-2.6). Laboratory studies most associated with secondary hypertension were microalbuminuria (sensitivity, 0.13; specificity, 0.99; LR, 13 [95% CI, 3.1-53]) and serum uric acid concentration of 5.5 mg/dL or lower (sensitivity range, 0.70-0.73; specificity range, 0.65-0.89; LR range, 2.1-6.3). Increased daytime diastolic blood pressure load combined with increased nocturnal systolic blood pressure load on 24-hour ambulatory blood pressure monitoring was associated with secondary hypertension (sensitivity, 0.40; specificity, 0.82; LR, 4.8 [95% CI, 1.2-20]). Findings associated with a decreased likelihood of secondary hypertension were asymptomatic presentation (LR range, 0.19-0.36), obesity (LR, 0.34 [95% CI, 0.13-0.90]), and family history of any hypertension (LR, 0.42 [95% CI, 0.30-0.57]). Hypertension stage, headache, and left ventricular hypertrophy did not distinguish secondary from primary hypertension.Conclusions and RelevanceFamily history of secondary hypertension, younger age, lower body weight, and increased blood pressure load using 24-hour ambulatory blood pressure monitoring were associated with a higher likelihood of secondary hypertension. No individual sign or symptom definitively differentiates secondary hypertension from primary hypertension.
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- 2023
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34. Kidney Disease, Hypertension Treatment, and Cerebral Perfusion and Structure
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Manjula Kurella Tamura, Sarah Gaussoin, Nicholas M. Pajewski, Greg Zaharchuk, Barry I. Freedman, Stephen R. Rapp, Alexander P. Auchus, William E. Haley, Suzanne Oparil, Jessica Kendrick, Christianne L. Roumie, Srinivasan Beddhu, Alfred K. Cheung, Jeff D. Williamson, John A. Detre, Sudipto Dolui, R. Nick Bryan, Ilya M. Nasrallah, Paul Whelton, Karen C. Johnson, Joni Snyder, Diane Bild, Denise Bonds, Nakela Cook, Jeffrey Cutler, Lawrence Fine, Peter Kaufmann, Paul Kimmel, Lenore Launer, Claudia Moy, William Riley, Laurie Ryan, Eser Tolunay, Song Yang, David Reboussin, Jeff Williamson, Walter T. Ambrosius, William Applegate, Greg Evans, Capri Foy, Dalane Kitzman, Mary Lyles, Nick Pajewski, Steve Rapp, Scott Rushing, Neel Shah, Kaycee M. Sink, Mara Vitolins, Lynne Wagenknecht, Valerie Wilson, Letitia Perdue, Nancy Woolard, Tim Craven, Katelyn Garcia, Laura Lovato, Jill Newman, James Lovato, Lingyi Lu, Chris McLouth, Greg Russell, Bobby Amoroso, Patty Davis, Jason Griffin, Darrin Harris, Mark King, Kathy Lane, Wes Roberson, Debbie Steinberg, Donna Ashford, Phyllis Babcock, Dana Chamberlain, Vickie Christensen, Loretta Cloud, Christy Collins, Delilah Cook, Katherine Currie, Debbie Felton, Stacy Harpe, Marjorie Howard, Michelle Lewis, Pamela Nance, Nicole Puccinelli-Ortega, Laurie Russell, Jennifer Walker, Brenda Craven, Candace Goode, Margie Troxler, Janet Davis, Sarah Hutchens, Anthony A. Killeen, Anna M. Lukkari, Robert Ringer, Brandi Dillard, Norbert Archibeque, Stuart Warren, Mike Sather, James Pontzer, Zach Taylor, Elsayed Z. Soliman, Zhu-Ming Zhang, Yabing Li, Chuck Campbell, Susan Hensley, Julie Hu, Lisa Keasler, Mary Barr, Tonya Taylor, Christos Davatzikos, Ilya Nasarallah, Lisa Desiderio, Mark Elliott, Ari Borthakur, Harsha Battapady, Guray Erus, Alex Smith, Ze Wang, Jimit Doshi, Jackson T. Wright, Mahboob Rahman, Alan J. Lerner, Carolyn Still, Alan Wiggers, Sara Zamanian, Alberta Bee, Renee Dancie, George Thomas, Martin Schreiber, Sankar Dass Navaneethan, John Hickner, Michael Lioudis, Michelle Lard, Susan Marczewski, Jennifer Maraschky, Martha Colman, Andrea Aaby, Stacey Payne, Melanie Ramos, Carol Horner, Paul Drawz, Pratibha P. Raghavendra, Scott Ober, Ronda Mourad, Muralidhar Pallaki, Peter Russo, Pratibha Raghavendra, Pual Fantauzzo, Lisa Tucker, Bill Schwing, John R. Sedor, Edward J. Horwitz, Jeffrey R. Schellling, John F. O’Toole, Lisa Humbert, Wendy Tutolo, Suzanne White, Alishea Gay, Walter Clark, Robin Hughes, Mirela Dobre, Carolyn H. Still, Monique Williams, Udayan Bhatt, Lee Hebert, Anil Agarwal, Melissa Brown Murphy, Nicole Ford, Cynthia Stratton, Jody Baxter, Alicia A. Lykins, Alison McKinley Neal Leena Hirmath, Osei Kwame, Kyaw Soe, William F. Miser, Colleen Sagrilla, Jan Johnston, Amber Anaya, Ashley Mintos, Angel A. Howell, Kelly Rogers, Sara Taylor, Donald Ebersbacher, Lucy Long, Beth Bednarchik, Adrian Schnall, Jonathan Smith, Lori Peysha, Lisa Leach, Megan Tribout, Carla Harwell, Pinkie Ellington, Mary Ann Banerji, Pranav Ghody, Melissa Vahídeh Rambaud, Raymond Townsend, Debbie Cohen, Yonghong Huan, Mark Duckworth, Virginia Ford, Juliet Leshner, Ann Davison, Sarah Vander Veen, Crystal A. Gadegbeku, Avi Gillespie, Anuradha Paranjape, Sandra Amoroso, Zoe Pfeffer, Sally B. Quinn, Jiang He, Jing Chen, Eva Lustigova, Erin Malone, Marie Krousel-Wood, Richard Deichmann, Patricia Ronney, Susan Muery, Donnalee Trapani, Michael Rocco, David Goff, Carlos Rodriguez, Laura Coker, Amret Hawfield, Joseph Yeboah, Lenore Crago, John Summerson, Anita Hege, Matt Diamond, Laura Mulloy, Marcela Hodges, Michelle Collins, Charlene Weathers, Heather Anderson, Emily Stone, Walida Walker, Andrew McWilliams, Michael Dulin, Lindsay Kuhn, Susan Standridge, Lindsay Lowe, Kelly Everett, Kelry Preston, Susan Norton, Silena Gaines, Ali A. Rizvi, Andrew W. Sides, Diamond Herbert, Matthew M. Hix, Melanie Whitmire, Brittany Arnold, Philip Hutchinson, Joseph Espiritu, Mark Feinglos, Eugene Kovalik, Georgianne Gedon-Lipscomb, Kathryn Evans, Connie Thacker, Ronna Zimmer, Mary Furst, MaryAnn Mason, James Powell, Paul Bolin, Junhong Zhang, Mary Pinion, Gail Davis, Winifred Bryant, Presley Phelps, Connie Garris-Sutton, Beatrice Atkinson, Gabriele Contreras, Maritza Suarez, Ivonne Schulman, Don Koggan, Jackie Vassallo, Gloria Peruyera, Sheri Whittington, Cassandra Bethea, Laura Gilliam, Carolyn Pedley, Geraldine Zurek, Miriam Baird, Charles Herring, Mary Martha Smoak, Julie Williams, Samantha Rogers, Lindsay Gordon, Erin Kennedy, Beverly Belle, Jessica McCorkle-Doomy, Jonathan Adams, Ramon Lopez, Juris Janavs, Frederic Rahbari-Oskoui, Arlene Chapman, Allen Dollar, Olubunmi Williams, Yoosun Han, William Haley, Peter Fitzpatrick, Joseph Blackshear, Brian Shapiro, Anna Harrell, Arta Palaj, Katelyn Henderson, Ashley Johnson, Heath Gonzalez, Jermaine Robinson, Leonardo Tamariz, Jennifer Denizard, Rody Barakat, Dhurga Krishnamoorthy, Frank Greenway, Ron Monce, Timothy Church, Chelsea Hendrick, Aimee Yoches, Leighanne Sones, Markee Baltazar, Priscilla Pemu, Connie Jones, Derrick Akpalu, Gordon Chelune, Jeffrey Childs, Lisa Gren, Anne Randall, Laura Dember, Denise Soares, Jerry Yee, Kausik Umanath, Naima Ogletree, Schawana Thaxton, Karen Campana, Dayna Sheldon, Krista MacArthur, J. Brent Muhlestein, Nathan Allred, Brian Clements, Ritesh Dhar, Kent Meredith, Viet Le, Edward Miner, James Orford, Erik R. Riessen, Becca Ballantyne, Ben Chisum, Kevin Johnson, Dixie Peeler, Glenn Chertow, Manju Tamura, Tara Chang, Kevin Erickson, Jenny Shen, Randall S. Stafford, Gregory Zaharchuk, Margareth Del Cid, Michelle Dentinger, Jennifer Sabino, Rukmani Sahay, Ekaterina Telminova, Daniel E. Weiner, Mark Sarnak, Lily Chan, Amanda Civiletto, Alyson Heath, Amy Kantor, Priyanka Jain, Bethany Kirkpatrick, Andrew Well, Barry Yuen, Michel Chonchol, Beverly Farmer, Heather Farmer, Carol Greenwald, Mikaela Malaczewski, James Lash, Anna Porter, Ana Ricardo, Robert T. Rosman, Janet Cohan, Nieves Lopez Barrera, Daniel Meslar, Patricia Meslar, Margaret Conroy, Mark Unruh, Rachel Hess, Manisha Jhamb, Holly Thomas, Pam Fazio, Elle Klixbull, Melissa Komlos-Weimer, LeeAnne Mandich, Tina Vita, Robert Toto, Peter Van Buren, Julia Inrig, Martha Cruz, Tammy Lightfoot, Nancy Wang, Lori Webster, Kalani Raphael, Barry Stults, Tahir Zaman, Debra Simmons, Tooran Lavasani, Rebecca Filipowicz, Guo Wei, Gracie Mary Miller, Jenice Harerra, Jeff Christensen, Ajay Giri, Xiaorui Chen, Natalie Anderton, Arianna Jensen, Julia Lewis, Anna Burgner, Jamie P. Dwyer, Gerald Schulman, Terri Herrud, Ewanda Leavell, Tiffany McCray, Edwina McNeil-Simaan, Munmun Poudel, Malia Reed, Mohammed Sika, Delia Woods, Janice L. Zirkenbach, Dominic S. Raj, Scott Cohen, Samir Patel, Manuel Velasquez, Roshni S. Bastian, Maria Wing, Akshay Roy-Chaudhury, Thomas Depner, Lorien Dalyrymple, George Kaysen, Susan Anderson, John Nord, Joachim H. Ix, Leonard Goldenstein, Cynthia M. Miracle, Nketi Forbang, Maja Mircic, Brenda Thomas, Tiffany Tran, Anjay Rastogi, Mihae Kim, Mohamad Rashid, Bianca Lizarraga, Amy Hocza, Kristine Sarmosyan, Jason Norris, Tushar Sharma, Amanda Chioy, Eric Bernard, Eleanore Cabrera, Christina Lopez, Susana Nunez, Joseph Riad, Suzanne Schweitzer, Siran Sirop, Sarah Thomas, Lauren Wada, Holly Kramer, Vinod Bansal, Corliss E. Taylor, Mark S. Segal, Karen L. Hall, Amir Kazory, Lesa Gilbert, Linda Owens, Danielle Poulton, Elaine Whidden, Jocelyn Wiggins, Caroline Blaum, Linda Nyquist, Lillian Min, Tanya Gure, Ruth Lewis, Jennifer Mawby, Eileen Robinson, Cora E. Lewis, Virginia Bradley, David Calhoun, Stephen Glasser, Kim Jenkins, Tom Ramsey, Nauman Qureshi, Karen Ferguson, Sumrah Haider, Mandy James, Christy Jones, Kim Renfroe, April Seay, Carrie Weigart, Denyse Thornley-Brown, Dana Rizik, Bari Cotton, Meredith Fitz-Gerald, Tiffany Grimes, Carolyn Johnson, Sara Kennedy, Chanel Mason, Lesa Rosato-Burson, Robin Willingham, Eric Judd, Tonya Breaux-Shropshire, Felice Cook, Julia Medina, Lama Ghazi, Hemal Bhatt, James Lewis, Roman Brantley, John Brouilette, Jeffrey Glaze, Stephanie Hall, Nancy Hiott, David Tharpe, Spencer Boddy, Catherine Mack, Catherine Womack, Keiko Asao, Beate Griffin, Carol Hendrix, Karen Johnson, Lisa Jones, Chelsea Towers, Henry Punzi, Kathy Cassidy, Kristin Schumacher, Carmen Irizarry, Ilma Colon, Pedro Colon-Ortiz, Pedro J. Colón-Hernández, Orlando J. Carrasquillo-Navarro, Merari Carrasquillo, Nivea Vazquez, Miguel Sosa-Padilla, Alex Cintron-Pinero, Mayra Ayala, Olga Pacheco, Catalina Rivera, Irma Sotomayor-Gonzalez, Jamie Claudio, Jose Lazaro, Migdalia Arce, Lourdes Heres, Alba Perez, Jose Tavarez-Valle, Ferlinda Arocho, Mercedes Torres, Melvaliz Vazquez, Gerard P. Aurigemma, Rebecca Takis-Smith, Julia Andrieni, Noelle Bodkin, Kiran Chaudhary, Paula Hu, John Kostis, Nora Cosgrove, Denise Bankowski, Monica Boleyn, Laurie Casazza, Victoria Giresi, Tosha Patel, Erin Squindo, Yan Wu, Zeb Henson, Marion Wofford, Jessica Lowery, Deborah Minor, Kimberley Harkins, Alexander Auchus, Michael Flessner, Cathy Adair, Jordan Asher, Debbie Loope, Rita Cobb, Reiner Venegas, Thomas Bigger, Natalie Bello, Shunichi Homma, Daniel Donovan, Carlos Lopez-Jimenez, Amilcar Tirado, Asqual Getaneh, Rocky Tang, Sabrina Durant, Mathew Maurer, Sergio Teruya, Stephen Helmke, Julissa Alvarez, Ruth Campbell, Roberto Pisoni, Rachel Sturdivant, Deborah Brooks, Caroline Counts, Vickie Hunt, Lori Spillers, Donald Brautigam, Timothy Kitchen, Timothy Gorman, Jessica Sayers, Sarah Button, June Chiarot, Rosemary Fischer, Melissa Lyon, Maria Resnick, Nicole Hodges, Jennifer Ferreira, William Cushman, Barry Wall, Linda Nichols, Robert Burns, Jennifer Martindale-Adams, Dan Berlowitz, Elizabeth Clark, Sandy Walsh, Terry Geraci, Carol Huff, Linda Shaw, Karen Servilla, Darlene Vigil, Terry Barrett, Mary Ellen Sweeney, Rebecca Johnson, Susan McConnell, Khadijeh Shahid Salles, Francoise Watson, Cheryl Schenk, Laura Whittington, Maxine Maher, Jonathan Williams, Stephen Swartz, Paul Conlin, George Alexis, Rebecca Lamkin, Patti Underwood, Helen Gomes, Clive Rosendorff, Stephen Atlas, Saadat Khan, Waddy Gonzalez, Samih Barcham, Lawrence Kwon, Matar Matar, Anwar Adhami, Jan Basile, Joseph John, Deborah Ham, Hadi Baig, Mohammed Saklayen, Jason Yap, Helen Neff, Carol Miller, Ling Zheng-Phelan, Saib Gappy, Shiva Rau, Arathi Raman, Vicki Berchou, Elizabeth Jones, Erin Olgren, Cynthia Marbury, Michael Yudd, Sithiporn Sastrasinh, Jennine Michaud, Jessica Fiore, Marianne Kutza, Ronald Shorr, Rattana Mount, Helen Dunn, Susan Stinson, Jessica Hunter, Addison Taylor, Jeffery Bates, Catherine Anderson, Kent Kirchner, Jodi Stubbs, Ardell Hinton, Anita Spencer, Santosh Sharma, Thomas Wiegmann, Smita Mehta, Michelle Krause, Kate Dishongh, Richard Childress, Geeta Gyamlani, Atossa Niakan, Cathy Thompson, Janelle Moody, Carolyn Gresham, Jeffrey Whittle, Gary Barnas, Dawn Wolfgram, Heidi Cortese, Jonette Johnson, Christianne Roumie, Adriana Hung, Jennifer Wharton, Kurt Niesner, Lois Katz, Elizabeth Richardson, George Brock, Joanne Holland, Troy Dixon, Athena Zias, Christine Spiller, Penelope Baker, James Felicetta, Shakaib Rehman, Kelli Bingham, Suzanne Watnick, David Cohen, Jessica Weiss, Tera Johnston, Stephen Giddings, Hala Yamout, Andrew Klein, Caroline Rowe, Kristin Vargo, Kristi Waidmann, Vasilios Papademetriou, Jean Pierre Elkhoury, Barbara Gregory, Susan Amodeo, Mary Bloom, Dalia Goldfarb-Waysman, Richard Treger, Mehran Kashefi, Christina Huang, Karen Knibloe, Areef Ishani, Yelena Slinin, Christine Olney, Jacqueline Rust, Paolo Fanti, Christopher Dyer, Shweta Bansal, Monica Dunnam, Lih-Lan Hu, and Perla Zarate-Abbott
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Male ,medicine.medical_specialty ,Renal function ,Perfusion scanning ,Blood Pressure ,Article ,chemistry.chemical_compound ,Internal medicine ,medicine ,Humans ,Cerebral perfusion pressure ,Renal Insufficiency, Chronic ,Antihypertensive Agents ,Aged ,Creatinine ,business.industry ,medicine.disease ,Perfusion ,Blood pressure ,chemistry ,Cerebral blood flow ,Nephrology ,Cerebrovascular Circulation ,Hypertension ,Albuminuria ,Cardiology ,Female ,medicine.symptom ,business ,Kidney disease ,Glomerular Filtration Rate - Abstract
RATIONALE AND OBJECTIVE: The safety of intensive blood pressure (BP) targets is controversial for persons with chronic kidney disease (CKD). We studied the effects of hypertension treatment on cerebral perfusion and structure in those with and without CKD. STUDY DESIGN: Neuroimaging substudy of a randomized trial. SETTING & PARTICIPANTS: A subset of participants in the Systolic Blood Pressure Intervention Trial who underwent brain MRI studies. Presence of baseline CKD was assessed by estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (UACR). INTERVENTION: Participants were randomly assigned to intensive (systolic BP 30 mg/g (N=151), the effects of intensive versus standard BP treatment on change in global cerebral blood flow, WMLs and total brain volume were 1.91 ml/100g/min (95% CI −3.01, 6.82), 0.003 cm(3) (asinh transformed, 95% CI −0.13, 0.13), and −7.0 cm(3) (95% CI −13.3, −0.3), respectively. The overall treatment effects on cerebral blood flow and total brain volume were not modified by baseline eGFR or UACR; however the effect on WMLs was attenuated in participants with albuminuria (interaction p-value 0.04). LIMITATIONS: Measurement variability due to multi-site design. CONCLUSIONS: Among hypertensive adults with primarily early kidney disease, intensive versus standard blood pressure treatment did not appear to have a detrimental effect on brain perfusion or structure. The findings support the safety of intensive blood pressure treatment targets on brain health in persons with early kidney disease. FUNDING: The Systolic Blood Pressure Intervention Trial was funded by the National Institutes of Health (including the National Heart, Lung, and Blood Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute on Aging, and the National Institute of Neurological Disorders and Stroke), and this substudy was funded by the National Institutes of Diabetes and Digestive and Kidney Diseases. TRIAL REGISTRATION: SPRINT was registered at ClinicalTrials.gov with the study number NCT01206062.
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- 2021
35. Abstract 57: Risk Factors For Severe Reductions In Blood Pressure After Treatment Of Severe Inpatient Hypertension
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Jonathan Hanna, Eric Y. Chen, Fan Li, Aldo J. Peixoto, Aditya Biswas, Yu Yamamoto, F. Perry Wilson, Michael Simonov, Lama Ghazi, and Tayyab Shah
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Blood pressure ,nervous system ,business.industry ,Anesthesia ,Internal Medicine ,Medicine ,cardiovascular diseases ,business ,After treatment - Abstract
Background: Incident severe HTN during hospitalization is far more common than admission for HTN, however treatment guidelines are lacking. Severe inpatient HTN is poorly studied, therefore our goal is to characterize inpatients who develop severe HTN and assess BP response to antihypertensive treatment. Methods: This is a cohort study of adults admitted for reasons other than HTN and developed severe HTN within a single healthcare system. We defined severe inpatient HTN as the first documentation of BP elevation (>180 systolic or >110 diastolic) at least 1 hour after hospital admission. Treatment was defined as receiving antihypertensive medications within 6 hours of BP elevation. We studied the association between treatment and BP drop ≥30%. Results: Among 224,265 hospitalized adults, 23,147 developed severe HTN of which 40% were treated. Compared to inpatients who did not develop severe HTN, those who did were older, more commonly women and Black, and had more comorbidities. Of the treated and untreated patients, 45.5 and 46.4% had a MAP drop ≥30% (p-value= 0.2). Risk factors for severe MAP drop include older age, Black race, HTN, and diabetes. Additionally, treatment vs. no treatment and treatment with intravenous vs. oral medications were associated with greater odds of MAP drop ≥30% ( Table 1 ). Conclusion: While there was no difference in the proportion of treated and untreated patients with severe MAP reduction, after adjustment for factors independently associated with HTN we found that treatment was associated with severe BP drop. Further research is needed to phenotype inpatients with severe HTN to help establish treatment guidelines.
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- 2021
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36. Abstract P112: Orthostatic Hypotension, Orthostatic Hypertension And Ambulatory Blood Pressure In Patients With Chronic Kidney Disease: Findings From The Chronic Renal Insufficiency Cohort Study
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Nishigandha Pradhan, Matthew R. Weir, Raymond R. Townsend, Stephen P. Juraschek, Jordana B. Cohen, Lama Ghazi, Debbie L. Cohen, Hernan Rincon-Choles, Paul E. Drawz, and Mahboob Rahman
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medicine.medical_specialty ,Ambulatory blood pressure ,business.industry ,medicine.disease ,Orthostatic vital signs ,Blood pressure ,Internal medicine ,Internal Medicine ,Cardiology ,medicine ,Chronic renal insufficiency ,In patient ,Orthostatic hypertension ,medicine.symptom ,business ,Cohort study ,Kidney disease - Abstract
Background: We recently demonstrated how orthostatic hypotension might be used to identify out-of-office blood pressure phenotypes, including white coat effects and nocturnal non-dipping patterns. However, these findings have not been replicated in a population with chronic kidney disease (CKD). Objective: To examine the association between orthostatic hypotension (OH) or hypertension (OHTN) with ambulatory BP in adults with CKD. Methods: CRIC is a prospective multicenter observation cohort study of participants with CKD. Standing BP at 1 minute and ABPM were obtained on 1467 participants. OH was defined as a 20mmHg drop in systolic BP (SBP) or 10 mmHg drop in diastolic BP (DBP) when changing from seated to standing positions. OHTN was defined as a 20 mmHg or 10mmHg rise in SBP or DBP respectively when changing from seated to standing position. White coat effects, based on ABPM, was defined as the difference between seated clinic and ambulatory BP. Systolic and diastolic night to day ratio was also calculated. Results: Of the 1467 participants (age: 58 ± 10 yrs, 44% female, 39% black) 73 had OH and 165 had OHTN). OH was positively associated with systolic and diastolic white coat effect (β=5.9 [0.9, 10.9] and 4.2 [1.3, 7.1]). OHTN was negatively associated with diastolic white coat effect (-4.9 [-6.9, -3]). OH was positively associated with systolic and diastolic night-to-day ratio (0.03 [0.01, 0.05] and 0.03 [0.01, 0.06] respectively). Conclusions: Clinic-based assessments of OH and OHTN may be useful for identifying BP phenotypes often missed with seated office BP measurements in CKD patients.
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- 2021
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37. Abstract P110: Intravenous Hydralazine Effect On Blood Pressure Following Severe Inpatient Hypertension Development
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Tayyab Shah, Michael Simonov, Jonathan Hanna, Aditya Biswas, Lama Ghazi, Eric Y. Chen, Yu Yamamoto, Fan Li, F. Perry Wilson, and Aldo J. Peixoto
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Blood pressure ,nervous system ,business.industry ,Anesthesia ,Internal Medicine ,medicine ,Hydralazine ,business ,medicine.drug - Abstract
Background: BP elevations in the hospital are commonly treated with intravenous medications, specifically hydralazine. However, treatment guidelines are lacking. Our goal is to assess the effect of intravenous hydralazine on BP following severe inpatient HTN development. Methods: This is a cohort study of adults admitted for reasons other than HTN and developed severe HTN within a single healthcare system. We defined severe inpatient HTN as the first documentation of BP elevation (>180 systolic or >110 diastolic) at least 1 hour after admission. Pregnant women were excluded. Mixed-effects models with nonlinear time trend were used to assess and visualize the time-dependent effect of intravenous hydralazine on BP within 6 hours of BP elevation. Results: Of the 23,147 inpatients who developed severe HTN, 13,753 were untreated and 9,166 were treated of which 12% received intravenous hydralazine. Of the treated and untreated patients, 57 and 46% had a severe MAP reduction (drop ≥30%) (p-valueFigure 1 ). Conclusion: Severe MAP reduction is observed in both treated and untreated inpatients with severe HTN, however adjusted absolute decrease in MAP is greater in inpatients treated with intravenous hydralazine.
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- 2021
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38. Role of Inflammatory Biomarkers in the Prevalence and Incidence of Hypertension Among HIV-Positive Participants in the START Trial
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Coca Necsoi, James D. Neaton, Shweta Sharma, Mamta K. Jain, Paul E. Drawz, Lama Ghazi, Adrian Palfreeman, Jason V. Baker, and Daniel D Murray
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Adult ,Male ,medicine.medical_specialty ,Anti-HIV Agents ,Original Contributions ,Blood Pressure ,HIV Infections ,030204 cardiovascular system & hematology ,Risk Assessment ,Drug Administration Schedule ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Diabetes mellitus ,Prevalence ,Internal Medicine ,medicine ,Humans ,cardiovascular diseases ,030212 general & internal medicine ,Interleukin-6 ,Proportional hazards model ,business.industry ,Incidence ,Incidence (epidemiology) ,Hazard ratio ,Middle Aged ,medicine.disease ,Confidence interval ,C-Reactive Protein ,Cross-Sectional Studies ,Blood pressure ,Hypertension ,Biomarker (medicine) ,Female ,Inflammation Mediators ,business ,Body mass index ,Biomarkers - Abstract
BACKGROUND The association between hypertension (HTN) and inflammatory biomarkers (interleukin-6 [IL-6] and high-sensitivity C-reactive protein [hsCRP]) in HIV-positive persons with CD4+ count >500 cells/mm3 is unknown. METHODS We studied HTN in participants of the Strategic Timing of AntiRetroviral Treatment (START) trial of immediate vs. deferred antiretroviral therapy (ART) in HIV-positive, ART naive adults with CD4+ count > 500 cells/mm3. HTN was defined as having a systolic blood pressure (BP) ≥140 mmHg, a diastolic BP ≥90 mmHg, or using BP-lowering therapy. Logistic and discrete Cox regression models were used to study the association between baseline biomarker levels with prevalent and incident HTN. RESULTS Among 4,249 participants with no history of cardiovascular disease, the median age was 36 years, 55% were nonwhite, and the prevalence of HTN at baseline was 18.9%. After adjustment for race, age, gender, body mass index (BMI), diabetes, smoking, HIV RNA and CD4+ levels, associations of IL-6 and hsCRP with HTN prevalence were not significant (OR per twofold higher:1.10, 95% confidence interval [CI]: 0.99, 1.20 for IL-6 and 1.05, 95% CI: 0.99, 1.10 for hsCRP). Overall incidence of HTN was 6.8 cases/100 person years. In similarly adjusted models, neither IL-6 (Hazard ratios [HR] per twofold higher IL-6 levels: 0.97, 95% CI: 0.88, 1.08) nor hsCRP (HR per twofold higher hsCRP levels: 0.97, 95% CI: 0.92, 1.02) were associated with risk of incident HTN. Associations did not differ by treatment group. Age, race, gender, and BMI were significantly associated with both the prevalence and incidence of HTN. CONCLUSIONS Traditional risk factors and not baseline levels of IL-6 or hsCRP were associated with the prevalence and incidence of HTN in START.
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- 2019
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39. Alerting Clinicians to 1-Year Mortality Risk in Patients Hospitalized With Heart Failure
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Tariq, Ahmad, Nihar R, Desai, Yu, Yamamoto, Aditya, Biswas, Lama, Ghazi, Melissa, Martin, Michael, Simonov, Ravi, Dhar, Allen, Hsiao, Nitu, Kashyap, Larry, Allen, Eric J, Velazquez, and F Perry, Wilson
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Aged, 80 and over ,Heart Failure ,Hospitalization ,Male ,Humans ,Female ,Stroke Volume ,Empiricism ,Cardiology and Cardiovascular Medicine ,Quality Improvement ,Ventricular Function, Left ,Aged - Abstract
Heart failure is a major cause of morbidity and mortality worldwide. The use of risk scores has the potential to improve targeted use of interventions by clinicians that improve patient outcomes, but this hypothesis has not been tested in a randomized trial.To evaluate whether prognostic information in heart failure translates into improved decisions about initiation and intensity of treatment, more appropriate end-of-life care, and a subsequent reduction in rates of hospitalization or death.This was a pragmatic, multicenter, electronic health record-based, randomized clinical trial across the Yale New Haven Health System, comprising small community hospitals and large tertiary care centers. Patients hospitalized for heart failure who had N-terminal pro-brain natriuretic peptide (NT-proBNP) levels of greater than 500 pg/mL and received intravenous diuretics within 24 hours of admission were automatically randomly assigned to the alert (intervention) or usual-care groups.The alert group had their risk of 1-year mortality calculated using an algorithm that was derived and validated using similar historic patients in the electronic health record. This estimate, including a categorical risk assessment, was presented to clinicians while they were interacting with a patient's electronic health record.The primary outcome was a composite of 30-day hospital readmissions and all-cause mortality at 1 year.Between November 27, 2019, through March 7, 2021, 3124 patients were randomly assigned to the alert (1590 [50.9%]) or usual-care (1534 [49.1%]) group. The alert group had a median (IQR) age of 76.5 (65-86) years, and 796 were female patients (50.1%). Patients from the following race and ethnicity groups were included: 13 Asian (0.8%), 324 Black (20.4%), 136 Hispanic (8.6%), 1448 non-Hispanic (91.1%), 1126 White (70.8%), 6 other ethnicity (0.4%), and 127 other race (8.0%). The usual-care group had a median (IQR) age of 77 (65-86) years, and 788 were female patients (51.4%). Patients from the following race and ethnicity groups were included: 11 Asian (1.4%), 298 Black (19.4%), 162 Hispanic (10.6%), 1359 non-Hispanic (88.6%), 1077 White (70.2%), 13 other ethnicity (0.9%), and 137 other race (8.9%). Median (IQR) NT-proBNP levels were 3826 (1692-8241) pg/mL in the alert group and 3867 (1663-8917) pg/mL in the usual-care group. A total of 284 patients (17.9%) and 270 patients (17.6%) were admitted to the intensive care unit in the alert and usual-care groups, respectively. A total of 367 patients (23.1%) and 359 patients (23.4%) had a left ventricular ejection fraction of 40% or less in the alert and usual-care groups, respectively. The model achieved an area under the curve of 0.74 in the trial population. The primary outcome occurred in 619 patients (38.9%) in the alert group and 603 patients (39.3%) in the usual-care group (P = .89). There were no significant differences between study groups in the prescription of heart failure medications at discharge, the placement of an implantable cardioverter-defibrillator, or referral to palliative care.Provision of 1-year mortality estimates during heart failure hospitalization did not affect hospitalization or mortality, nor did it affect clinical decision-making.ClinicalTrials.gov Identifier NCT03845660.
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- 2022
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40. Hypertension in Women Across the Lifespan
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Natalie A. Bello and Lama Ghazi
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Adult ,Male ,Gerontology ,medicine.medical_specialty ,Population level ,Concordance ,Longevity ,Blood Pressure ,030204 cardiovascular system & hematology ,Article ,Young Adult ,03 medical and health sciences ,0302 clinical medicine ,Pregnancy ,Risk Factors ,Humans ,Medicine ,030212 general & internal medicine ,Young adult ,Aged ,Angiology ,business.industry ,Guideline ,medicine.disease ,Clinical trial ,Menopause ,Blood pressure ,Hypertension ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
PURPOSE OF REVIEW: We will highlight the biological processes across a women’s lifespan from young adulthood through menopause and beyond that impact blood pressure and summarize women’s representation in hypertension clinical trials. RECENT FINDINGS: Throughout their lifetime, women potentially undergo several unique sex-specific changes that may impact their risk of developing hypertension. Blood pressure diagnostic criteria for pregnant women remains 140/90 mmHg and has not been updated for concordance with the 2017 ACC/AHA guideline due to a lack of data. Although on a population level, women develop hypertension at later ages than men, new data shows women’s BP starts to increase as early as the third decade Understanding how age and sex both contribute to hypertension in elderly women is crucial to identify optimal blood pressure and treatment targets. SUMMARY: Effective screening, monitoring, and treatment of hypertension throughout a women’s lifespan is necessary to reduce CVD risk. We highlight several gaps in the literature pertaining to understanding sex-specific hypertension mechanisms.
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- 2021
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41. The Association of COVID-19 With Acute Kidney Injury Independent of Severity of Illness: A Multicenter Cohort Study
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Patrick E. Young, Michael Simonov, Jameel Alausa, Melissa Martin, Monique Hinchcliff, Tanima Arora, Lama Ghazi, Jason H. Greenberg, F. Perry Wilson, Sherry G. Mansour, Lloyd G. Cantley, Yu Yamamoto, Labeebah Subair, Jeffrey M. Testani, Aditya Biswas, Ugochukwu Ugwuowo, Dennis G. Moledina, Wade L. Schulz, Aldo J. Peixoto, and Chenxi Huang
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,030232 urology & nephrology ,Original Investigations ,Severity of Illness Index ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Renal Dialysis ,Risk Factors ,Internal medicine ,Severity of illness ,medicine ,Humans ,Vasoconstrictor Agents ,Hospital Mortality ,030212 general & internal medicine ,Renal Insufficiency, Chronic ,Diuretics ,Dialysis ,Aged ,Proportional Hazards Models ,Inflammation ,SARS-CoV-2 ,business.industry ,Hazard ratio ,Acute kidney injury ,Absolute risk reduction ,COVID-19 ,Acute Kidney Injury ,Length of Stay ,Middle Aged ,medicine.disease ,Respiration, Artificial ,United States ,Intensive Care Units ,C-Reactive Protein ,Respiratory failure ,Nephrology ,Creatinine ,Female ,business ,Kidney disease ,Cohort study - Abstract
Rationale and objective While COVID-19 infection has been associated with acute kidney injury (AKI), it is unclear whether this association is independent of traditional risk factors such as hypotension, nephrotoxin exposure, and inflammation. We tested the independent association of COVID-19 with AKI. Study Design Multicenter, observational, cohort study. Setting and participants Patients admitted to one of six hospitals within the Yale-New Haven Health System between 3/10/2020 and 8/31/2020 and tested for SARS-CoV-2 via nasopharyngeal PCR test. Exposure Positive test for SARS-CoV-2. Outcome AKI by Kidney Disease: Improving Global Outcomes criteria. Analytic approach Evaluated the association of COVID-19 with AKI after controlling for time-invariant factors at admission (e.g., demographics, comorbidities) and time-varying factors updated continuously during hospitalization (e.g., vital signs, medications, laboratory results, respiratory failure) using time-updated Cox proportional hazard models. Results Of the 22,122 patients hospitalized between, 2,600 tested positive and 19,522 tested negative for SARS-CoV-2. Compared to patients who tested negative, patients with COVID-19 had more AKI [30.6% vs. 18.2%, absolute risk difference 12.5 (95% CI, 10.6, 14.3)%] and dialysis-requiring AKI (8.5% vs. 3.6%) and lower recovery from AKI (58% vs. 69.8%]. Compared to patients who tested negative, patients with COVID-19 had higher inflammatory markers (C-reactive protein, ferritin), and greater use of vasopressors and diuretics. Compared to patients who tested negative, patients with COVID-19 had higher rate of AKI in univariable analysis (HR, 1.84 [1.73, 1.95]). In fully adjusted model controlling for demographics, comorbidities, vital signs, medications, and laboratory results, COVID-19 remained associated with a high rate of AKI (adjusted HR, 1.40 [1.29-1.53]). Limitations Possibility of residual confounding. Conclusions COVID-19 is associated with high rates of AKI not fully explained by adjustment for known risk factors. This suggests the presence of mechanisms of AKI not accounted for in this analysis, which may include a direct effect of COVID-19 on the kidney or other unmeasured mediators. Future studies should evaluate the possible unique pathways by which COVID-19 may cause AKI., One-third of patients hospitalized with COVID-19 experience acute kidney injury (AKI), which is higher than in other hospitalized patients. Patients with COVID-19 carry many well-known risk factors for AKI including severe lung disease requiring mechanical ventilation, shock and significant inflammation. Whether higher rates of AKI in COVID-19 are above what could be expected in patients with similar risk factors is unknown. We compared AKI rates between those with and without COVID-19 after controlling for risk factors for AKI both before and during hospitalization. We found that COVID-19 was independently associated with high rates of AKI. This indicates that some of the AKI risk in patients with COVID-19 is unexplained by traditional AKI risk factors and is unique to this disease.
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- 2021
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42. REVeAL-HF: Design and Rationale of a Pragmatic Randomized Controlled Trial Embedded Within Routine Clinical Practice
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Tariq, Ahmad, Yu, Yamamoto, Aditya, Biswas, Lama, Ghazi, Melissa, Martin, Michael, Simonov, Allen, Hsiao, Nitu, Kashyap, Eric J, Velazquez, Nihar R, Desai, and F Perry, Wilson
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Adult ,Heart Failure ,Hospitalization ,Aftercare ,Heart Transplantation ,Humans ,Patient Discharge ,Randomized Controlled Trials as Topic - Abstract
Heart failure (HF) is one of the most common causes of hospitalization in the United States and carries a significant risk of morbidity and mortality. Use of evidence-based interventions may improve outcomes, but their use is encumbered in part by limitations in accurate prognostication. The REVeAL-HF (Risk EValuation And its Impact on ClinicAL Decision Making and Outcomes in Heart Failure) trial is the first to definitively evaluate the impact of knowledge about prognosis on clinical decision making and patient outcomes. The REVeAL-HF trial is a pragmatic, completely electronic, randomized controlled trial that has completed enrollment of 3,124 adults hospitalized for HF, defined as having an N-terminal pro-B-type natriuretic peptide level of500 pg/ml and receiving intravenous diuretic agents within 24 h of admission. Patients randomized to the intervention had their risk of 1-year mortality generated with information in the electronic health record and presented to their providers, who had the option to give feedback on their impression of this risk assessment. The authors are examining the impact of this information on clinical decision-making (use of HF pharmacotherapies, referral to electrophysiology, palliative care referral, and referral for advanced therapies like heart transplantation or mechanical circulatory support) and patient outcomes (length of stay, post-discharge 30-day rehospitalizations, and 1-year mortality). The REVeAL-HF trial will definitively examine whether knowledge about prognosis in HF has an impact on clinical decision making and patient outcomes. It will also examine the relationship between calculated, perceived, and real risk of mortality in this patient population. (Risk EValuation And Its Impact on ClinicAL Decision Making and Outcomes in Heart Failure [REVeAL-HF]; NCT03845660).
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- 2021
43. Predicting patients with false negative SARS-CoV-2 testing at hospital admission: A retrospective multi-center study
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Aditya Biswas, Dennis G. Moledina, Michael Simonov, Jason H. Greenberg, Lama Ghazi, Yu Yamamoto, F. Perry Wilson, and Sherry G. Mansour
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Male ,RNA viruses ,Percentile ,Nosocomial Infections ,Coronaviruses ,Epidemiology ,Physiology ,Electronic Medical Records ,030501 epidemiology ,Logistic regression ,Cohort Studies ,COVID-19 Testing ,0302 clinical medicine ,Medical Conditions ,Medicine and Health Sciences ,030212 general & internal medicine ,Medical Personnel ,False Negative Reactions ,Pathology and laboratory medicine ,Virus Testing ,education.field_of_study ,Multidisciplinary ,Middle Aged ,Medical microbiology ,Hospitals ,Test (assessment) ,Body Fluids ,Hospitalization ,Professions ,Infectious Diseases ,Blood ,Hospital admission ,Viruses ,Medicine ,Female ,SARS CoV 2 ,Pathogens ,Anatomy ,0305 other medical science ,Information Technology ,Cohort study ,Research Article ,medicine.medical_specialty ,Computer and Information Sciences ,SARS coronavirus ,Health Personnel ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,Science ,Population ,Microbiology ,Article ,03 medical and health sciences ,Diagnostic Medicine ,Internal medicine ,medicine ,Humans ,education ,Aged ,Retrospective Studies ,Biology and life sciences ,SARS-CoV-2 ,business.industry ,Organisms ,Viral pathogens ,COVID-19 ,Retrospective cohort study ,Health Information Technology ,Models, Theoretical ,Microbial pathogens ,Health Care ,Blood Counts ,Health Care Facilities ,Multi center study ,Medical Risk Factors ,People and Places ,Population Groupings ,business ,Forecasting - Abstract
Importance False negative SARS-CoV-2 tests can lead to spread of infection in the inpatient setting to other patients and healthcare workers. However, the population of patients with COVID who are admitted with false negative testing is unstudied. Objective To characterize and develop a model to predict true SARS-CoV-2 infection among patients who initially test negative for COVID by PCR. Design Retrospective cohort study. Setting Five hospitals within the Yale New Haven Health System between 3/10/2020 and 9/1/2020. Participants Adult patients who received diagnostic testing for SARS-CoV-2 virus within the first 96 hours of hospitalization. Exposure We developed a logistic regression model from readily available electronic health record data to predict SARS-CoV-2 positivity in patients who were positive for COVID and those who were negative and never retested. Main outcomes and measures This model was applied to patients testing negative for SARS-CoV-2 who were retested within the first 96 hours of hospitalization. We evaluated the ability of the model to discriminate between patients who would subsequently retest negative and those who would subsequently retest positive. Results We included 31,459 hospitalized adult patients; 2,666 of these patients tested positive for COVID and 3,511 initially tested negative for COVID and were retested. Of the patients who were retested, 61 (1.7%) had a subsequent positive COVID test. The model showed that higher age, vital sign abnormalities, and lower white blood cell count served as strong predictors for COVID positivity in these patients. The model had moderate performance to predict which patients would retest positive with a test set area under the receiver-operator characteristic (ROC) of 0.76 (95% CI 0.70–0.83). Using a cutpoint for our risk prediction model at the 90th percentile for probability, we were able to capture 35/61 (57%) of the patients who would retest positive. This cutpoint amounts to a number-needed-to-retest range between 15 and 77 patients. Conclusion and relevance We show that a pragmatic model can predict which patients should be retested for COVID. Further research is required to determine if this risk model can be applied prospectively in hospitalized patients to prevent the spread of SARS-CoV-2 infections.
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- 2021
44. Screening for Hypertension in Children With and Without Autism Spectrum Disorder
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James T, Nugent, Christine, Bakhoum, Lama, Ghazi, and Jason H, Greenberg
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Autism Spectrum Disorder ,Hypertension ,Humans ,Mass Screening ,General Medicine ,Child ,Medical History Taking - Published
- 2022
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45. Fine Particulate Matter (PM2.5) is Associated with Chronic Kidney Disease: Findings Using Electronic Health Record Data
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Paul E. Drawz, Lama Ghazi, and Jesse D. Berman
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business.industry ,Electronic health record ,Fine particulate ,Environmental health ,General Earth and Planetary Sciences ,Medicine ,business ,medicine.disease ,General Environmental Science ,Kidney disease - Published
- 2020
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46. Abstract P172: Orthostatic Hypotension And 24-hr Ambulatory Blood Pressure Monitoring In The Sprint Trial
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Stephen P. Juraschek, Paul E. Drawz, Lama Ghazi, and Nicholas M. Pajewski
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medicine.medical_specialty ,Supine position ,Ambulatory blood pressure ,business.industry ,White coat ,Orthostatic vital signs ,Blood pressure ,Sprint ,Internal medicine ,Ambulatory ,Internal Medicine ,Cardiology ,Medicine ,business - Abstract
Background: Clinic blood pressure (BP) is measured in the seated position, which can miss important home BP phenotypes such as low ambulatory BP (white coat effects) or high supine BP (nocturnal non-dippers). Orthostatic hypotension (OH) is determined based on BP measurements in both seated (or supine) and standing positions, and thus could theoretically identify these important phenotypes in clinic. Objective: To determine the association of OH with white coat effects or night-to-daytime systolic BP (SBP) Methods: SPRINT was a randomized trial testing the effects of intensive (0.9. Results: Of 897 adults (mean age 71.5 [SD, 9.5] yrs, 28.7% female, 28.0% black), 128 had OH at least once. Among those with OH, 14.8% had white coat effects versus 7.2% among those without OH. Moreover, 68.8% of those with OH demonstrated non-dipping patterns versus only 52.0% of those without OH. OH was positively associated with both white coat effects (OR=2.24; 95% CI: 1.28, 4.27) and higher night-to-daytime SBP (β=0.04; 95% CI: 0.02, 0.06) ( Table ). Conclusions: Clinic-based assessments of OH may be a useful tool for identifying BP phenotypes often missed with traditional seated BP assessments.
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- 2020
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47. Effects of Intensive Versus Standard Office-Based Hypertension Treatment Strategy on White Coat Effect and Masked Uncontrolled Hypertension: From the SPRINT ABPM Ancillary Study
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Lama Ghazi, Paul Muntner, Paul E. Drawz, Laura P. Cohen, and Daichi Shimbo
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Male ,medicine.medical_specialty ,Blood Pressure ,030204 cardiovascular system & hematology ,Article ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,Masked Hypertension ,Internal Medicine ,Medicine ,Humans ,030212 general & internal medicine ,Antihypertensive Agents ,Antihypertensive medication ,Aged ,Aged, 80 and over ,Office based ,Hypertension treatment ,business.industry ,Ancillary Study ,Guideline ,Blood Pressure Monitoring, Ambulatory ,Middle Aged ,Blood pressure ,Sprint ,Female ,White coat effect ,business ,White Coat Hypertension - Abstract
Guidelines recommend using out-of-office blood pressure (BP) measurements to confirm the diagnoses of hypertension and in the titration of antihypertensive medication. The prevalence of out-of-office BP phenotypes for an office systolic/diastolic BP goal
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- 2020
48. Association of 24-Hour Ambulatory Blood Pressure Patterns with Cognitive Function and Physical Functioning in CKD
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Jiang He, Matthew R. Weir, Jordana B. Cohen, Manjula Kurella Tamura, Chi-yuan Hsu, Kristine Yaffe, Sankar D. Navaneethan, Amanda H. Anderson, Paul E. Drawz, Debbie L. Cohen, Lama Ghazi, Harold I. Feldman, Raymond R. Townsend, Mahboob Rahman, Michael J. Fischer, and Edgar R. Miller
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Transplantation ,medicine.medical_specialty ,Ambulatory blood pressure ,Epidemiology ,business.industry ,Cross-sectional study ,Cognition ,Original Articles ,Critical Care and Intensive Care Medicine ,Masked Hypertension ,Nephrology ,Interquartile range ,Internal medicine ,Ambulatory ,Cohort ,Medicine ,business ,Cohort study - Abstract
BACKGROUND AND OBJECTIVES: Hypertension is highly prevalent in patients with CKD as is cognitive impairment and frailty, but the link between them is understudied. Our objective was to determine the association between ambulatory BP patterns, cognitive function, physical function, and frailty among patients with nondialysis-dependent CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Ambulatory BP readings were obtained on 1502 participants of the Chronic Renal Insufficiency Cohort. We evaluated the following exposures: (1) BP patterns (white coat, masked, sustained versus controlled hypertension) and (2) dipping patterns (reverse, extreme, nondippers versus normal dippers). Outcomes included the following: (1) cognitive impairment scores from the Modified Mini Mental Status Examination of
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- 2020
49. Abstract P558: Association Between Stroke Prevalence and Depression, Functional Ability, and Cognitive Function in Six Low and Middle Income Countries: The WHO Study on Global AGEing and Adult Health
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Lama Ghazi and Carin Northuis
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Gerontology ,Stroke prevalence ,business.industry ,Cognition ,Ageing ,Low and middle income countries ,Physiology (medical) ,Medicine ,Functional ability ,Cardiology and Cardiovascular Medicine ,Association (psychology) ,business ,Depression (differential diagnoses) ,Adult health - Abstract
Background: There are substantial gaps in stroke morbidity in low and middle income countries (LMIC) compared to high income countries (HIC). Stroke incidence and mortality are higher in LMIC compared to HIC. While education has been associated with stroke incidence and common stroke outcomes in HIC, the pattern of this social determinant of health may be reversed in LMIC. We examined the association between stroke prevalence and depression, cognitive function and functional ability utilizing the WHO Study on Global AGEing and Adult Health (SAGE). We also assessed if education modified this association. Methods: We used data from the WHO SAGE, wave 1 (2007-10), which is a nationally representative cohort from six LMIC: China, Ghana, India, Mexico, Russia, and South Africa. Stroke prevalence was classified by self-reported stroke or stroke symptoms. Outcomes included 1) depression [ICD-10 diagnostic criteria]; 2) cognitive function [z-score of performance on executive function, verbal fluency, and memory]; and 3) functional ability [WHO Disability Assessment Schedule]. Generalized linear models were fit for the association between stroke prevalence and outcomes. For our secondary analysis, educational attainment was included as a modifier. All models were adjusted for demographics, socioeconomic status, and health variables. Results: We included 39,896 individuals who had data on their stroke status. Stroke prevalence was 5.1% (n=2,034). Stroke survivors had lower mean cognitive function (-0.1±.8 vs 0.1±0.7, p Conclusion: Stroke was associated with a higher odds of depression and higher risk of reduced cognitive function and functional ability. Unlike in HIC, these six LMIC did not display a significant inverse association between education and depression and cognitive function. Future studies should assess predictors of poorer post-stroke outcomes and if other socioeconomic measures modify consequences of stroke in LMIC.
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- 2020
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50. Neighborhood Socioeconomic Status and Identification of Patients With CKD Using Electronic Health Records
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Lama Ghazi, Russell V. Luepker, Theresa L. Osypuk, Paul E. Drawz, J. Michael Oakes, and Richard F. MacLehose
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Adult ,Male ,medicine.medical_specialty ,Minnesota ,030232 urology & nephrology ,Disease ,Article ,03 medical and health sciences ,0302 clinical medicine ,Residence Characteristics ,Diabetes mellitus ,Internal medicine ,medicine ,Electronic Health Records ,Humans ,Mass Screening ,030212 general & internal medicine ,Renal Insufficiency, Chronic ,Socioeconomic status ,Mass screening ,Aged ,business.industry ,Middle Aged ,medicine.disease ,Health equity ,Quartile ,Social Class ,Nephrology ,Cohort ,Female ,business ,Kidney disease - Abstract
RATIONALE & OBJECTIVE: Screening for chronic kidney disease (CKD) is recommended for patients with diabetes and hypertension as stated by the respective professional societies. However, CKD, a silent disease usually detected at later stages, is associated with low socioeconomic status (SES). We assessed whether adding census tract SES status to the standard screening approach improves our ability to identify patients with CKD. STUDY DESIGN: Screening test analysis. SETTINGS & PARTICIPANTS: Electronic health records (EHR) of 256,162 patients seen at a health care system in the 7-county Minneapolis/St. Paul area and linked census tract data. EXPOSURE: The first quartile of census tract SES (median value of owner-occupied housing units 25 years of age with a bachelor’s degree or higher 30 mg/g, or urinary protein-creatinine ratio >150 mg/g, or urinary analysis [albuminuria] >30 mg/d). ANALYTICAL APPROACH: Sensitivity, specificity, and number needed to screen (NNS) to detect CKD if we screened patients who had hypertension and/or diabetes and/or who lived in low-SES tracts (belonging to the first quartile of any of the 3 measures of tract SES) versus the standard approach. RESULTS: CKD was prevalent in 13% of our cohort. Sensitivity, specificity, and NNS of detecting CKD after adding tract SES to the screening approach were 67% (95% CI, 66.2%−67.2%), 61% (95% CI, 61.1%−61.5%), and 5, respectively. With the standard approach, sensitivity of detecting CKD was 60% (95% CI, 59.4%−60.4%), specificity was 73% (95% CI, 72.4%−72.7%), and NNS was 4. LIMITATIONS: One health care system and selection bias. CONCLUSIONS: Leveraging patients’ addresses from the EHR and adding tract-level SES to the standard screening approach modestly increases the sensitivity of detecting patients with CKD at a cost of decreased specificity. Identifying further factors that improve CKD detection at an early stage are needed to slow the progression of CKD and prevent cardiovascular complications.
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- 2020
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