Implementation of a dedicated cardiovascular and stroke unit in a crowded emergency department of a tertiary public hospital in Brazil: effect on mortality rates.

BACKGROUND: Emergency department (ED) care for acute vascular diseases faces the challenge of overcrowding. A vascular unit is a specialized, protocol-oriented unit in the ED with a team trained to manage acute vascular disorders, including stroke, coronary syndromes, pulmonary embolism (PE), and aortic diseases. OBJECTIVES: The objective was to compare case fatality rates for selected cardiovascular conditions before and after the implementation of a vascular unit. METHODS: Patients with the selected diagnoses admitted to the ED in two different time periods, 2002 through 2005 (before unit opening) and 2007 to 2010 (after vascular unit opening), were identified by ICD-10 codes, and their electronic records were reviewed. Case fatality rates were calculated and compared for both time periods. RESULTS: The period prior to unit implementation (2002 through 2005) included 4,164 patients, and the vascular unit period (2007 to 2010) included 6,280 patients. Overall, the case fatality rate for acute vascular conditions decreased from 9% to 7.3% with vascular unit implementation (p = 0.002). The in-hospital mortality rates for acute coronary syndrome (ACS) dropped from 6% to 3.8% (p = 0.003), and for acute PE dropped from 32.1% to 10.8% (p < 0.001). The stroke case-fatality rate did not decrease despite improvements in the quality of stroke health care indicators. CONCLUSIONS: The vascular unit strategy has the potential to reduce overall mortality for most acute vascular conditions.

Efficacy of isolated home blood pressure monitoring for blood pressure control: randomized controlled trial with ambulatory blood pressure monitoring - MONITOR study.

BACKGROUND: Rates of control of hypertension remain unsatisfactory worldwide and simple methods to encourage patients to adhere to treatments are still necessary. In this randomized controlled trial, we evaluated the efficacy of a protocol of home blood pressure monitoring (HBPM), without medication titration, to improve BP assessed by ambulatory BPM (ABPM). METHODS: Patients with hypertension under drug treatment and with uncontrolled BP at office and by 24-h ABPM were randomly assigned to HBPM or usual care. The treatment was not modified during the trial. Follow-up visits were conducted at 7 and 30 days after randomization, and at 60 days to assess the outcome. Deltas between baseline and final ABPM measurements were calculated for 24-h, nightly and daily ambulatory SBP and DBP. RESULTS: Of 558 patients screened, 136 fulfilled the eligibility criteria and were randomized, and 121 (89%) completed the trial. The between groups deltas (95% confidence interval) of variation of 24 h, nightly and daily SBP were 5.4 (0.9-9.8) (P = 0.018), 10.9 (2.9-18.9) (P = 0.012) and 4.4 mmHg (-0.1 to 8.8) (P = 0.055), respectively; the corresponding deltas for DBP were 4.5 (1.6-7.4) (P = 0.003), 3.4 (0.4-6.3) (P = 0.025) and 5.8 mmHg (2.5-9.0) (P = 0.001), respectively. At the end of the trial, 32.4% of patients of the HBPM groups and 16.2% of the control group had 24-h SBP less than 130/80 mmHg (P = 0.03). CONCLUSION: A protocol of HBPM without medication titration enhances the control of BP assessed by ABPM.