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About 65 million Americans, one fourth of the adult population in the United States, and over 1 billion people worldwide have hypertension (HTN). HTN therefore is present in 1 of every 4 patients admitted to any US hospital. Surprisingly, no guidelines are available for the management of inpatient HTN. Based on a comprehensive search of the literature we are proposing a pathway for the management of HTN in nonpregnant hospitalized patients. The pathway provides a definition and clinical assessment of HTN for patients admitted to the hospital. The assessment is followed by an organ/system based therapeutic approach specifying timing, blood pressure goals, recommended antihypertensive drug therapy and the sequence of add-on drugs. The pathway specifically discusses assessment and management of HTN in patients with (1) acute aortic syndrome, (2) acute neurologic syndrome, (3) acute coronary syndrome, (4) congestive heart failure, (5) renal failure, and (6) secondary forms. Finally, the pathway provides a step by step recommendation for the management of in hospital HTN and of hypertensive emergencies.

In cardiac resynchronization therapy (CRT), positive clinical response and reverse remodeling have been reported using robotically assisted left ventricular (LV) epicardial lead placement. However, the long-term performance of epicardial leads and long-term outcome of patients who undergo CRT via robotic assistance are unknown. In addition, since the LV lead placement is more invasive than a transvenous procedure, it is important to identify patients at higher risk of complications.We evaluated 78 consecutive patients (70 ± 11 years, 50 male) who underwent robotic epicardial LV lead placement. The short- (12 months) and long-term (≥ 12 months) lead performance was determined through device interrogations. Mortality data were determined by contact with the patient's family and referring physicians and confirmed using the Social Security Death Index.All patients had successful lead placement and were discharged in stable condition. When compared to the time of implantation, there was a significant increase in pacing threshold (1.0 ± 0.5 vs 2.14 ± 1.2; P0.001) and decrease in lead impedance (1010 ± 240 Ω vs 491 ± 209 Ω; P0.001) at short-term follow-up. The pacing threshold (2.3 ± 1.2 vs 2.14 ± 1.2; P = 0.30) and lead impedance (451 ± 157 Ω vs 491 ± 209 Ω; P = 0.10) remained stable during long-term follow-up when compared to short-term values. At a follow-up of 44 ± 21 months, there were 20 deaths (26%). These patients were older (77 ± 7 vs 67 ± 11 years; P = 0.001) and had a lower ejection fraction (EF) (13 ± 7% vs 18 ± 9%; P = 0.02) than surviving patients.Robotically implanted epicardial LV leads for CRT perform well over short- and long-term follow-up. Older patients with a very low EF are at higher risk of death. The risks and benefits of this procedure should be carefully considered in these patients.

INTRODUCTION: In cardiac resynchronization therapy (CRT), our group has previously reported on positive clinical response and reverse remodeling using a novel robotically assisted left ventricular (LV) epicardial lead placement approach for pts with primary lead implant failure. In addition, CRT via transvenous approach is associated with an approximate 20% mortality rate at 18 mos. Long term mortality via robotic placement is unknown. METHODS: We evaluated 71 pts (70 ± 11 yrs, 48 [68%] male) who underwent robotic LV lead placement after failed transvenous LV lead placement. Leads were placed based on Tissue Doppler Imaging to localize the site of latest mechanical activation. The Social Security Death Index was queried to identify mortality. RESULTS: All pts had successful lead placement and were discharged in stable condition. During a follow-up (f/u) of 27 ± 16 mos, there were 18 deaths (25%) after 17.3 ± 14.5 mos (range 1.3 – 50.2 mos) (Figure ). These pts were older (77 ± 6 v. 68 ± 11 yrs; p < 0.001), with a lower EF (13 ± 7% v. 18 ± 9%; p < 0.05) and carried a greater symptom burden by NYHA class (3.6 ± 0.5 v. 3.1 ± 0.5; p = 0.02) when compared to those alive. There was no difference in pts with respect to HF duration, cardiomyopathy etiology or atrial fibrillation prevalence. A significant improvement in symptoms by NYHA class (3.1 ± 0.5 to 2.3 ± 0.7; p < 0.001) was seen at 8 ± 3 mos. CONCLUSION: Pts undergoing robotic LV lead implant show symptomatic improvement, and have a similar mortality rate to transvenous placement during f/u. Those at greatest risk for death include older pts with a very low EF; risk/benefit for these pts should be carefully considered before undergoing implant.