Validating emergency department vital signs using a data quality engine for data warehouse.

BACKGROUND: Vital signs in our emergency department information system were entered into free-text fields for heart rate, respiratory rate, blood pressure, temperature and oxygen saturation. OBJECTIVE: We sought to convert these text entries into a more useful form, for research and QA purposes, upon entry into a data warehouse. METHODS: We derived a series of rules and assigned quality scores to the transformed values, conforming to physiologic parameters for vital signs across the age range and spectrum of illness seen in the emergency department. RESULTS: Validating these entries revealed that 98% of free-text data had perfect quality scores, conforming to established vital sign parameters. Average vital signs varied as expected by age. Degradations in quality scores were most commonly attributed logging temperature in Fahrenheit instead of Celsius; vital signs with this error could still be transformed for use. Errors occurred more frequently during periods of high triage, though error rates did not correlate with triage volume. CONCLUSIONS: In developing a method for importing free-text vital sign data from our emergency department information system, we now have a data warehouse with a broad array of quality-checked vital signs, permitting analysis and correlation with demographics and outcomes.

A pilot study on usability analysis of emergency department information system by nurses.

OBJECTIVES: Employing new health information technologies while concurrently providing quality patient care and reducing risk is a major challenge in all health care sectors. In this study, we investigated the usability gaps in the Emergency Department Information System (EDIS) as ten nurses differentiated by two experience levels, namely six expert nurses and four novice nurses, completed two lists of nine scenario-based tasks. METHODS: Standard usability tests using video analysis, including four sets of performance measures, a task completion survey, the system usability scale (SUS), and sub-task analysis were conducted in order to analyze usability gaps between the two nurse groups. RESULTS: A varying degree of usability gaps were observed between the expert and novice nurse groups, as novice nurses completed the tasks both less efficiently, and expressed less satisfaction with the EDIS. The most interesting finding in this study was the result of 'percent task success rate,' the clearest performance measure, with no substantial difference observed between the two nurse groups. Geometric mean values between expert and novice nurse groups for this measure were 60% vs. 62% in scenario 1 and 66% vs. 55% in scenario 2 respectively, while there were some marginal to substantial gaps observed in other performance measures. In addition to performance measures and the SUS, sub-task analysis highlighted navigation pattern differences between users, regardless of experience level. CONCLUSION: This study will serve as a baseline study for a future comparative usability evaluation of EDIS in other institutions with similar clinical settings.

Adoption of health information exchange by emergency physicians at three urban academic medical centers.

OBJECTIVES: Emergency physicians are trained to make decisions quickly and with limited patient information. Health Information Exchange (HIE) has the potential to improve emergency care by bringing relevant patient data from non-affiliated organizations to the bedside. NYCLIX (New York CLinical Information eXchange) offers HIE functionality among multiple New York metropolitan area provider organizations and has pilot users in several member emergency departments (EDs). METHODS: We conducted semi-structured interviews at three participating EDs with emergency physicians trained to use NYCLIX. Among "users" with > 1 login, responses to questions regarding typical usage scenarios, successful retrieval of data, and areas for improving the interface were recorded. Among "non-users" with ≤1 login, questions about NYCLIX accessibility and utility were asked. Both groups were asked to recall items from prior training regarding data sources and availability. RESULTS: Eighteen NYCLIX pilot users, all board certified emergency physicians, were interviewed. Of the 14 physicians with more than one login ,half estimated successful retrieval of HIE data affecting patient care. Four non-users (one login or less) cited forgotten login information as a major reason for non-use. Though both groups made errors, users were more likely to recall true NYCLIX member sites and data elements than non-users. Improvements suggested as likely to facilitate usage included a single automated login to both the ED information system (EDIS) and HIE, and automatic notification of HIE data availability in the EDIS All respondents reported satisfaction with their training. CONCLUSIONS: Integrating HIE into existing ED workflows remains a challenge, though a substantial fraction of users report changes in management based on HIE data. Though interviewees believed their training was adequate, significant errors in their understanding of available NYCLIX data elements and participating sites persist.

High risk hypertensives: pre-hospital management of acute myocardial infarction--results from the French nationwide registry USIC 2000.

OBJECTIVE: To assess the use of mobile coronary care units (MCU) in hypertensive patients previously treated for cardiovascular diseases in comparison with those with no history of cardiovascular disease and to estimate the influence of the use of MCU on cardiovascular outcome in this population. PATIENTS: We used a nationwide prospective registry of all patients admitted for AMI in French intensive care units in 2000. Patients without history of hypertension or patients admitted with pulmonary oedema or cardiogenic shock were excluded. Men (N = 514) and women (N = 291) were analysed separately. RESULTS: The proportion of patients with history of myocardial infarction, peripheral artery disease and stroke was not significantly higher in subjects who used physician-staffed MCU as compared with patients with no history of myocardial infarction, peripheral artery disease or stroke. In each sex, revascularization (pre hospital fibrinolysis, in hospital fibrinolysis or coronary angioplasty) were more frequent in patients who used MCU. Also, one year cardiovascular mortality was lower in men who used MCU. CONCLUSION: Known high risk hypertensive patients did not use physician-staffed MCU more than subjects free of such condition. Education of hypertensive patients at risk during routine visits is required to increase of the use of physician-staffed MCU in case of symptoms suggestive of AMI.

Major impact of admission glycaemia on 30 day and one year mortality in non-diabetic patients admitted for myocardial infarction: results from the nationwide French USIC 2000 study.

OBJECTIVE: To analyse the short and long term prognostic significance of admission glycaemia in a large registry of non-diabetic patients with acute myocardial infarction. METHODS: Assessment of short and long term prognostic significance of admission blood glucose in a consecutive population of 1604 non-diabetic patients admitted to intensive care units in France in November 2000 for a recent (

[Management of patients admitted for acute myocardial infarction in France from 1995 to 2000: time to admission dependent improvement in outcome]. / Prise en charge de l'infarctus du myocarde en France dans les études USIK 1995 et USIC 2000: amélioration pronoslique et rôle du délai d'admission.

The in-hospital management and short- and long-term outcomes was assessed in 2 registries of consecutive patients admitted for acute myocardial infarction, 5 years apart, in France. The 2000 cohort was younger and with a less frequent history of cardiac diseases, but was more often diabetic and with anterior infarcts. Time to admission was actually longer in 2000 than in 1995 (median 5.25 hours vs 4.00 hours). Overall, reperfusion therapy was used in 43% of the patients in both registries. However, the use of reperfusion therapy increased from 1995 to 2000 in patients admitted within 6 hours of symptom onset (64 vs 58%), with an increasing use of primary angioplasty (from 12 to 30%). Five-day mortality significantly improved from 7.7 to 6.1% (p < 0.03) and one-year survival was also less in the most recent period (85 vs 81%, p < 0.01). Multivariate analyses showed that the period of inclusion (2000 vs 1995) was an independent predictor of both short- and long-term mortality in patients admitted within 6 hours of symptom onset. Thus, in the real world setting, a continued decline in one-year mortality was observed in patients admitted to intensive care units for recent acute myocardial infarction, especially for patients admitted early. This goes along with a shift in reperfusion therapy towards a broader use of primary angioplasty, and with an increased use of the early prescription of recognised secondary prevention medications.

Detection of masked hypertension by home blood pressure measurement: is the number of measurements an important issue?

BACKGROUND: Office blood pressure (OBP) and home blood pressure (HBP) enable the identification of patients with masked hypertension. Masked hypertension is defined by normal OBP and high HBP and is known as a pejorative cardiovascular risk factor. OBJECTIVE: The objective was to evaluate in the SHEAF study the influence of the number of office or home blood pressure measurements on the classification of patients as masked hypertensives. METHODS: Patients with OBP <140/90 mmHg (mean of six values: three measurements at two separate visits, V1 and V2) and HBP >135/85 mmHg (mean of all valid measurements performed over a 4-day period) were the masked hypertensive reference group. The consistency of the classification was evaluated by using five definitions of HBP values (mean of the 3, 6, 9, 12 and 15 first measurements) and two definitions of OBP values (mean of three measurements at V1 and mean of three measurements at V2). RESULTS: Among the 4939 treated hypertensives included in the SHEAF study, 463 (9.4%) were classified as masked hypertensives (reference group). By decreasing the number of office or home measurements, the prevalence of masked hypertension ranged from 8.9-12.1%. The sensitivity of the classification ranged from 94-69% therefore 6-31% of the masked hypertensives were not detected. The specificity ranged from 98-94% therefore 1-6% of patients were wrongly classified as masked hypertensives. CONCLUSION: A limited number of home and office BP measurements allowed the detection of masked hypertension with a high specificity and a low sensitivity. A sufficient number of measurements (three measurements at two visits for OBP and three measurements in the morning and in the evening over 2 days for HBP) are required to diagnose masked hypertension.

Management and in-hospital outcome of patients with acute myocardial infarction admitted to intensive care units at the turn of the century: results from the French nationwide USIC 2000 registry.

OBJECTIVE: To assess actual practices and in-hospital outcome of patients with acute myocardial infarction on a nationwide scale. METHODS: Of 443 intensive care units in France, 369 (83%) prospectively collected data on all cases of infarction (within < 48 hours of symptom onset) in November 2000. RESULTS: 2320 patients (median age 68 years, 73% men) were included, of whom 83% had ST segment elevation infarction (STEMI). Patients without STEMI were older and had a more frequent history of cardiovascular disease. Median time to admission was 5.0 hours for patients with and 6.5 hours for those without STEMI. Reperfusion therapy was used for 53% of patients with STEMI (thrombolysis 28%, primary angioplasty 25%). In-hospital mortality was 8.7% (5.5% of patients without and 9.3% of those with STEMI). Multivariate analysis found that age, Killip class, lower blood pressure, higher heart rate on admission, anterior location of infarct, STEMI, diabetes mellitus, previous stroke, and no current smoking independently predicted in-hospital mortality. At hospital discharge, 95% received antiplatelet agents, 75% received beta blockers, and over 60% received statins. Angiotensin converting enzyme inhibitors were prescribed for 40% of the patients without and 52% of those with ST elevation. CONCLUSIONS: This nationwide registry, including all types of centres irrespective of their size and experience, shows continued improvement in patient care and outcomes. Time from symptom onset to admission, however, has not improved in recent years and reperfusion therapy is used for just over 50% of patients with STEMI, with an increasing use of primary angioplasty.

[Evolution of the management and outcomes of patients admitted for acute myocardial infarction in France from 1995 to 2000: data from the USIK 1995 and USIC 2000 nationwide registries]. / Evolution de la prise en charge et du pronostic de l'infarctus du myocarde en France entre 1995 et 2000: résultats des études USIK 1995 et USIC 2000.

We assessed the in-hospital management and short- and long-term outcomes of two series of patients admitted for acute myocardial infarction, 5 years apart, in France. The most recent cohort was younger and with a less frequent history of cardiac diseases, but was more often diabetic and with anterior infarcts. Five-day mortality significantly improved from 7.7% to 6.1% (P < 0.03) and 1-year survival was also less in the most recent period (15% versus 19%, P < 0.01). Multivariate analyses showed that the period of inclusion (2000 versus 1995) was an independent predictor of both short- and long-term mortality. In analyses restricted to the patients who were alive by day 5, initial treatment with statins was associated with a 38% decrease in the risk of death at 1 year. Likewise, in patients with left ventricular ejection fraction < or = 35%, the early prescription of ACE inhibitors was associated with a 41% reduction in the risk of 1-year mortality. Thus, in the real world setting, a continued decline in 1-year mortality is observed in patients admitted to intensive care units for recent acute myocardial infarction. This goes along with a shift in reperfusion therapy towards a broader use of coronary angioplasty and with an increased use of the early prescription of recognised secondary prevention medications.

Angiotensin-I-converting enzyme insertion/deletion polymorphism and high urinary albumin concentration in French Type 2 diabetes patients.

AIMS: Family-based studies suggest a genetic basis for nephropathy in Type 2 diabetes. The angiotensin-I-converting enzyme (ACE) gene is a candidate gene for Type 1 diabetes nephropathy. We assessed the association between high urinary albumin concentration and ACE insertion/deletion (I/D) polymorphism, in French Type 2 diabetes patients. METHODS: We studied 3139 micro/macroalbuminuric French patients recruited in the DIABHYCAR Study, an ACE inhibition trial in Type 2 diabetes patients with renal and cardiovascular outcomes. The main inclusion criteria were age >/= 50 years, urinary albumin concentration >/= 20 mg/l assessed centrally during two consecutive screening visits, and plasma creatinine concentration

Control of diabetes and cardiovascular risk factors in patients with type 2 diabetes: a nationwide French survey.

OBJECTIVES: To evaluate in France in 2001 the therapeutic management and control of diabetes and of modifiable cardiovascular risk factors in patients with type 2 diabetes receiving specialist care. METHODS: The study was proposed to 575 diabetologists across France. The first 8 consecutive ambulatory patients with type 2 diabetes treated by oral antidiabetic drugs (OADs) and/or insulin attending for consultation with a diabetologist were eligible for inclusion in the survey. The following data were collected: demographics, diabetic and cardiovascular history, cardiovascular risk factors, blood pressure, last recorded measurements of HbA(1c) and LDL cholesterol, and details of diabetes medication and cardiovascular medication. RESULTS: 4, 930 patients (53% men) aged 62 +/- 11 years were recruited by 410 specialists in diabetes care. The mean duration of diabetes was 12 +/- 9 years. 71% of patients were treated with OADs, 18% with an OAD + insulin and 9% with insulin alone. Mean HbA(1c) was 7.6 +/- 1.6%; HbA(1c) was<=6.5% in 27% of patients, between 6.6% and 8% in 39% of patients, and > 8% in 34% of patients. Mean blood pressure was 140 +/- 16/80 +/- 9 mmHg. In the study population as a whole the target blood pressure (systolic BP<140 mmHg and diastolic BP<80 mmHg) was attained by 29% of patients. Among the 3, 085 patients (63%) treated for hypertension, this target was attained in only 23% of patients; 40% of patients treated for hypertension received one single antihypertensive treatment, 36% received 2 treatments and 24% received 3 treatments or more. Among the 1, 845 patients considered by the investigators as not having hypertension, the target blood pressure was attained by 39%. A measurement for LDL cholesterol was available in 4, 036 patients (82%). 58% of these patients had LDL cholesterol<1.3 g/l, 29% had values between 1.3 and 1.6 g/l, and 13% had values > 1.6 g/l. 52% of patients were not receiving any lipid-lowering agents, 28% were treated with statins, 19% with fibrates, and 1% with statins + fibrates. LDL cholesterol was<1.3 g/l in only 66% of the 646 patients with associated coronary heart disease. CONCLUSION: According to this large nationwide survey, the prevalence of cardiovascular risk factors remains high. Control of glycaemia, blood pressure and LDL cholesterol does not appear to be optimal. This is due in part to the severity of diabetes in these patients seen by specialists in diabetes care; however, both awareness and application of published recommendations need to be reinforced.

[Trends in discharge prescriptions for patients hospitalized for acute coronary syndromes in France from 1995 to 2000. Data from the Usik 1995, Prevenir 1, Prevenir 2 and Usic 2000 surveys]. / Evolution du traitement de sortie après hospitalisation pour syndrome coronaire aigu en France entre 1995 et 2000: données des études Usik 1995, Prévenir 1 et 2 et Usic 2000.

The use of cardiovascular secondary prevention medications in patients with acute coronary syndromes was compared in 4 sequential observational surveys carried out in France from 1995 to 2000. The Usik 1995 and Usic 2000 surveys included patients admitted for acute myocardial infarction, while the 2 Prevenir surveys (1998 and 1999) assessed the medications prescribed in patients with acute coronary syndromes. Antiplatelet agents were prescribed in 91% of the patients in 1995, 93% in 1998 and 1999 and 96% in 2000; for beta-blockers, the respective figures were: 64%, 68%, 75% and 76%. For ACE-Inhibitors, the figures were: 46%, 41%, 41% and 50%. For statins, the prescription increased from 10% to 36%, 59% and 64%. In 1995, 8% of the patients received both antiplatelet agents, beta-blockers and statins (4% of them also had an ACE-Inhibitor); in 2000, the respective figures were 53% and 27%. The results of the recent trials of secondary prevention medications have had a considerable impact on real-life practice in France during the late 1990s.

[Efficacy of early reperfusion therapy at the acute stage of myocardial infarction in elderly patients: the USIK database]. / Efficacité du traitement de reperfusion au stade aigu de l'infarctus dans la population âgée: données du registre USIK 1995.

The role of early reperfusion therapy at the acute stage of myocardial infarctus in elderly patients is debated. The aim of this study was to analyze the prognostic role of reperfusion with i.v. thrombolysis or primary PTCA in the nationwide USIK database, which prospectively included all pts admitted to a CCU for an AMI < 48 hours in France in November 1998. For the purpose of the present study, only patients admitted within 24 hours of AMI and with one-year follow-up available were included. Of the 1838 patients included, 785 were > 70 years-old, of whom 225 (29%) had early reperfusion therapy with thrombolysis (N = 173) or primary PTCA (N = 52). Patients treated with early reperfusion had a baseline profile that differed substantially from that of patients treated conventionally: women (31% vs 50%, p < 0.001), admission within six hours of symptom onset (84% vs 55%, p < 0.001), history of systemic hypertension (48% vs 60%, p < 0.002), stroke (5% vs 11%, p < 0.01), peripheral arterial disease (8% vs 18%, p < 0.001); congestive heart failure (5% vs 20%, p < 0.001) or previous MI (12% vs 25%, p < 0.001), more anterior location of current MI (40% vs 28%, p < 0.002). Overall one-year Kaplan-Meier survival was 78% for patients with versus 64% for those without reperfusion therapy (p < 0.01). In patients with Q wave myocardial infarction, Cox multivariate analysis showed that reperfusion therapy was an independent predictor of survival (RR 0.66; 95% Confidence Interval: 0.45-0.96), along with age, anterior location and history of congestive heart failure. Therefore, data from this large "real life" registry indicate that reperfusion therapy with either thrombolysis or primary PTCA is associated with improved one-year survival in patients over 70 years of age.

[Hypertension management in patients with stable coronary disease]. / Prise en charge de l'hypertension chez le patient coronarien en cardiologie libérale.

AIMS: To assess hypertension control in patients with stable coronary disease in France. DESIGN: A cross sectional study was conducted in a representative sample of 794 cardiologists. PARTICIPANTS: The first 6 patients with coronary disease received at practitioner's office were included. MAIN OUTCOME MEASURES: Cardiovascular risk factors, antihypertensive drugs, cardiovascular history were reported. BP was measured. Patients considered as hypertensive by his cardiologist and receiving antihypertensive drugs were considered as hypertensive. Controlled hypertension was defined as a blood pressure < 140/90 mmHg. Uncontrolled hypertension was defined as blood pressure > or = 140/90 mmHg. Among the uncontrolled hypertensives we distinguished patients with isolated systolic hypertension: diastolic blood pressure < 90 mmHg and systolic blood pressure > or = 140 mmHg. RESULTS: All variables were available in 6,349 patients who form the basis of this report. 3,161 patients were hypertensive. Of them, 1,846 (58.4%) were uncontrolled hypertensives, whom 1,280 (69.3%) were uncontrolled on the basis of systolic blood pressure alone. CONCLUSION: This study conducted in a representative sample of French cardiologists indicates that there is a considerable potential to further reduce cardiovascular morbidity in patients in secondary prevention.

[Arterial hypertension management in patients with type 2 diabetes]. / Prise en charge de l'hypertension artérielle chez le diabétique de type 2.

AIMS: To assess hypertension management and blood pressure control in patients with type 2 diabetes in France. DESIGN: A cross sectional study was conducted in a representative sample of 410 diabetologists. The first 8 patients with type 2 diabetes, treated with oral antidiabetic agents and/or insulin, received at practitioner's office were included. Cardiovascular risk factors, antihypertensive drugs, cardiovascular history were reported. BP was measured. Patients considered as hypertensive by his practitioner and receiving antihypertensive drugs were considered as hypertensives. Controlled hypertension was defined as a blood pressure < 140/80 mmHg. Uncontrolled hypertension was defined as blood pressure > or = 140/80 mmHg. RESULTS: 4,930 diabetics were included in the study. Of them 3,085 (63%) patients were hypertensives. They were markedly older, overweight and reported most frequently complications. Only 723 (23%) patients presented with controlled hypertension. 40% of hypertensives were under monotherapy, 36% received 2 antihypertensive treatments and 24% received 3 treatments or more. ACE-inhibitors (49%), diuretics (41%), beta-blockers (35%), calcium channel blockers (33%), angiotensin II antagonists (19%) were the most commonly prescribed agents. Apart from hypertension, the main risk factors associated with each kind of prescription was micro or macroalbuminuria for ACE-I (OR = 1.5), coronary artery disease for beta-blockers and calcium channel blockers (OR = 3.8 and 2.5 respectively), and age for diuretics and angiotensin II antagonists (OR = 1.05 and 1.03). CONCLUSION: This study conducted in a representative sample of french diabetologists indicated that despite the large use of antihypertensive treatments only 23% of hypertensive diabetics were well controlled. Due to the high CV risk of these patients, hypertension management is of major importance.

Is "isolated home" hypertension as opposed to "isolated office" hypertension a sign of greater cardiovascular risk?

BACKGROUND: The SHEAF (Self-Measurement of Blood Pressure at Home in the Elderly: Assessment and Follow-up) study is an observational study (from February 1998 to early 2002) designed to determine whether home blood pressure (BP) measurement has a greater cardiovascular prognostic value than office BP measurement among elderly (> or =60 years) French patients with hypertension. The objective of this present work is to describe the baseline characteristics of the treated patients in the SHEAF study from February 1998 to March 1999, placing special emphasis on "isolated office" and "isolated home" hypertension. METHODS: Baseline office BP measurement was assessed using a mercury sphygmomanometer. Home BP measurement was performed over a 4-day period. A 140/90-mm Hg threshold was chosen to define office hypertension, and a 135/85-mm Hg threshold to define home hypertension. RESULTS: Of the 5211 hypertensive patients in the SHEAF study with a valid home BP measurement, 4939 received treatment with at least 1 antihypertensive drug. Patients with isolated office hypertension represented 12.5% of this population, while patients with isolated home hypertension represented 10.8%. The characteristics of the patients with isolated office hypertension were similar to those of patients with controlled hypertension. However, patients with isolated office hypertension had fewer previous cardiovascular complications. In contrast, rates of cardiovascular risk factors and history of cardiovascular disease in patients with isolated home hypertension resembled those in patients with uncontrolled hypertension. CONCLUSIONS: This retrospective analysis suggests that patients with isolated home hypertension belong to a high-risk subgroup. The 3-year follow-up of these patients will provide prospective data about the cardiovascular prognosis of these subgroups.

Injection molding of chondrocyte/alginate constructs in the shape of facial implants.

Over one million patients per year undergo some type of procedure involving cartilage reconstruction. Polymer hydrogels, such as alginate, have been shown to be effective carriers for chondrocytes in subcutaneous cartilage formation. The goal of our current study was to develop a method to create complex structures (nose bridge, chin, etc.) with good dimensional tolerance to form cartilage in specific shapes. Molds of facial implants were prepared using Silastic ERTV. Suspensions of chondrocytes in 2% alginate were gelled by mixing with CaSO(4) (0.2 g/mL) and injected into the molds. Constructs of various cell concentrations (10, 25, and 50 million/mL) were implanted in the dorsal aspect of nude mice and harvested at times up to 30 weeks. Analysis of implanted constructs indicated progressive cartilage formation with time. Proteoglycan and collagen constructs increased with time to approximately 60% that of native tissue. Equilibrium modulus likewise increased with time to 15% that of normal tissue, whereas hydraulic permeability decreased to 20 times that of native tissue. Implants seeded with greater concentrations of cells increased proteoglycan content and collagen content and equilibrium and decreased permeability. Production of shaped cartilage implants by this technique presents several advantages, including good dimensional tolerance, high sample-to-sample reproducibility, and high cell viability. This system may be useful in the large-scale production of precisely shaped cartilage implants.

Blood pressure levels, risk factors and antihypertensive treatments: lessons from the SHEAF study.

OBJECTIVES: The SHEAF study (Self measurement of blood pressure at Home in the Elderly: Assessment and Follow-up) is a 3-year prospective cohort study of French elderly (> or =60 years) hypertensive patients designed to assess whether home blood pressure (HBP) measurement provides additional prognostic information over office blood pressure (OBP) in terms of cardiovascular mortality and morbidity. The objective of the present work is to describe the baseline data of the population enrolled in the SHEAF study with special emphasis on blood pressure control in treated hypertensives. METHODS: During the 2-week initial inclusion phase, baseline demographics, cardiovascular risk factors, antihypertensive treatments as well as office and home blood pressure were recorded. Baseline OBP was assessed using a mercury sphygmomanometer (three consecutive measurements during two visits performed 2 weeks apart). HBP was performed over a 4-day period (three consecutive measurements in the morning and in the evening). RESULTS: A total of 4939 (95%) of the 5211 patients included in the SHEAF study were treated with at least one antihypertensive drug. Their ages ranged from 60 to 99 years (mean age 70 +/- 7 years); 49% were men, 12% had a previous history of coronary artery disease, 14% diabetes and 43% a treated dyslipidaemia. A total of 45% of the treated patients received a single antihypertensive drug, 34% two drugs, 21% three drugs or more. Overall 23% of treated hypertensives were normalised at the doctor's office (systolic BP <140 mm Hg and diastolic BP <90 mm Hg) and 27% at home (home systolic BP <135 mm Hg and home diastolic BP <85 mm Hg). Poor blood pressure control was associated with age, an increasing presence of diabetes and prescription of several antihypertensives. The proportion of subjects with controlled blood pressure decrease with age from 26% (60-69 years) to 21% (> or =80 years). Blood pressure control of diabetic patients was particularly poor as only 19% had an OBP <140/90 mm Hg and 6% a blood pressure <130/85 mm Hg. The percentage of patients with controlled OBP decreased from 26% when receiving a single antihypertensive drug to 11% when receiving four antihypertensives or more. CONCLUSION: In the SHEAF study, less than one-third of the patients had an OBP adequately controlled thus confirming previous studies performed in younger populations. Presence of associated cardiovascular risk factors including diabetes did not give rise to a better blood pressure control. When blood pressure control was assessed using HBP measurement similar results were found. As the beneficial effect of antihypertensive treatment has been particularly well established in the elderly, the data of this study underlines the need for a closer and more rigorous management of elderly hypertensives.

[The feasibility of at-home self-monitoring blood pressure in elderly hypertensive patients]. / Faisabilité de l'automesure tensionnelle à domicile chez le sujet hypertendu âgé.

The goal of the SHEAF study is to determine whether self blood pressure measurement (SBPM) has a better cardiovascular prognostic value than office blood pressure (OBP) among French elderly (> or = 60 y) hypertensive patients (pts) followed-up by general practitioners. Baseline SBPM was performed over a 4-day period: every day a series of 3 consecutive measurements was requested in the morning (8:00 am) and in the evening (8:00 pm), using a validated device OMRON 705 CP. Measurements performed out of predefined morning and evening time (outside the 4:00-12:00 am range or the 4:00-12:00 pm range) were discarded as well as aberrant values. Pts were included in the study only if they exhibited at least 15 valid measurements with at least 6 in the morning and 6 in the evening. 5,649 pts were selected. 186 pts were excluded for age < 60 years. Thus SBPM analysis was performed for 5,463 pts: 2,687 men (49%) and 2,776 women (51%) aged 70 +/- 7 years. Only 252 pts (5%) were excluded for non valid SBPM (207 pts < 15 measurements, 106 pts < 6 measurements in the morning and 205 pts < 6 measurements in the evening). 5,211 pts (95%) with valid SBPM were included. The distribution of pts according to the number of measurements performed is the following: [table: see text] The number of measurements performed in the morning is highly related to the number of measurements performed in the evening. None of the following variables is significantly associated with the poor compliance of measurement protocol: age, gender, CV history, CV risk factors, hypertension duration. In a large cohort of elderly hypertensive living in the community, SBPM is easily performed both in the morning and in the evening by most of the pts. If the SHEAF study demonstrates the prognostic value of SBPM, this would provide the basis for the use of this measurement method by a majority of elderly hypertensives.

Comparison of three blood pressure measurement methods for the evaluation of two antihypertensive drugs: feasibility, agreement, and reproducibility of blood pressure response.

Our objective was to compare three different methods of blood pressure measurement through the results of a controlled study aimed at comparing the antihypertensive effects of trandolapril and losartan. Two hundred and twenty-nine hypertensive patients were randomized in a double-blind parallel group study. After a 3-week placebo period, they received either 2 mg trandolapril or 50 mg losartan once daily for 6 weeks. At the end of both placebo and active treatment periods, three methods of blood pressure measurement were used: a) office blood pressure (three consecutive measurements); b) home self blood pressure measurements (SBPM), consisting of three consecutive measurements performed at home in the morning and in the evening for 7 consecutive days; and c) ambulatory blood pressure measurements (ABPM), 24-h BP recordings with three measurements per hour. Of the 229 patients, 199 (87%) performed at least 12 valid SBPM measurements during both placebo and treatment periods, whereas only 160 (70%) performed good quality 24-h ABPM recordings during both periods (P < .0001). One hundred-forty patients performed the three methods of measurement well. At baseline and with treatment, agreement between office measurements and ABPM or SBPM was weak. Conversely, there was a good agreement between ABPM and SBPM. The mean difference (SBP/DBP) between ABPM and SBPM was 4.6 +/- 10.4/3.5 +/- 7.1 at baseline and 3.5 +/- 10.0/4.0 +/- 7.0 at the end of the treatment period. The correlation between SBPM and ABPM expressed by the r coefficient and the P values were the following: at baseline 0.79/0.70 (< 0.001/< .0001), with active treatment 0.74/0.69 (0.0001/.0001). Hourly and 24-h reproducibility of blood pressure response was quantified by the standard deviation of BP response. Compared with office blood pressure, both global and hourly SBPM responses exhibited a lower standard deviation. Hourly reproducibility of SBPM response (10.8 mm Hg/6.9 mm Hg) was lower than hourly reproducibility of ABPM response (15.6 mm Hg/11.9 mm Hg). In conclusion, SBPM was easier to perform than ABPM. There was a good agreement between these two methods whereas concordance between SBPM or ABPM and office measurements was weak. As hourly reproducibility of SBPM response is better than reproducibility of both hourly ABPM and office BP response, SBPM seems to be the most appropriate method for evaluating residual antihypertensive effect.