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Rapid reduction of severe asymptomatic hypertension
Abstracts
actually decreased for 3 of the observers after review of the clinical information. Interobserver agreement on the etiologic diagnosis was generally poor and revealed no consistent pattern for development of guidelines to differentiate bacterial pneumonia. This study does not dispute the value of chest films in the detection of pneumonia in children, but does demonstrate their unreliability in differentiating bacterial from nonbacterial even when clinical laboratory information is pneumonia, [Peter Pruett, MD] available. Editor’s Note: Disagreement over findings is the soft underbelly of medicine. It is extremely common, typically about this severe, and almost never discussed in practice or in the literature. One wonders how much disagreement might have been demonstrated had some of these physicians (unknowingly) been given the same case twice.
0 OUTCOMES OF CARDIOPULMONARY RESUSCITATION IN THE ELDERLY. Murphy DJ, Murray AM, Robinson BE, et al. Ann Intern Med. 1989;111:199-205. This retrospective chart review measured the success rate of cardiopulmonary resuscitation (CPR) and the characteristics of elderly patients in whom it is most and least successful. The study included 503 elderly patients from 5 health-care institutions. The authors note that when “success” is defined as restoration of pulse and blood pressure, success rates reported by others vary from 26% to 63%. They defined success as being discharged alive from the hospital and found an overall success of 3.8%. In-hospital arrests did much better (6.5%) than out of hospital arrests (0.8%). Other factors positively correlating with success included: a previously independently functioning individual with normal mental status, a witnessed arrest, ventricular fibrillation or tachycardia that responded in less than 5 minutes to cardiac massage, and patients who regained consciousness promptly. Only 2 patients survived out-of-hospital CPR, both under unusual circumstances (one was just entering the emergency department, and the other didn’t need massage). The authors conclude that CPR is futile for elderly patients who arrest outside the hospital, or present with asystole, electromechanical dissociation, or agonal rhythms, or who sustain unwitnessed arrest. Although the study had insufficient power to distinguish between the effect of age and that of concomitant disease, the authors noted that elderly patients with significant organ system impairment had a very poor [Peter Pruett, MD] prognosis after CPR. Editor’s Note: Knowledge of the poor outcome following CPR may make do-not-resuscitate decisions easier for the family, but application of these results to the emergency department setting where premorbid condition is frequently unknown will require scientific confirmation and societal consensus.
? ?RAPID REDUCTION OF SEVERE ASYMPTOMATIC HYPERTENSION. Zeller KR, Kuhnert LV, Matthews C. Arch Intern Med. 1989;146:2186-9. Rapid reduction of severe asymptomatic hypertension has become common emergency department practice. This prospective randomized study of 74 patients with asymptomatic severe (diastolic pressures 116139 mmHg) hypertension com-
525
pares the effects of oral clonidine loading with the initiation of maintenance therapy without loading. Patients were randomized to 3 treatments: hourly doses of clonidine (up to 4 hourly doses) and chlorthalidone followed by maintenance therapy; an initial dose of clonidine followed by hourly placebo and maintenance therapy; or maintenance therapy alone. Groups 1 and 2 showed no significant difference in the time required to reduce blood pressure to what was considered to be acceptable levels. Although the time to reduction was not measured in Group 3, after 24 hours there was no significant difference in blood pressure between groups 1, 2, and 3. Forty-four patients available for follow-up at one week demonstrated adequate control of blood pressure without significant difference between the three groups. The authors question the need to acutely lower blood pressure in asymptomatic patients with severe hypertension presenting to an emergency department. [HL Skaggs Jr, J McGoldrick] Editor’s Note: Those of us who are old enough will recall that these patients never used to be treated acutely because no rapid acting agents were available orally. The rationale for treating asymptomatic patients by anything other than simply restarting their maintenance regimen is unclear; it may make the doctor feel better, but the benefit to the patient is questionable.
0 SEPARATION OF AFTERLOAD REDUCTION AND A DIRECT BENEFICIAL CARDIAC EFFECT OF NIFEDIPINE IN CONGESTIVE CARDIOMYOPATHY. Percy RF, Bass TA, Conetea DA, et al. Clin Cardiol. 1989;12: 4354. This study sought to observe and measure separately the afterload-reducing effect of nifedipine and its specific cardiac effect on left ventricular (LV) diastolic function in patients with idiopathic congestive cardiomyopathy. Ten patients with ejection fractions of 25% to 50% had hemodynamic assessment (by Swan-Ganz catheter) and echocardiography before, at 30 minutes, and at 2 and 6 hours after 10 mg of sublingual nifedipine. Baseline values reflected abnormal LV function with elevated wedge pressure and low cardiac index. At 30 minutes and at 2 hours, the cardiac index was significantly elevated and wedge pressure was lowered. Echocardiography revealed a significant increase in early diastolic filling at 2 hours. By 6 hours, all measurements except wedge pressure had returned to baseline. No patients had significant diuresis. The LV end-diastolic area did not change with nifedipine. The decline in LV end-diastolic pressure at six hours, in the absence of change in LV end-diastolic volume, afterload, pulmonary vascular resistance, or volume status, suggests improved LV compliance during the slow filling phase of diastole. The authors conclude that despite the negative inotropic effect of nifedipine, the net effect on congestive heart failure may be beneficial. [Laurie Vanderkrol, MD]
0 A PROSPECTIVE RANDOMIZED DOUBLE-BLIND STUDY TO EVALUATE THE EFFECT OF DEXAMETIIASONE IN ACUTE LARYNGOTRACIIEITIS. Super DM, Cartelli NA, Brooks LJ, et al. J Pediatr. 1989;115: 323-9. This prospective double-blind, placebo-controlled random
actually decreased for 3 of the observers after review of the clinical information. Interobserver agreement on the etiologic diagnosis was generally poor and revealed no consistent pattern for development of guidelines to differentiate bacterial pneumonia. This study does not dispute the value of chest films in the detection of pneumonia in children, but does demonstrate their unreliability in differentiating bacterial from nonbacterial even when clinical laboratory information is pneumonia, [Peter Pruett, MD] available. Editor’s Note: Disagreement over findings is the soft underbelly of medicine. It is extremely common, typically about this severe, and almost never discussed in practice or in the literature. One wonders how much disagreement might have been demonstrated had some of these physicians (unknowingly) been given the same case twice.
0 OUTCOMES OF CARDIOPULMONARY RESUSCITATION IN THE ELDERLY. Murphy DJ, Murray AM, Robinson BE, et al. Ann Intern Med. 1989;111:199-205. This retrospective chart review measured the success rate of cardiopulmonary resuscitation (CPR) and the characteristics of elderly patients in whom it is most and least successful. The study included 503 elderly patients from 5 health-care institutions. The authors note that when “success” is defined as restoration of pulse and blood pressure, success rates reported by others vary from 26% to 63%. They defined success as being discharged alive from the hospital and found an overall success of 3.8%. In-hospital arrests did much better (6.5%) than out of hospital arrests (0.8%). Other factors positively correlating with success included: a previously independently functioning individual with normal mental status, a witnessed arrest, ventricular fibrillation or tachycardia that responded in less than 5 minutes to cardiac massage, and patients who regained consciousness promptly. Only 2 patients survived out-of-hospital CPR, both under unusual circumstances (one was just entering the emergency department, and the other didn’t need massage). The authors conclude that CPR is futile for elderly patients who arrest outside the hospital, or present with asystole, electromechanical dissociation, or agonal rhythms, or who sustain unwitnessed arrest. Although the study had insufficient power to distinguish between the effect of age and that of concomitant disease, the authors noted that elderly patients with significant organ system impairment had a very poor [Peter Pruett, MD] prognosis after CPR. Editor’s Note: Knowledge of the poor outcome following CPR may make do-not-resuscitate decisions easier for the family, but application of these results to the emergency department setting where premorbid condition is frequently unknown will require scientific confirmation and societal consensus.
? ?RAPID REDUCTION OF SEVERE ASYMPTOMATIC HYPERTENSION. Zeller KR, Kuhnert LV, Matthews C. Arch Intern Med. 1989;146:2186-9. Rapid reduction of severe asymptomatic hypertension has become common emergency department practice. This prospective randomized study of 74 patients with asymptomatic severe (diastolic pressures 116139 mmHg) hypertension com-
525
pares the effects of oral clonidine loading with the initiation of maintenance therapy without loading. Patients were randomized to 3 treatments: hourly doses of clonidine (up to 4 hourly doses) and chlorthalidone followed by maintenance therapy; an initial dose of clonidine followed by hourly placebo and maintenance therapy; or maintenance therapy alone. Groups 1 and 2 showed no significant difference in the time required to reduce blood pressure to what was considered to be acceptable levels. Although the time to reduction was not measured in Group 3, after 24 hours there was no significant difference in blood pressure between groups 1, 2, and 3. Forty-four patients available for follow-up at one week demonstrated adequate control of blood pressure without significant difference between the three groups. The authors question the need to acutely lower blood pressure in asymptomatic patients with severe hypertension presenting to an emergency department. [HL Skaggs Jr, J McGoldrick] Editor’s Note: Those of us who are old enough will recall that these patients never used to be treated acutely because no rapid acting agents were available orally. The rationale for treating asymptomatic patients by anything other than simply restarting their maintenance regimen is unclear; it may make the doctor feel better, but the benefit to the patient is questionable.
0 SEPARATION OF AFTERLOAD REDUCTION AND A DIRECT BENEFICIAL CARDIAC EFFECT OF NIFEDIPINE IN CONGESTIVE CARDIOMYOPATHY. Percy RF, Bass TA, Conetea DA, et al. Clin Cardiol. 1989;12: 4354. This study sought to observe and measure separately the afterload-reducing effect of nifedipine and its specific cardiac effect on left ventricular (LV) diastolic function in patients with idiopathic congestive cardiomyopathy. Ten patients with ejection fractions of 25% to 50% had hemodynamic assessment (by Swan-Ganz catheter) and echocardiography before, at 30 minutes, and at 2 and 6 hours after 10 mg of sublingual nifedipine. Baseline values reflected abnormal LV function with elevated wedge pressure and low cardiac index. At 30 minutes and at 2 hours, the cardiac index was significantly elevated and wedge pressure was lowered. Echocardiography revealed a significant increase in early diastolic filling at 2 hours. By 6 hours, all measurements except wedge pressure had returned to baseline. No patients had significant diuresis. The LV end-diastolic area did not change with nifedipine. The decline in LV end-diastolic pressure at six hours, in the absence of change in LV end-diastolic volume, afterload, pulmonary vascular resistance, or volume status, suggests improved LV compliance during the slow filling phase of diastole. The authors conclude that despite the negative inotropic effect of nifedipine, the net effect on congestive heart failure may be beneficial. [Laurie Vanderkrol, MD]
0 A PROSPECTIVE RANDOMIZED DOUBLE-BLIND STUDY TO EVALUATE THE EFFECT OF DEXAMETIIASONE IN ACUTE LARYNGOTRACIIEITIS. Super DM, Cartelli NA, Brooks LJ, et al. J Pediatr. 1989;115: 323-9. This prospective double-blind, placebo-controlled random