Cardiology

Hypertension remains one of the most important modifiable risk factors for the prevention of cardiovascular (CV) events. According to a population-based study, 25% of CV events (CV death, heart disease, coronary revascularization, stroke, or heart failure) are attributable to hypertension.¹ Recent guidelines have emphasized the importance of accurate blood pressure (BP) measurement in facilitating appropriate hypertension diagnosis and management.^2-4

Currently, there are different BP measurement methods endorsed by practice guidelines. These include conventional in-office measurement, 24-hour ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), and automated office BP (AOBP) measurement.^2-4 AOBP device protocols vary but generally involve devices automatically taking multiple BP measurements while the patient is unattended. These measurements are then presented as a single averaged reading, with individual BP values available for review by the clinician.

Researchers have found that AOBP measurements have a greater association with ABPM values and can mitigate the white coat effect observed in a substantial proportion of patients during in-clinic BP measurement.⁵ A meta-analysis found that the use of AOBP was associated with a 10.5 mm Hg reduction in systolic BP (SBP) compared with traditional office-based BP assessments.⁵ Similarly, a separate meta-analysis found that AOBP SBP measures were on average 14.5 mm Hg lower than routine office or research setting values.⁶ In addition, CV risk outcomes data support the use of AOBP to screen and manage patients with hypertension. The Cardiovascular Health Awareness Program (CHAP) study used AOBP values to determine the risk for CV events (myocardial infarction, congestive heart failure, and stroke) in community-based patients aged ≥ 65 years.⁷ The study showed a significantly higher risk of CV events in patients with an SBP of 135 to 144 mm Hg and a diastolic BP (DBP) of 80 to 89 mm Hg. Therefore, the CHAP study researchers suggested an AOBP target of < 135/85 mm Hg to decrease the risk of CV events.⁷The landmark SPRINT trial, which was a major contributor to the development of BP target recommendations in guidelines, utilized AOBP to classify hypertension and guide management.^2-4,8 SPRINT ultimately showed that intensive BP-lowering treatment (to SBP < 120 mm Hg) was associated with a 25% reduction in major CV events and a 27% reduction in all-cause mortality.⁸ Other evaluations found a close association between AOBP values and left ventricular mass index and carotid artery wall thickness as surrogate markers for end-organ damage.^9,10 These data show AOBP as a reliable method to guide antihypertensive therapy interventions in the clinical setting.

Considering these proposed advantages, the 2017 Canadian guidelines for hypertension management recommend AOBP as the preferred method for clinic-based BP measurement, and the 2018 European Society of Cardiology/European Society of Hypertension blood pressure guidelines recommend the use of AOBP when feasible.^3,4 The 2017 American College of Cardiology/American Heart Association Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults also discusses AOBP as a method to minimize potential confounders in BP values.²

This study evaluated the difference between AOBP and conventional in-office BP measurements obtained during cardiology clinic visits at the West Palm Beach Veterans Affairs Medical Center (WPBVAMC).

METHODS

A retrospective review of AOBP measurements was performed at the WPBVAMC cardiology clinic between May 26, 2017, and February 19, 2019. These AOBP measurements were taken at the discretion of a nurse or other clinician after initial, conventional BP measurements had been taken as part of clinic check-in procedures. No formal protocols dictated the use or timing of AOBP measurements. Similarly, the AOBP results were factored into clinical care decisions.

Clinicians at the cardiology clinic used AOBP averages that were derived using the BpTRU BPM-100 (BpTRU Medical Devices) meter, which averaged 5 BP readings taken at 1-minute intervals. Clinicians selected cuff size based on manufacturer recommendations. The testing was done with the patient seated alone in either a nursing triage area or a clinic office.

Data collected during the retrospective review included the clinician associated with the visit, the patient’s physical location and accompaniment status during AOBP measurement, conventionally measured BP and heart rates, and AOBP-derived BP and heart rate averages. Differences in BP values were compared with the paired t test, while binary comparisons were conducted through the McNemar test. Data collection and analysis were performed using Microsoft Excel.

During data collection, all information was stored in a secure drive accessible only to the investigators. The project was approved by the West Palm Beach Veterans Affairs Healthcare System Research and Development Committee as a nonresearch activity in accordance with Veterans Health Administration Handbook 1058.05; thus, institutional review board approval was not required.

RESULTS

Ninety-five nonconsecutive patients were included in the analysis. AOBP measurements were taken with the patient sitting alone in either a clinic office (n = 83) or nursing triage area (n = 12). Most patients were coming in for follow-up appointments; 13 patients (14%) had appointments related to a 24-hour ABPM session.

The mean SBP and DBP values were lower for the AOBP measurements vs the conventional BP measurements (mean SBP difference, 14.6 mm Hg; P < .001; mean DBP difference, 3.5 mm Hg; P = .0002) (Table). There were no appreciable differences in heart rates. The white coat effect was suggested based on an SBP reduction of > 20 mm Hg from conventional to AOBP measurements in 22 patients (23%), a DBP reduction of > 10 mm Hg in 21 patients (22%), and a reduction in both values in 8 patients (8%).

A controlled BP (< 130/80 mm Hg) was more common in the AOBP group than in the conventional group (22% vs 7%, respectively; P =.001).² Review of conventional BP measurements indicated that 11 patients had systolic readings ≥ 180 mm Hg, 2 had diastolic readings ≥ 110 mm Hg, and 1 had a reading that was ≥ 180/110 mm Hg. AOBP measurements indicated that these 14 patients had SBP readings < 180 mm Hg and DBP readings < 110 mm Hg. The use of AOBP measurements may have mitigated unnecessary emergency room visits for these patients.

On review of clinic notes and actions associated with episodes of AOBP testing during routine follow-up clinic appointments, AOBP was determined to be useful with regard to clinical decision-making for 65 (79%) patients. Impacts of AOBP inclusion vs conventional BP assessments included clinician notation of AOBP, support for making changes that would have been considered based on conventional BP assessment. AOBP results gave support to forgoing a therapeutic intervention (ie, therapy addition or intensification) that may have been pursued based on conventional BP measurements in 25 of 82 patients (30%). These data suggest that AOBP readings can be useful and actionable by clinicians.

DISCUSSION

The findings of this study add to the growing evidence regarding AOBP use, application, and advantages in clinical practice. In this evaluation, the mean difference in SBP and DBP was 14.6 mm Hg and 3.5 mm Hg, respectively, from the conventional office measurements to the AOBP measurements. This difference is similar to that reported by the CAMBO trial and other evaluations, where the use of AOBP measurements corresponded to a reduction in SBP of between 10 and 20 mm Hg vs conventional measures.^5,11-18

These findings showed a significantly higher percentage of controlled BP values (< 130/80 mm Hg) with AOBP values compared with conventional office measurements. The data supported the decision to defer antihypertensive therapy intervention in 30% of patients. Without AOBP data, patients may have been classified as uncontrolled, prompting therapy addition or intensification that could increase the risk of adverse events. Additionally, 14 patients would have met the criteria for hypertensive urgency under the guidelines at that time.² With the use of AOBP readings, none of these patients were identified as having a hypertensive urgency, and they avoided an acute care referral or urgent intervention.

The discrepancy between AOBP and conventional office BP measurements suggested a white coat effect based on SBP and DBP readings in 22 (23%) and 21 (22%) patients, respectively. Practice guidelines recommend ABPM to mitigate a potential white coat effect.^2-4 However, ABPM can be inconvenient for patients, as they need to travel to and from the clinic for fitting and removal (assuming that a facility has the device available for patient use). In addition, some patients may find it uncomfortable. Based on the correlation between AOBP and awake ABPM values, AOBP represents a feasible way to identify a white coat effect.

AOBP monitoring does not appear to be affected by the type of practice setting, as it has been evaluated in a variety of locations, including community-based pharmacies, primary care offices, and waiting rooms.^12,19-22 However, potential AOBP implementation challenges may include office space constraints, clinician perception that it will delay workflow, and device cost. Costs associated with an AOBP meter vary widely based on device and procurement source, but have been estimated to range from $650 to > $2000.²³ Published reports have described how to overcome AOBP implementation barriers.^24,25

Limitations

The results of this evaluation should be interpreted cautiously due to several limitations. First, the retrospective study was conducted at a single clinic that may not be representative of other Veterans Health Administration or community-based populations. In addition, patient data such as age, sex, and body mass index were not available. AOBP measurements were obtained at the discretion of the clinician and not according to a prespecified protocol.

Conclusions

This analysis showed AOBP measurement leads to a greater percentage of controlled BP values compared with conventional office BP measurement, positioning it as a way to reduce BP misclassification, prevent potentially unnecessary therapeutic interventions, and mitigate the white coat effect.

Hypertension remains one of the most important modifiable risk factors for the prevention of cardiovascular (CV) events. According to a population-based study, 25% of CV events (CV death, heart disease, coronary revascularization, stroke, or heart failure) are attributable to hypertension.¹ Recent guidelines have emphasized the importance of accurate blood pressure (BP) measurement in facilitating appropriate hypertension diagnosis and management.^2-4

Currently, there are different BP measurement methods endorsed by practice guidelines. These include conventional in-office measurement, 24-hour ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), and automated office BP (AOBP) measurement.^2-4 AOBP device protocols vary but generally involve devices automatically taking multiple BP measurements while the patient is unattended. These measurements are then presented as a single averaged reading, with individual BP values available for review by the clinician.

Researchers have found that AOBP measurements have a greater association with ABPM values and can mitigate the white coat effect observed in a substantial proportion of patients during in-clinic BP measurement.⁵ A meta-analysis found that the use of AOBP was associated with a 10.5 mm Hg reduction in systolic BP (SBP) compared with traditional office-based BP assessments.⁵ Similarly, a separate meta-analysis found that AOBP SBP measures were on average 14.5 mm Hg lower than routine office or research setting values.⁶ In addition, CV risk outcomes data support the use of AOBP to screen and manage patients with hypertension. The Cardiovascular Health Awareness Program (CHAP) study used AOBP values to determine the risk for CV events (myocardial infarction, congestive heart failure, and stroke) in community-based patients aged ≥ 65 years.⁷ The study showed a significantly higher risk of CV events in patients with an SBP of 135 to 144 mm Hg and a diastolic BP (DBP) of 80 to 89 mm Hg. Therefore, the CHAP study researchers suggested an AOBP target of < 135/85 mm Hg to decrease the risk of CV events.⁷The landmark SPRINT trial, which was a major contributor to the development of BP target recommendations in guidelines, utilized AOBP to classify hypertension and guide management.^2-4,8 SPRINT ultimately showed that intensive BP-lowering treatment (to SBP < 120 mm Hg) was associated with a 25% reduction in major CV events and a 27% reduction in all-cause mortality.⁸ Other evaluations found a close association between AOBP values and left ventricular mass index and carotid artery wall thickness as surrogate markers for end-organ damage.^9,10 These data show AOBP as a reliable method to guide antihypertensive therapy interventions in the clinical setting.

Considering these proposed advantages, the 2017 Canadian guidelines for hypertension management recommend AOBP as the preferred method for clinic-based BP measurement, and the 2018 European Society of Cardiology/European Society of Hypertension blood pressure guidelines recommend the use of AOBP when feasible.^3,4 The 2017 American College of Cardiology/American Heart Association Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults also discusses AOBP as a method to minimize potential confounders in BP values.²

This study evaluated the difference between AOBP and conventional in-office BP measurements obtained during cardiology clinic visits at the West Palm Beach Veterans Affairs Medical Center (WPBVAMC).

METHODS

A retrospective review of AOBP measurements was performed at the WPBVAMC cardiology clinic between May 26, 2017, and February 19, 2019. These AOBP measurements were taken at the discretion of a nurse or other clinician after initial, conventional BP measurements had been taken as part of clinic check-in procedures. No formal protocols dictated the use or timing of AOBP measurements. Similarly, the AOBP results were factored into clinical care decisions.

Clinicians at the cardiology clinic used AOBP averages that were derived using the BpTRU BPM-100 (BpTRU Medical Devices) meter, which averaged 5 BP readings taken at 1-minute intervals. Clinicians selected cuff size based on manufacturer recommendations. The testing was done with the patient seated alone in either a nursing triage area or a clinic office.

Data collected during the retrospective review included the clinician associated with the visit, the patient’s physical location and accompaniment status during AOBP measurement, conventionally measured BP and heart rates, and AOBP-derived BP and heart rate averages. Differences in BP values were compared with the paired t test, while binary comparisons were conducted through the McNemar test. Data collection and analysis were performed using Microsoft Excel.

During data collection, all information was stored in a secure drive accessible only to the investigators. The project was approved by the West Palm Beach Veterans Affairs Healthcare System Research and Development Committee as a nonresearch activity in accordance with Veterans Health Administration Handbook 1058.05; thus, institutional review board approval was not required.

RESULTS

Ninety-five nonconsecutive patients were included in the analysis. AOBP measurements were taken with the patient sitting alone in either a clinic office (n = 83) or nursing triage area (n = 12). Most patients were coming in for follow-up appointments; 13 patients (14%) had appointments related to a 24-hour ABPM session.

The mean SBP and DBP values were lower for the AOBP measurements vs the conventional BP measurements (mean SBP difference, 14.6 mm Hg; P < .001; mean DBP difference, 3.5 mm Hg; P = .0002) (Table). There were no appreciable differences in heart rates. The white coat effect was suggested based on an SBP reduction of > 20 mm Hg from conventional to AOBP measurements in 22 patients (23%), a DBP reduction of > 10 mm Hg in 21 patients (22%), and a reduction in both values in 8 patients (8%).

A controlled BP (< 130/80 mm Hg) was more common in the AOBP group than in the conventional group (22% vs 7%, respectively; P =.001).² Review of conventional BP measurements indicated that 11 patients had systolic readings ≥ 180 mm Hg, 2 had diastolic readings ≥ 110 mm Hg, and 1 had a reading that was ≥ 180/110 mm Hg. AOBP measurements indicated that these 14 patients had SBP readings < 180 mm Hg and DBP readings < 110 mm Hg. The use of AOBP measurements may have mitigated unnecessary emergency room visits for these patients.

On review of clinic notes and actions associated with episodes of AOBP testing during routine follow-up clinic appointments, AOBP was determined to be useful with regard to clinical decision-making for 65 (79%) patients. Impacts of AOBP inclusion vs conventional BP assessments included clinician notation of AOBP, support for making changes that would have been considered based on conventional BP assessment. AOBP results gave support to forgoing a therapeutic intervention (ie, therapy addition or intensification) that may have been pursued based on conventional BP measurements in 25 of 82 patients (30%). These data suggest that AOBP readings can be useful and actionable by clinicians.

DISCUSSION

The findings of this study add to the growing evidence regarding AOBP use, application, and advantages in clinical practice. In this evaluation, the mean difference in SBP and DBP was 14.6 mm Hg and 3.5 mm Hg, respectively, from the conventional office measurements to the AOBP measurements. This difference is similar to that reported by the CAMBO trial and other evaluations, where the use of AOBP measurements corresponded to a reduction in SBP of between 10 and 20 mm Hg vs conventional measures.^5,11-18

These findings showed a significantly higher percentage of controlled BP values (< 130/80 mm Hg) with AOBP values compared with conventional office measurements. The data supported the decision to defer antihypertensive therapy intervention in 30% of patients. Without AOBP data, patients may have been classified as uncontrolled, prompting therapy addition or intensification that could increase the risk of adverse events. Additionally, 14 patients would have met the criteria for hypertensive urgency under the guidelines at that time.² With the use of AOBP readings, none of these patients were identified as having a hypertensive urgency, and they avoided an acute care referral or urgent intervention.

The discrepancy between AOBP and conventional office BP measurements suggested a white coat effect based on SBP and DBP readings in 22 (23%) and 21 (22%) patients, respectively. Practice guidelines recommend ABPM to mitigate a potential white coat effect.^2-4 However, ABPM can be inconvenient for patients, as they need to travel to and from the clinic for fitting and removal (assuming that a facility has the device available for patient use). In addition, some patients may find it uncomfortable. Based on the correlation between AOBP and awake ABPM values, AOBP represents a feasible way to identify a white coat effect.

AOBP monitoring does not appear to be affected by the type of practice setting, as it has been evaluated in a variety of locations, including community-based pharmacies, primary care offices, and waiting rooms.^12,19-22 However, potential AOBP implementation challenges may include office space constraints, clinician perception that it will delay workflow, and device cost. Costs associated with an AOBP meter vary widely based on device and procurement source, but have been estimated to range from $650 to > $2000.²³ Published reports have described how to overcome AOBP implementation barriers.^24,25

Limitations

The results of this evaluation should be interpreted cautiously due to several limitations. First, the retrospective study was conducted at a single clinic that may not be representative of other Veterans Health Administration or community-based populations. In addition, patient data such as age, sex, and body mass index were not available. AOBP measurements were obtained at the discretion of the clinician and not according to a prespecified protocol.

Conclusions

This analysis showed AOBP measurement leads to a greater percentage of controlled BP values compared with conventional office BP measurement, positioning it as a way to reduce BP misclassification, prevent potentially unnecessary therapeutic interventions, and mitigate the white coat effect.

Hypertension remains one of the most important modifiable risk factors for the prevention of cardiovascular (CV) events. According to a population-based study, 25% of CV events (CV death, heart disease, coronary revascularization, stroke, or heart failure) are attributable to hypertension.¹ Recent guidelines have emphasized the importance of accurate blood pressure (BP) measurement in facilitating appropriate hypertension diagnosis and management.^2-4

Currently, there are different BP measurement methods endorsed by practice guidelines. These include conventional in-office measurement, 24-hour ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), and automated office BP (AOBP) measurement.^2-4 AOBP device protocols vary but generally involve devices automatically taking multiple BP measurements while the patient is unattended. These measurements are then presented as a single averaged reading, with individual BP values available for review by the clinician.

Researchers have found that AOBP measurements have a greater association with ABPM values and can mitigate the white coat effect observed in a substantial proportion of patients during in-clinic BP measurement.⁵ A meta-analysis found that the use of AOBP was associated with a 10.5 mm Hg reduction in systolic BP (SBP) compared with traditional office-based BP assessments.⁵ Similarly, a separate meta-analysis found that AOBP SBP measures were on average 14.5 mm Hg lower than routine office or research setting values.⁶ In addition, CV risk outcomes data support the use of AOBP to screen and manage patients with hypertension. The Cardiovascular Health Awareness Program (CHAP) study used AOBP values to determine the risk for CV events (myocardial infarction, congestive heart failure, and stroke) in community-based patients aged ≥ 65 years.⁷ The study showed a significantly higher risk of CV events in patients with an SBP of 135 to 144 mm Hg and a diastolic BP (DBP) of 80 to 89 mm Hg. Therefore, the CHAP study researchers suggested an AOBP target of < 135/85 mm Hg to decrease the risk of CV events.⁷The landmark SPRINT trial, which was a major contributor to the development of BP target recommendations in guidelines, utilized AOBP to classify hypertension and guide management.^2-4,8 SPRINT ultimately showed that intensive BP-lowering treatment (to SBP < 120 mm Hg) was associated with a 25% reduction in major CV events and a 27% reduction in all-cause mortality.⁸ Other evaluations found a close association between AOBP values and left ventricular mass index and carotid artery wall thickness as surrogate markers for end-organ damage.^9,10 These data show AOBP as a reliable method to guide antihypertensive therapy interventions in the clinical setting.

Considering these proposed advantages, the 2017 Canadian guidelines for hypertension management recommend AOBP as the preferred method for clinic-based BP measurement, and the 2018 European Society of Cardiology/European Society of Hypertension blood pressure guidelines recommend the use of AOBP when feasible.^3,4 The 2017 American College of Cardiology/American Heart Association Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults also discusses AOBP as a method to minimize potential confounders in BP values.²

This study evaluated the difference between AOBP and conventional in-office BP measurements obtained during cardiology clinic visits at the West Palm Beach Veterans Affairs Medical Center (WPBVAMC).

METHODS

A retrospective review of AOBP measurements was performed at the WPBVAMC cardiology clinic between May 26, 2017, and February 19, 2019. These AOBP measurements were taken at the discretion of a nurse or other clinician after initial, conventional BP measurements had been taken as part of clinic check-in procedures. No formal protocols dictated the use or timing of AOBP measurements. Similarly, the AOBP results were factored into clinical care decisions.

Clinicians at the cardiology clinic used AOBP averages that were derived using the BpTRU BPM-100 (BpTRU Medical Devices) meter, which averaged 5 BP readings taken at 1-minute intervals. Clinicians selected cuff size based on manufacturer recommendations. The testing was done with the patient seated alone in either a nursing triage area or a clinic office.

Data collected during the retrospective review included the clinician associated with the visit, the patient’s physical location and accompaniment status during AOBP measurement, conventionally measured BP and heart rates, and AOBP-derived BP and heart rate averages. Differences in BP values were compared with the paired t test, while binary comparisons were conducted through the McNemar test. Data collection and analysis were performed using Microsoft Excel.

During data collection, all information was stored in a secure drive accessible only to the investigators. The project was approved by the West Palm Beach Veterans Affairs Healthcare System Research and Development Committee as a nonresearch activity in accordance with Veterans Health Administration Handbook 1058.05; thus, institutional review board approval was not required.

RESULTS

Ninety-five nonconsecutive patients were included in the analysis. AOBP measurements were taken with the patient sitting alone in either a clinic office (n = 83) or nursing triage area (n = 12). Most patients were coming in for follow-up appointments; 13 patients (14%) had appointments related to a 24-hour ABPM session.

The mean SBP and DBP values were lower for the AOBP measurements vs the conventional BP measurements (mean SBP difference, 14.6 mm Hg; P < .001; mean DBP difference, 3.5 mm Hg; P = .0002) (Table). There were no appreciable differences in heart rates. The white coat effect was suggested based on an SBP reduction of > 20 mm Hg from conventional to AOBP measurements in 22 patients (23%), a DBP reduction of > 10 mm Hg in 21 patients (22%), and a reduction in both values in 8 patients (8%).

A controlled BP (< 130/80 mm Hg) was more common in the AOBP group than in the conventional group (22% vs 7%, respectively; P =.001).² Review of conventional BP measurements indicated that 11 patients had systolic readings ≥ 180 mm Hg, 2 had diastolic readings ≥ 110 mm Hg, and 1 had a reading that was ≥ 180/110 mm Hg. AOBP measurements indicated that these 14 patients had SBP readings < 180 mm Hg and DBP readings < 110 mm Hg. The use of AOBP measurements may have mitigated unnecessary emergency room visits for these patients.

On review of clinic notes and actions associated with episodes of AOBP testing during routine follow-up clinic appointments, AOBP was determined to be useful with regard to clinical decision-making for 65 (79%) patients. Impacts of AOBP inclusion vs conventional BP assessments included clinician notation of AOBP, support for making changes that would have been considered based on conventional BP assessment. AOBP results gave support to forgoing a therapeutic intervention (ie, therapy addition or intensification) that may have been pursued based on conventional BP measurements in 25 of 82 patients (30%). These data suggest that AOBP readings can be useful and actionable by clinicians.

DISCUSSION

The findings of this study add to the growing evidence regarding AOBP use, application, and advantages in clinical practice. In this evaluation, the mean difference in SBP and DBP was 14.6 mm Hg and 3.5 mm Hg, respectively, from the conventional office measurements to the AOBP measurements. This difference is similar to that reported by the CAMBO trial and other evaluations, where the use of AOBP measurements corresponded to a reduction in SBP of between 10 and 20 mm Hg vs conventional measures.^5,11-18

These findings showed a significantly higher percentage of controlled BP values (< 130/80 mm Hg) with AOBP values compared with conventional office measurements. The data supported the decision to defer antihypertensive therapy intervention in 30% of patients. Without AOBP data, patients may have been classified as uncontrolled, prompting therapy addition or intensification that could increase the risk of adverse events. Additionally, 14 patients would have met the criteria for hypertensive urgency under the guidelines at that time.² With the use of AOBP readings, none of these patients were identified as having a hypertensive urgency, and they avoided an acute care referral or urgent intervention.

The discrepancy between AOBP and conventional office BP measurements suggested a white coat effect based on SBP and DBP readings in 22 (23%) and 21 (22%) patients, respectively. Practice guidelines recommend ABPM to mitigate a potential white coat effect.^2-4 However, ABPM can be inconvenient for patients, as they need to travel to and from the clinic for fitting and removal (assuming that a facility has the device available for patient use). In addition, some patients may find it uncomfortable. Based on the correlation between AOBP and awake ABPM values, AOBP represents a feasible way to identify a white coat effect.

AOBP monitoring does not appear to be affected by the type of practice setting, as it has been evaluated in a variety of locations, including community-based pharmacies, primary care offices, and waiting rooms.^12,19-22 However, potential AOBP implementation challenges may include office space constraints, clinician perception that it will delay workflow, and device cost. Costs associated with an AOBP meter vary widely based on device and procurement source, but have been estimated to range from $650 to > $2000.²³ Published reports have described how to overcome AOBP implementation barriers.^24,25

Limitations

The results of this evaluation should be interpreted cautiously due to several limitations. First, the retrospective study was conducted at a single clinic that may not be representative of other Veterans Health Administration or community-based populations. In addition, patient data such as age, sex, and body mass index were not available. AOBP measurements were obtained at the discretion of the clinician and not according to a prespecified protocol.

Conclusions

This analysis showed AOBP measurement leads to a greater percentage of controlled BP values compared with conventional office BP measurement, positioning it as a way to reduce BP misclassification, prevent potentially unnecessary therapeutic interventions, and mitigate the white coat effect.

Abdominal aortic aneurysm (AAA) is a public health threat, with a global prevalence of 4.8% and a prevalence in males that increases with age, from 1.3% between ages 45 and 54 years to 12.5% between ages 75 and 84 years.¹ AAA is often asymptomatic until it ruptures and can become life-threatening, with mortality rates near 90% in the event of rupture with survival rates of about 50% to 70% for individuals with rupture who require urgent surgical intervention.^2,3 Males experience AAA at 4 times the rate of females.⁴

Previous research has found that the awareness of having an AAA causes anxiety that some have described as “living with a ticking time bomb.”⁵ Others reported worries and concerns about life’s fragility and mortality due to an AAA diagnosis.⁶ However, the psychological impact on the individuals’ quality of life (QoL) remains unclear, especially for individuals with a small AAA (< 5.5 cm).⁷ Factors such as age, male sex, smoking, family history, hypertension, carotid artery disease, and hypercholesterolemia have been strongly associated with increased growth rate and the risk of small AAA ruptures.^8,9

Most patients with a small AAA enter surveillance awaiting future repair and not only have the anxiety of living with an AAA despite the low risk of rupture, but also a worse QoL than those who have undergone repair.^10,11 However, data are sparse regarding the effects on QoL of knowing they have an AAA, whether repaired or not. This study sought to examine the impact an AAA diagnosis had on male QoL at the initial investigation and after 12 months.

Methods

This prospective study was examined and approved by the Veterans Affairs Northern California Health Care System (NCHCS) Institutional Review Board. It was conducted at the Sacramento US Department of Veterans Affairs (VA) Medical Center from January 1, 2019, to February 28, 2022. Patients were identified through the vascular clinic. One hundred sixteen patients with AAA were eligible and agreed to participate. Of these, 91 (78%) completed the survey at baseline and 12 months later. Participation was voluntary; written informed consent was obtained from every patient before completing the survey. This study included only male patients due to their higher prevalence than female patients.⁴ Patients were also eligible if they were aged > 18 years and had a previously known AAA that was being followed with a recorded clinical imaging study in the NCHCS vascular clinic. Patients were excluded if they were unable to return for their 12-month follow-up investigation, were incapable of giving informed consent, were unable to complete the 12-item short form health survey version 2 (SF-12v2), had a documented history of psychiatric illness, or refused to participate. The SF-12v2, an abbreviated version of the 36-item short form health survey (SF-36), is a generic health-related quality-of-life survey that measures 8 domains of general health status: general health (GH), physical functioning (PF), role limitations due to physical problems (RP), bodily pain (BP), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH). A higher number on the QoL scale indicates better QoL. The GH, PF, RP, and BP scales yield a physical component score (PCS), and the VT, SF, RE, and MH scales generate a mental component score (MCS). Although SF-12v2 has not been validated for patients with AAA, it has been widely used and validated to measure health-related QoL in cohorts of healthy and chronically ill individuals.^12,13

Analysis

Descriptive statistics, including means, SDs, frequency, percentages, 95% CIs, and correlations were calculated. The t test was used to analyze differences in mean scores. For continuous variables, such as SF-12v2 domains, PCS, and MCS, mean, SD, 95% CI, and range were determined. Comparisons were performed using X² or t test. P < .05 was considered statistically significant. Clinical risk factors, including age, race, body mass index (BMI), diabetes, hypertension, hyperlipidemia, coronary artery disease, cerebrovascular accident, myocardial infarction, and smoking status, were also recorded.

Results

Between January 1, 2019, and February 28, 2022, 91 patients were diagnosed with an AAA and completed the survey at the initial and 12-month investigations. Patients had a mean (SD) age of 76.0 (5.6) years (range, 64-93) and BMI of 29.7 (6.4). Comorbid diabetes was present in 31% of patients, hypertension in 75%, hyperlipidemia 66%, and coronary artery disease in 12% (Table 1). Most patients smoked tobacco: 71% indicated previous use and 22% were current users.

When comparing baseline vs 12-month follow-up, patients indicated a higher QoL in GH (3.2 vs 3.5, respectively; P < .05) and BP (3.1 vs 3.6, respectively; P < .05). No statistically significant difference was seen PF, RP, VT, SF, RE, MH, as well as PCS and MCS between baseline and follow-up with respect to QoL (P < .05). However, the 5 domains of SF-12v2: PF, RP, SF, RE, MH, and PCS had lower QoL scores at the 12-month follow-up when compared with baseline, but with no statistically significant difference between both investigations (Table 2).

Discussion

Previous studies have characterized the results of QoL measures as subjective because they are based on patient perceptions of their physical and psychological condition.^14,15 However, SF-36 and SF-12v2 responses provide a multifaceted account that encompasses the physical, psychological, and social aspects of QoL. Despite being the most widely used generic instrument in many fields of medicine, SF-36 is time consuming for clinicians who may prefer simpler and more time-efficient instruments.^16-18 The SF-12v2 not only imposes less burden on respondents but also generates accurate summary scores for patients physical and mental health.¹⁹

The replicability of SF-12v2 PCS and MCS scores has been demonstrated. In the United Kingdom, Jenkinson and Layte constructed SF-12v2 summary measures from a large scale dataset by sending the SF-36 and other questions on health and lifestyles to 9332 individuals and compared the results of the SF-36 and SF-12v2 across diverse patient groups (eg, Parkinson disease, congestive heart failure, sleep apnea, benign prostatic hypertrophy). Results from SF-36 PCS, SF-36 MCS, and PCS-12v2 (ρ, 0.94; P < .001) and SF-12v2 MCS (ρ, 0.96; P < .001) were found to be highly correlated, and also produced similar results, both in the community sample and across a variety of disease-specific groups.²⁰

The aim of this longitudinal observational study was to measure the QoL of males with an AAA ≥ 3.0 cm at baseline and 12 months later. The mean age of participants was 76 years, which aligns with previous research that found the prevalence of AAAs increased with age.¹ Study participants had a mean BMI of 29.7, which also supports previous research that indicated that obesity is independently associated with an AAA.²¹ Patients with an AAA and a history of smoking (former or current), hypertension, or hyperlipidemia had lower mean scores for 3 of 8 SF-12v2 domains at the 12-month follow-up.

These findings support previous research that indicated smoking is not only a very strong risk factor for the presence of an AAA but also associated with increased rates of expansion and the risk of rupture in patients with an AAA.²² Bath et al found that patients with an AAA compared to patients without an AAA were older (age 72.6 vs 69.8 years; P < .001), had a higher BMI (28.1 vs 27.0; P < .001), were more likely to be a current smoker (15.1% vs 5.2%; P < .001), and were more likely to have diabetes (18.8% vs 10.0%; P < .001), ischemic heart disease (12.2% vs 4.4%; P < .001), high cholesterol (53.2% vs 30.8%; P <. 001), previous stroke (6.1% vs 2.9%; P < .001), and a previous myocardial infarction (21.1% vs 5.8%; P < .001).²³ Lesjak et al found that men with AAA reported significantly lower scores in the domains of social functioning, pain, and general health 6 months after ultrasound compared with men without AAA.²⁴

Previous research indicates that patients with an AAA have a higher risk of cardiovascular diseases and comorbidities that may impact their perceived QoL. In a study assessing cardiovascular risk in 2323 patients with a small AAA, Bath et al found a high prevalence of coronary artery disease (44.9%), myocardial infarction (26.8%), heart failure (4.4%) and cerebrovascular accident (14.0%) which may have contributed to the decreased level of self-perceived QoL in these patients.²⁵

This aligned with a study by Golledge et al, who found that participants diagnosed with an AAA and peripheral artery disease not only had significantly poorer QoL scores in 5 SF-36 domains (PF, RP, GH, VT, and PCS)when compared with participants diagnosed with an AAA alone. They also had significantly poorer QoL scores in 7 domains of the SF-36 (PF, RP, GH, VT, SF, RE, and PCS) when compared with controls without an AAA.²⁶

Our analysis found that males with an AAA had a rise in SF-12v2 QoL scores from baseline to 12-month follow-up in the GH and BP domains. There was no statistically significant difference in QoL in the other 6 domains (PF, RP, VT, SF, RE, and MH) between the initial and 12-month investigations. Bath et al also found that men with an AAA had a transient reduction in mental QoL during the first year after the initial screening but returned to baseline.²³

Strengths and Limitations

This study is notable for its sample of patients who previously had a diagnosed AAA that were followed with a recorded clinical imaging study and the use of a validated QoL measure (SF-12v2) that provided virtually identical summary scores (PCS and MCS) as the SF-36.27 However, this study was limited by the brevity of the SF-12v2 instrument which made it difficult to extract sufficient reliable information for the 8 domains.²⁸ Subjective perception of patients is another limitation inherent to any QoL study. QoL scores were not available before the initial investigation. Measuring QoL at baseline and 12 months later does not capture the potential fluctuations and changes in QoL that the patient may experience some months later. Another limitation arises from the fact that the AAA patient population in the study included patients under surveillance and patients who had undergone repair.

Fourteen patients (15%) had received AAA repair: 10 had endovascular reconstruction and 4 had open surgical repair. Including patients with a previous AAA repair may have influenced reported QoL levels. Suckow et al performed a 2-phase study on 1008 patients, 351 (35%) were under surveillance and 657 (65%) had undergone repair. In that study, patients under AAA surveillance had worse emotional impact scores compared with patients with repair (22 vs 13; P < .001).¹¹ Additionally, the size of the abdominal aorta at the time of survey was not addressed in the study, which could constitute explanatory variables.

Conclusions

This study found higher QoL at 12-month follow-up compared to baseline in both the GH and BP domains of the SF-12v2 health survey for male veterans with an AAA. Periodic QoL assessments for patients with an AAA may be helpful in tracking QoL course, minimizing their physical and psychological concerns, and improving overall care and support. However, further research is necessary to assess the QoL of patients with an AAA who are under surveillance compared with those who had an aneurysm repair to accurately measure the impact of an AAA on QoL.

Abdominal aortic aneurysm (AAA) is a public health threat, with a global prevalence of 4.8% and a prevalence in males that increases with age, from 1.3% between ages 45 and 54 years to 12.5% between ages 75 and 84 years.¹ AAA is often asymptomatic until it ruptures and can become life-threatening, with mortality rates near 90% in the event of rupture with survival rates of about 50% to 70% for individuals with rupture who require urgent surgical intervention.^2,3 Males experience AAA at 4 times the rate of females.⁴

Previous research has found that the awareness of having an AAA causes anxiety that some have described as “living with a ticking time bomb.”⁵ Others reported worries and concerns about life’s fragility and mortality due to an AAA diagnosis.⁶ However, the psychological impact on the individuals’ quality of life (QoL) remains unclear, especially for individuals with a small AAA (< 5.5 cm).⁷ Factors such as age, male sex, smoking, family history, hypertension, carotid artery disease, and hypercholesterolemia have been strongly associated with increased growth rate and the risk of small AAA ruptures.^8,9

Most patients with a small AAA enter surveillance awaiting future repair and not only have the anxiety of living with an AAA despite the low risk of rupture, but also a worse QoL than those who have undergone repair.^10,11 However, data are sparse regarding the effects on QoL of knowing they have an AAA, whether repaired or not. This study sought to examine the impact an AAA diagnosis had on male QoL at the initial investigation and after 12 months.

Methods

This prospective study was examined and approved by the Veterans Affairs Northern California Health Care System (NCHCS) Institutional Review Board. It was conducted at the Sacramento US Department of Veterans Affairs (VA) Medical Center from January 1, 2019, to February 28, 2022. Patients were identified through the vascular clinic. One hundred sixteen patients with AAA were eligible and agreed to participate. Of these, 91 (78%) completed the survey at baseline and 12 months later. Participation was voluntary; written informed consent was obtained from every patient before completing the survey. This study included only male patients due to their higher prevalence than female patients.⁴ Patients were also eligible if they were aged > 18 years and had a previously known AAA that was being followed with a recorded clinical imaging study in the NCHCS vascular clinic. Patients were excluded if they were unable to return for their 12-month follow-up investigation, were incapable of giving informed consent, were unable to complete the 12-item short form health survey version 2 (SF-12v2), had a documented history of psychiatric illness, or refused to participate. The SF-12v2, an abbreviated version of the 36-item short form health survey (SF-36), is a generic health-related quality-of-life survey that measures 8 domains of general health status: general health (GH), physical functioning (PF), role limitations due to physical problems (RP), bodily pain (BP), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH). A higher number on the QoL scale indicates better QoL. The GH, PF, RP, and BP scales yield a physical component score (PCS), and the VT, SF, RE, and MH scales generate a mental component score (MCS). Although SF-12v2 has not been validated for patients with AAA, it has been widely used and validated to measure health-related QoL in cohorts of healthy and chronically ill individuals.^12,13

Analysis

Descriptive statistics, including means, SDs, frequency, percentages, 95% CIs, and correlations were calculated. The t test was used to analyze differences in mean scores. For continuous variables, such as SF-12v2 domains, PCS, and MCS, mean, SD, 95% CI, and range were determined. Comparisons were performed using X² or t test. P < .05 was considered statistically significant. Clinical risk factors, including age, race, body mass index (BMI), diabetes, hypertension, hyperlipidemia, coronary artery disease, cerebrovascular accident, myocardial infarction, and smoking status, were also recorded.

Results

Between January 1, 2019, and February 28, 2022, 91 patients were diagnosed with an AAA and completed the survey at the initial and 12-month investigations. Patients had a mean (SD) age of 76.0 (5.6) years (range, 64-93) and BMI of 29.7 (6.4). Comorbid diabetes was present in 31% of patients, hypertension in 75%, hyperlipidemia 66%, and coronary artery disease in 12% (Table 1). Most patients smoked tobacco: 71% indicated previous use and 22% were current users.

When comparing baseline vs 12-month follow-up, patients indicated a higher QoL in GH (3.2 vs 3.5, respectively; P < .05) and BP (3.1 vs 3.6, respectively; P < .05). No statistically significant difference was seen PF, RP, VT, SF, RE, MH, as well as PCS and MCS between baseline and follow-up with respect to QoL (P < .05). However, the 5 domains of SF-12v2: PF, RP, SF, RE, MH, and PCS had lower QoL scores at the 12-month follow-up when compared with baseline, but with no statistically significant difference between both investigations (Table 2).

Discussion

Previous studies have characterized the results of QoL measures as subjective because they are based on patient perceptions of their physical and psychological condition.^14,15 However, SF-36 and SF-12v2 responses provide a multifaceted account that encompasses the physical, psychological, and social aspects of QoL. Despite being the most widely used generic instrument in many fields of medicine, SF-36 is time consuming for clinicians who may prefer simpler and more time-efficient instruments.^16-18 The SF-12v2 not only imposes less burden on respondents but also generates accurate summary scores for patients physical and mental health.¹⁹

The replicability of SF-12v2 PCS and MCS scores has been demonstrated. In the United Kingdom, Jenkinson and Layte constructed SF-12v2 summary measures from a large scale dataset by sending the SF-36 and other questions on health and lifestyles to 9332 individuals and compared the results of the SF-36 and SF-12v2 across diverse patient groups (eg, Parkinson disease, congestive heart failure, sleep apnea, benign prostatic hypertrophy). Results from SF-36 PCS, SF-36 MCS, and PCS-12v2 (ρ, 0.94; P < .001) and SF-12v2 MCS (ρ, 0.96; P < .001) were found to be highly correlated, and also produced similar results, both in the community sample and across a variety of disease-specific groups.²⁰

The aim of this longitudinal observational study was to measure the QoL of males with an AAA ≥ 3.0 cm at baseline and 12 months later. The mean age of participants was 76 years, which aligns with previous research that found the prevalence of AAAs increased with age.¹ Study participants had a mean BMI of 29.7, which also supports previous research that indicated that obesity is independently associated with an AAA.²¹ Patients with an AAA and a history of smoking (former or current), hypertension, or hyperlipidemia had lower mean scores for 3 of 8 SF-12v2 domains at the 12-month follow-up.

These findings support previous research that indicated smoking is not only a very strong risk factor for the presence of an AAA but also associated with increased rates of expansion and the risk of rupture in patients with an AAA.²² Bath et al found that patients with an AAA compared to patients without an AAA were older (age 72.6 vs 69.8 years; P < .001), had a higher BMI (28.1 vs 27.0; P < .001), were more likely to be a current smoker (15.1% vs 5.2%; P < .001), and were more likely to have diabetes (18.8% vs 10.0%; P < .001), ischemic heart disease (12.2% vs 4.4%; P < .001), high cholesterol (53.2% vs 30.8%; P <. 001), previous stroke (6.1% vs 2.9%; P < .001), and a previous myocardial infarction (21.1% vs 5.8%; P < .001).²³ Lesjak et al found that men with AAA reported significantly lower scores in the domains of social functioning, pain, and general health 6 months after ultrasound compared with men without AAA.²⁴

Previous research indicates that patients with an AAA have a higher risk of cardiovascular diseases and comorbidities that may impact their perceived QoL. In a study assessing cardiovascular risk in 2323 patients with a small AAA, Bath et al found a high prevalence of coronary artery disease (44.9%), myocardial infarction (26.8%), heart failure (4.4%) and cerebrovascular accident (14.0%) which may have contributed to the decreased level of self-perceived QoL in these patients.²⁵

This aligned with a study by Golledge et al, who found that participants diagnosed with an AAA and peripheral artery disease not only had significantly poorer QoL scores in 5 SF-36 domains (PF, RP, GH, VT, and PCS)when compared with participants diagnosed with an AAA alone. They also had significantly poorer QoL scores in 7 domains of the SF-36 (PF, RP, GH, VT, SF, RE, and PCS) when compared with controls without an AAA.²⁶

Our analysis found that males with an AAA had a rise in SF-12v2 QoL scores from baseline to 12-month follow-up in the GH and BP domains. There was no statistically significant difference in QoL in the other 6 domains (PF, RP, VT, SF, RE, and MH) between the initial and 12-month investigations. Bath et al also found that men with an AAA had a transient reduction in mental QoL during the first year after the initial screening but returned to baseline.²³

Strengths and Limitations

This study is notable for its sample of patients who previously had a diagnosed AAA that were followed with a recorded clinical imaging study and the use of a validated QoL measure (SF-12v2) that provided virtually identical summary scores (PCS and MCS) as the SF-36.27 However, this study was limited by the brevity of the SF-12v2 instrument which made it difficult to extract sufficient reliable information for the 8 domains.²⁸ Subjective perception of patients is another limitation inherent to any QoL study. QoL scores were not available before the initial investigation. Measuring QoL at baseline and 12 months later does not capture the potential fluctuations and changes in QoL that the patient may experience some months later. Another limitation arises from the fact that the AAA patient population in the study included patients under surveillance and patients who had undergone repair.

Fourteen patients (15%) had received AAA repair: 10 had endovascular reconstruction and 4 had open surgical repair. Including patients with a previous AAA repair may have influenced reported QoL levels. Suckow et al performed a 2-phase study on 1008 patients, 351 (35%) were under surveillance and 657 (65%) had undergone repair. In that study, patients under AAA surveillance had worse emotional impact scores compared with patients with repair (22 vs 13; P < .001).¹¹ Additionally, the size of the abdominal aorta at the time of survey was not addressed in the study, which could constitute explanatory variables.

Conclusions

This study found higher QoL at 12-month follow-up compared to baseline in both the GH and BP domains of the SF-12v2 health survey for male veterans with an AAA. Periodic QoL assessments for patients with an AAA may be helpful in tracking QoL course, minimizing their physical and psychological concerns, and improving overall care and support. However, further research is necessary to assess the QoL of patients with an AAA who are under surveillance compared with those who had an aneurysm repair to accurately measure the impact of an AAA on QoL.

Abdominal aortic aneurysm (AAA) is a public health threat, with a global prevalence of 4.8% and a prevalence in males that increases with age, from 1.3% between ages 45 and 54 years to 12.5% between ages 75 and 84 years.¹ AAA is often asymptomatic until it ruptures and can become life-threatening, with mortality rates near 90% in the event of rupture with survival rates of about 50% to 70% for individuals with rupture who require urgent surgical intervention.^2,3 Males experience AAA at 4 times the rate of females.⁴

Previous research has found that the awareness of having an AAA causes anxiety that some have described as “living with a ticking time bomb.”⁵ Others reported worries and concerns about life’s fragility and mortality due to an AAA diagnosis.⁶ However, the psychological impact on the individuals’ quality of life (QoL) remains unclear, especially for individuals with a small AAA (< 5.5 cm).⁷ Factors such as age, male sex, smoking, family history, hypertension, carotid artery disease, and hypercholesterolemia have been strongly associated with increased growth rate and the risk of small AAA ruptures.^8,9

Most patients with a small AAA enter surveillance awaiting future repair and not only have the anxiety of living with an AAA despite the low risk of rupture, but also a worse QoL than those who have undergone repair.^10,11 However, data are sparse regarding the effects on QoL of knowing they have an AAA, whether repaired or not. This study sought to examine the impact an AAA diagnosis had on male QoL at the initial investigation and after 12 months.

Methods

This prospective study was examined and approved by the Veterans Affairs Northern California Health Care System (NCHCS) Institutional Review Board. It was conducted at the Sacramento US Department of Veterans Affairs (VA) Medical Center from January 1, 2019, to February 28, 2022. Patients were identified through the vascular clinic. One hundred sixteen patients with AAA were eligible and agreed to participate. Of these, 91 (78%) completed the survey at baseline and 12 months later. Participation was voluntary; written informed consent was obtained from every patient before completing the survey. This study included only male patients due to their higher prevalence than female patients.⁴ Patients were also eligible if they were aged > 18 years and had a previously known AAA that was being followed with a recorded clinical imaging study in the NCHCS vascular clinic. Patients were excluded if they were unable to return for their 12-month follow-up investigation, were incapable of giving informed consent, were unable to complete the 12-item short form health survey version 2 (SF-12v2), had a documented history of psychiatric illness, or refused to participate. The SF-12v2, an abbreviated version of the 36-item short form health survey (SF-36), is a generic health-related quality-of-life survey that measures 8 domains of general health status: general health (GH), physical functioning (PF), role limitations due to physical problems (RP), bodily pain (BP), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH). A higher number on the QoL scale indicates better QoL. The GH, PF, RP, and BP scales yield a physical component score (PCS), and the VT, SF, RE, and MH scales generate a mental component score (MCS). Although SF-12v2 has not been validated for patients with AAA, it has been widely used and validated to measure health-related QoL in cohorts of healthy and chronically ill individuals.^12,13

Analysis

Descriptive statistics, including means, SDs, frequency, percentages, 95% CIs, and correlations were calculated. The t test was used to analyze differences in mean scores. For continuous variables, such as SF-12v2 domains, PCS, and MCS, mean, SD, 95% CI, and range were determined. Comparisons were performed using X² or t test. P < .05 was considered statistically significant. Clinical risk factors, including age, race, body mass index (BMI), diabetes, hypertension, hyperlipidemia, coronary artery disease, cerebrovascular accident, myocardial infarction, and smoking status, were also recorded.

Results

Between January 1, 2019, and February 28, 2022, 91 patients were diagnosed with an AAA and completed the survey at the initial and 12-month investigations. Patients had a mean (SD) age of 76.0 (5.6) years (range, 64-93) and BMI of 29.7 (6.4). Comorbid diabetes was present in 31% of patients, hypertension in 75%, hyperlipidemia 66%, and coronary artery disease in 12% (Table 1). Most patients smoked tobacco: 71% indicated previous use and 22% were current users.

When comparing baseline vs 12-month follow-up, patients indicated a higher QoL in GH (3.2 vs 3.5, respectively; P < .05) and BP (3.1 vs 3.6, respectively; P < .05). No statistically significant difference was seen PF, RP, VT, SF, RE, MH, as well as PCS and MCS between baseline and follow-up with respect to QoL (P < .05). However, the 5 domains of SF-12v2: PF, RP, SF, RE, MH, and PCS had lower QoL scores at the 12-month follow-up when compared with baseline, but with no statistically significant difference between both investigations (Table 2).

Discussion

Previous studies have characterized the results of QoL measures as subjective because they are based on patient perceptions of their physical and psychological condition.^14,15 However, SF-36 and SF-12v2 responses provide a multifaceted account that encompasses the physical, psychological, and social aspects of QoL. Despite being the most widely used generic instrument in many fields of medicine, SF-36 is time consuming for clinicians who may prefer simpler and more time-efficient instruments.^16-18 The SF-12v2 not only imposes less burden on respondents but also generates accurate summary scores for patients physical and mental health.¹⁹

The replicability of SF-12v2 PCS and MCS scores has been demonstrated. In the United Kingdom, Jenkinson and Layte constructed SF-12v2 summary measures from a large scale dataset by sending the SF-36 and other questions on health and lifestyles to 9332 individuals and compared the results of the SF-36 and SF-12v2 across diverse patient groups (eg, Parkinson disease, congestive heart failure, sleep apnea, benign prostatic hypertrophy). Results from SF-36 PCS, SF-36 MCS, and PCS-12v2 (ρ, 0.94; P < .001) and SF-12v2 MCS (ρ, 0.96; P < .001) were found to be highly correlated, and also produced similar results, both in the community sample and across a variety of disease-specific groups.²⁰

The aim of this longitudinal observational study was to measure the QoL of males with an AAA ≥ 3.0 cm at baseline and 12 months later. The mean age of participants was 76 years, which aligns with previous research that found the prevalence of AAAs increased with age.¹ Study participants had a mean BMI of 29.7, which also supports previous research that indicated that obesity is independently associated with an AAA.²¹ Patients with an AAA and a history of smoking (former or current), hypertension, or hyperlipidemia had lower mean scores for 3 of 8 SF-12v2 domains at the 12-month follow-up.

These findings support previous research that indicated smoking is not only a very strong risk factor for the presence of an AAA but also associated with increased rates of expansion and the risk of rupture in patients with an AAA.²² Bath et al found that patients with an AAA compared to patients without an AAA were older (age 72.6 vs 69.8 years; P < .001), had a higher BMI (28.1 vs 27.0; P < .001), were more likely to be a current smoker (15.1% vs 5.2%; P < .001), and were more likely to have diabetes (18.8% vs 10.0%; P < .001), ischemic heart disease (12.2% vs 4.4%; P < .001), high cholesterol (53.2% vs 30.8%; P <. 001), previous stroke (6.1% vs 2.9%; P < .001), and a previous myocardial infarction (21.1% vs 5.8%; P < .001).²³ Lesjak et al found that men with AAA reported significantly lower scores in the domains of social functioning, pain, and general health 6 months after ultrasound compared with men without AAA.²⁴

Previous research indicates that patients with an AAA have a higher risk of cardiovascular diseases and comorbidities that may impact their perceived QoL. In a study assessing cardiovascular risk in 2323 patients with a small AAA, Bath et al found a high prevalence of coronary artery disease (44.9%), myocardial infarction (26.8%), heart failure (4.4%) and cerebrovascular accident (14.0%) which may have contributed to the decreased level of self-perceived QoL in these patients.²⁵

This aligned with a study by Golledge et al, who found that participants diagnosed with an AAA and peripheral artery disease not only had significantly poorer QoL scores in 5 SF-36 domains (PF, RP, GH, VT, and PCS)when compared with participants diagnosed with an AAA alone. They also had significantly poorer QoL scores in 7 domains of the SF-36 (PF, RP, GH, VT, SF, RE, and PCS) when compared with controls without an AAA.²⁶

Our analysis found that males with an AAA had a rise in SF-12v2 QoL scores from baseline to 12-month follow-up in the GH and BP domains. There was no statistically significant difference in QoL in the other 6 domains (PF, RP, VT, SF, RE, and MH) between the initial and 12-month investigations. Bath et al also found that men with an AAA had a transient reduction in mental QoL during the first year after the initial screening but returned to baseline.²³

Strengths and Limitations

This study is notable for its sample of patients who previously had a diagnosed AAA that were followed with a recorded clinical imaging study and the use of a validated QoL measure (SF-12v2) that provided virtually identical summary scores (PCS and MCS) as the SF-36.27 However, this study was limited by the brevity of the SF-12v2 instrument which made it difficult to extract sufficient reliable information for the 8 domains.²⁸ Subjective perception of patients is another limitation inherent to any QoL study. QoL scores were not available before the initial investigation. Measuring QoL at baseline and 12 months later does not capture the potential fluctuations and changes in QoL that the patient may experience some months later. Another limitation arises from the fact that the AAA patient population in the study included patients under surveillance and patients who had undergone repair.

Fourteen patients (15%) had received AAA repair: 10 had endovascular reconstruction and 4 had open surgical repair. Including patients with a previous AAA repair may have influenced reported QoL levels. Suckow et al performed a 2-phase study on 1008 patients, 351 (35%) were under surveillance and 657 (65%) had undergone repair. In that study, patients under AAA surveillance had worse emotional impact scores compared with patients with repair (22 vs 13; P < .001).¹¹ Additionally, the size of the abdominal aorta at the time of survey was not addressed in the study, which could constitute explanatory variables.

Conclusions

This study found higher QoL at 12-month follow-up compared to baseline in both the GH and BP domains of the SF-12v2 health survey for male veterans with an AAA. Periodic QoL assessments for patients with an AAA may be helpful in tracking QoL course, minimizing their physical and psychological concerns, and improving overall care and support. However, further research is necessary to assess the QoL of patients with an AAA who are under surveillance compared with those who had an aneurysm repair to accurately measure the impact of an AAA on QoL.

Background

Syncope presents a common diagnostic challenge due to its broad differential, ranging from benign to life-threatening conditions. Despite guidelines emphasizing a history- and physical examination- driven approach, nearly $33 billion is spent annually on syncope evaluations, often without yielding conclusive diagnoses. Here, we present a case of syncope secondary to cerebral venous sinus thrombosis, underscoring the importance of cerebrovascular imaging in select high-risk patient populations.

Case Presentation

An 80-year-old male with chronic sinusitis and history of pulmonary embolism (managed with thrombolysis and apixaban) presented due to an episode of transient loss of consciousness followed by nausea and vomiting. He denied any preceding symptoms but his wife did notice his arm move up for a few seconds. He didn’t have any headaches or post-ictal state. Physical exam showed normal orthostatic vital signs, symmetric blood pressure and radial pulses bilaterally. An extensive neurological exam was done and was unremarkable for any focal deficits including no vision changes. Initial evaluation including electrocardiogram, telemetry monitoring, transthoracic echocardiogram, and electroencephalography showed no significant abnormalities.

Chest CT angiography revealed right-sided segmental pulmonary emboli, unchanged from prior imaging. Head CT did not show any acute intracranial findings, and CT angiography demonstrated no vascular abnormality. Ultimately, an MRI brain revealed a left sigmoid sinus filling defect, suggestive of cerebral venous sinus thrombosis (CVST), in addition to chronic sinusitis. As CVST occurred while on apixaban, anticoagulation was switched to enoxaparin. He did not experience any recurrent symptoms during admission.

Conclusions

This case highlights the need for a patient- specific approach to syncope evaluation. Early neurovascular imaging may aid in prompt diagnosis and prevent unnecessary testing. CVST is a rare manifestation of venous thromboembolism and may present with symptoms mimicking vasovagal syncope, such as nausea and transient loss of consciousness. Typical symptoms of CVST include headaches, vomiting, vision changes, focal deficits, seizures, mental status changes, stupor or coma. Risk factors include prior thrombosis, hypercoagulable states like pregnancy or malignancy, obesity, OCPs, and chronic sinusitis. Noncontrast CT may miss CVST, and advanced neuroimaging is necessary for diagnosis in high-risk patients with thrombotic risk factors or symptoms suggestive of elevated intracranial pressure.

Background

Syncope presents a common diagnostic challenge due to its broad differential, ranging from benign to life-threatening conditions. Despite guidelines emphasizing a history- and physical examination- driven approach, nearly $33 billion is spent annually on syncope evaluations, often without yielding conclusive diagnoses. Here, we present a case of syncope secondary to cerebral venous sinus thrombosis, underscoring the importance of cerebrovascular imaging in select high-risk patient populations.

Case Presentation

An 80-year-old male with chronic sinusitis and history of pulmonary embolism (managed with thrombolysis and apixaban) presented due to an episode of transient loss of consciousness followed by nausea and vomiting. He denied any preceding symptoms but his wife did notice his arm move up for a few seconds. He didn’t have any headaches or post-ictal state. Physical exam showed normal orthostatic vital signs, symmetric blood pressure and radial pulses bilaterally. An extensive neurological exam was done and was unremarkable for any focal deficits including no vision changes. Initial evaluation including electrocardiogram, telemetry monitoring, transthoracic echocardiogram, and electroencephalography showed no significant abnormalities.

Chest CT angiography revealed right-sided segmental pulmonary emboli, unchanged from prior imaging. Head CT did not show any acute intracranial findings, and CT angiography demonstrated no vascular abnormality. Ultimately, an MRI brain revealed a left sigmoid sinus filling defect, suggestive of cerebral venous sinus thrombosis (CVST), in addition to chronic sinusitis. As CVST occurred while on apixaban, anticoagulation was switched to enoxaparin. He did not experience any recurrent symptoms during admission.

Conclusions

This case highlights the need for a patient- specific approach to syncope evaluation. Early neurovascular imaging may aid in prompt diagnosis and prevent unnecessary testing. CVST is a rare manifestation of venous thromboembolism and may present with symptoms mimicking vasovagal syncope, such as nausea and transient loss of consciousness. Typical symptoms of CVST include headaches, vomiting, vision changes, focal deficits, seizures, mental status changes, stupor or coma. Risk factors include prior thrombosis, hypercoagulable states like pregnancy or malignancy, obesity, OCPs, and chronic sinusitis. Noncontrast CT may miss CVST, and advanced neuroimaging is necessary for diagnosis in high-risk patients with thrombotic risk factors or symptoms suggestive of elevated intracranial pressure.

Background

Syncope presents a common diagnostic challenge due to its broad differential, ranging from benign to life-threatening conditions. Despite guidelines emphasizing a history- and physical examination- driven approach, nearly $33 billion is spent annually on syncope evaluations, often without yielding conclusive diagnoses. Here, we present a case of syncope secondary to cerebral venous sinus thrombosis, underscoring the importance of cerebrovascular imaging in select high-risk patient populations.

Case Presentation

An 80-year-old male with chronic sinusitis and history of pulmonary embolism (managed with thrombolysis and apixaban) presented due to an episode of transient loss of consciousness followed by nausea and vomiting. He denied any preceding symptoms but his wife did notice his arm move up for a few seconds. He didn’t have any headaches or post-ictal state. Physical exam showed normal orthostatic vital signs, symmetric blood pressure and radial pulses bilaterally. An extensive neurological exam was done and was unremarkable for any focal deficits including no vision changes. Initial evaluation including electrocardiogram, telemetry monitoring, transthoracic echocardiogram, and electroencephalography showed no significant abnormalities.

Chest CT angiography revealed right-sided segmental pulmonary emboli, unchanged from prior imaging. Head CT did not show any acute intracranial findings, and CT angiography demonstrated no vascular abnormality. Ultimately, an MRI brain revealed a left sigmoid sinus filling defect, suggestive of cerebral venous sinus thrombosis (CVST), in addition to chronic sinusitis. As CVST occurred while on apixaban, anticoagulation was switched to enoxaparin. He did not experience any recurrent symptoms during admission.

Conclusions

This case highlights the need for a patient- specific approach to syncope evaluation. Early neurovascular imaging may aid in prompt diagnosis and prevent unnecessary testing. CVST is a rare manifestation of venous thromboembolism and may present with symptoms mimicking vasovagal syncope, such as nausea and transient loss of consciousness. Typical symptoms of CVST include headaches, vomiting, vision changes, focal deficits, seizures, mental status changes, stupor or coma. Risk factors include prior thrombosis, hypercoagulable states like pregnancy or malignancy, obesity, OCPs, and chronic sinusitis. Noncontrast CT may miss CVST, and advanced neuroimaging is necessary for diagnosis in high-risk patients with thrombotic risk factors or symptoms suggestive of elevated intracranial pressure.

Background

Hypereosinophilic syndrome (HES) is a rare condition caused by an overproduction of eosinophils leading to tissue infiltration and end-organ damage. HES can infiltrate the heart and lead to rare but severe cases of eosinophilic endomyocarditis, potentially causing heart failure, restrictive cardiomyopathy, and thromboembolic events.

Case Presentation

A 53-year-old female presented for abdominal pain but was found to have significant leukocytosis and eosinophilia with an absolute eosinophil count of 15.50×109/L. Further imaging with cardiac MRI showed early nodular subendocardial enhancement suggestive of eosinophilic endomyocarditis. Bone marrow biopsy was negative for clonal disorders and gastric biopsy was negative for eosinophils and H. pylori. Treatment with high-dose prednisone caused reduction in eosinophils and repeat cardiac MRI showed significant improvement in endomyocarditis.

Discussion

HES is a rare condition characterized by persistently elevated eosinophilia that can cause end organ damage, mainly affecting the heart, lungs, skin and GI system. It can be caused by primary, secondary, or idiopathic mechanisms. Primary HES often involves genetic mutations, whereas secondary HES arises due to infections or malignancies. Idiopathic HES is mainly a diagnosis of exclusion. Workup includes bone marrow biopsies and molecular testing to help differentiate between different causes and guide treatment. Eosinophilic endomyocarditis (EM) is a rare and severe complication of HES caused by eosinophilic infiltration of the myocardium. It is characterized by myocardial inflammation, fibrosis, edema, arrhythmias and heart failure if left untreated. EM is a major cause of mortality and morbidity among patients with HES. Cardiac MRI is helpful for early detection but endomyocardial biopsy is the gold standard for definitive diagnosis. Early treatment with corticosteroids can significantly reduce eosinophilic infiltration and improve outcomes. Given the severity of this rare manifestation of HES, further research is needed to help improve diagnostic and treatment strategies for EM.

Conclusions

HES is a rare condition that can cause damage affecting multiple organs with one such complication being eosinophilic endomyocarditis, a condition known to increase mortality and morbidity in those with HES. Early but accurate diagnosis and timely intervention with corticosteroids is necessary for improving the overall outcomes of those affected with this.

Background

Hypereosinophilic syndrome (HES) is a rare condition caused by an overproduction of eosinophils leading to tissue infiltration and end-organ damage. HES can infiltrate the heart and lead to rare but severe cases of eosinophilic endomyocarditis, potentially causing heart failure, restrictive cardiomyopathy, and thromboembolic events.

Case Presentation

A 53-year-old female presented for abdominal pain but was found to have significant leukocytosis and eosinophilia with an absolute eosinophil count of 15.50×109/L. Further imaging with cardiac MRI showed early nodular subendocardial enhancement suggestive of eosinophilic endomyocarditis. Bone marrow biopsy was negative for clonal disorders and gastric biopsy was negative for eosinophils and H. pylori. Treatment with high-dose prednisone caused reduction in eosinophils and repeat cardiac MRI showed significant improvement in endomyocarditis.

Discussion

HES is a rare condition characterized by persistently elevated eosinophilia that can cause end organ damage, mainly affecting the heart, lungs, skin and GI system. It can be caused by primary, secondary, or idiopathic mechanisms. Primary HES often involves genetic mutations, whereas secondary HES arises due to infections or malignancies. Idiopathic HES is mainly a diagnosis of exclusion. Workup includes bone marrow biopsies and molecular testing to help differentiate between different causes and guide treatment. Eosinophilic endomyocarditis (EM) is a rare and severe complication of HES caused by eosinophilic infiltration of the myocardium. It is characterized by myocardial inflammation, fibrosis, edema, arrhythmias and heart failure if left untreated. EM is a major cause of mortality and morbidity among patients with HES. Cardiac MRI is helpful for early detection but endomyocardial biopsy is the gold standard for definitive diagnosis. Early treatment with corticosteroids can significantly reduce eosinophilic infiltration and improve outcomes. Given the severity of this rare manifestation of HES, further research is needed to help improve diagnostic and treatment strategies for EM.

Conclusions

HES is a rare condition that can cause damage affecting multiple organs with one such complication being eosinophilic endomyocarditis, a condition known to increase mortality and morbidity in those with HES. Early but accurate diagnosis and timely intervention with corticosteroids is necessary for improving the overall outcomes of those affected with this.

Background

Hypereosinophilic syndrome (HES) is a rare condition caused by an overproduction of eosinophils leading to tissue infiltration and end-organ damage. HES can infiltrate the heart and lead to rare but severe cases of eosinophilic endomyocarditis, potentially causing heart failure, restrictive cardiomyopathy, and thromboembolic events.

Case Presentation

A 53-year-old female presented for abdominal pain but was found to have significant leukocytosis and eosinophilia with an absolute eosinophil count of 15.50×109/L. Further imaging with cardiac MRI showed early nodular subendocardial enhancement suggestive of eosinophilic endomyocarditis. Bone marrow biopsy was negative for clonal disorders and gastric biopsy was negative for eosinophils and H. pylori. Treatment with high-dose prednisone caused reduction in eosinophils and repeat cardiac MRI showed significant improvement in endomyocarditis.

Discussion

HES is a rare condition characterized by persistently elevated eosinophilia that can cause end organ damage, mainly affecting the heart, lungs, skin and GI system. It can be caused by primary, secondary, or idiopathic mechanisms. Primary HES often involves genetic mutations, whereas secondary HES arises due to infections or malignancies. Idiopathic HES is mainly a diagnosis of exclusion. Workup includes bone marrow biopsies and molecular testing to help differentiate between different causes and guide treatment. Eosinophilic endomyocarditis (EM) is a rare and severe complication of HES caused by eosinophilic infiltration of the myocardium. It is characterized by myocardial inflammation, fibrosis, edema, arrhythmias and heart failure if left untreated. EM is a major cause of mortality and morbidity among patients with HES. Cardiac MRI is helpful for early detection but endomyocardial biopsy is the gold standard for definitive diagnosis. Early treatment with corticosteroids can significantly reduce eosinophilic infiltration and improve outcomes. Given the severity of this rare manifestation of HES, further research is needed to help improve diagnostic and treatment strategies for EM.

Conclusions

HES is a rare condition that can cause damage affecting multiple organs with one such complication being eosinophilic endomyocarditis, a condition known to increase mortality and morbidity in those with HES. Early but accurate diagnosis and timely intervention with corticosteroids is necessary for improving the overall outcomes of those affected with this.

Background

Immune checkpoint inhibitors (ICI) have changed the landscape of cancer therapy. Pembrolizumab is an ICI which targets programmed cell death protein-1 on T-cells and acts to release inhibition of the T-cell antitumor response. Pembrolizumab is approved for the treatment of multiple malignancies. However, ICI therapy may precipitate immune-related adverse events (IRAEs). We describe a unique presentation of irAE-cardiotoxicity.

Case Discussion

A 70-year-old female with a history of uterine cancer previously treated with pembrolizumab (discontinued in January) presented to the emergency department with acute onset nausea and vomiting. On arrival, she was afebrile, tachycardic, normotensive, and saturated well in room air. Labs were notable for troponin of 20, normal TSH, elevated proBNP, ESR and CRP. EKG revealed atrial fibrillation with rapid ventricular response and subtle ST changes in leads II, aVF, V4-V6. She was started on diltiazem infusion for rate control and was subsequently transitioned to oral amiodarone. Given the concern for pericarditis, NSAIDs were initiated. Transthoracic echocardiogram was notable for an ejection fraction of 58% with moderate circumferential pericardial effusion without tamponade. Given her recent ICI exposure and evolving clinical course, she was diagnosed with pembrolizumab- induced pericarditis with associated atrial fibrillation and pericardial effusion. High-dose corticosteroids and colchicine were initiated for stabilization and symptomatic improvement.

Discussion

IRAEs usually occur within 3 months of therapy but may develop later. They are classified as low-grade (1-2), high-grade (3-4), or lethal (5). Anti- PD1 therapy is frequently associated with minor IRAEs, which develop in ~70% of patients; dermatologic IRAEs are most common. Major IRAEs develop in 10-15% of patients, and lethal IRAEs may develop in up to 3%. Cardiac IRAEs are infrequent but significant. Presentation is variable and may involve the myocardium, pericardium, or conductive system. In the case of pericardial disease, high-dose IV methylprednisolone with oral steroid taper should be considered. Re-challenge with ICI therapy should only be considered if clinically stable and pericarditis or myocarditis are excluded.

Conclusions

Our patient illustrates a rare but significant IRAE associated with ICI with improvement following immunosuppressive and rate-control therapy.

Background

Immune checkpoint inhibitors (ICI) have changed the landscape of cancer therapy. Pembrolizumab is an ICI which targets programmed cell death protein-1 on T-cells and acts to release inhibition of the T-cell antitumor response. Pembrolizumab is approved for the treatment of multiple malignancies. However, ICI therapy may precipitate immune-related adverse events (IRAEs). We describe a unique presentation of irAE-cardiotoxicity.

Case Discussion

A 70-year-old female with a history of uterine cancer previously treated with pembrolizumab (discontinued in January) presented to the emergency department with acute onset nausea and vomiting. On arrival, she was afebrile, tachycardic, normotensive, and saturated well in room air. Labs were notable for troponin of 20, normal TSH, elevated proBNP, ESR and CRP. EKG revealed atrial fibrillation with rapid ventricular response and subtle ST changes in leads II, aVF, V4-V6. She was started on diltiazem infusion for rate control and was subsequently transitioned to oral amiodarone. Given the concern for pericarditis, NSAIDs were initiated. Transthoracic echocardiogram was notable for an ejection fraction of 58% with moderate circumferential pericardial effusion without tamponade. Given her recent ICI exposure and evolving clinical course, she was diagnosed with pembrolizumab- induced pericarditis with associated atrial fibrillation and pericardial effusion. High-dose corticosteroids and colchicine were initiated for stabilization and symptomatic improvement.

Discussion

IRAEs usually occur within 3 months of therapy but may develop later. They are classified as low-grade (1-2), high-grade (3-4), or lethal (5). Anti- PD1 therapy is frequently associated with minor IRAEs, which develop in ~70% of patients; dermatologic IRAEs are most common. Major IRAEs develop in 10-15% of patients, and lethal IRAEs may develop in up to 3%. Cardiac IRAEs are infrequent but significant. Presentation is variable and may involve the myocardium, pericardium, or conductive system. In the case of pericardial disease, high-dose IV methylprednisolone with oral steroid taper should be considered. Re-challenge with ICI therapy should only be considered if clinically stable and pericarditis or myocarditis are excluded.

Conclusions

Our patient illustrates a rare but significant IRAE associated with ICI with improvement following immunosuppressive and rate-control therapy.

Background

Immune checkpoint inhibitors (ICI) have changed the landscape of cancer therapy. Pembrolizumab is an ICI which targets programmed cell death protein-1 on T-cells and acts to release inhibition of the T-cell antitumor response. Pembrolizumab is approved for the treatment of multiple malignancies. However, ICI therapy may precipitate immune-related adverse events (IRAEs). We describe a unique presentation of irAE-cardiotoxicity.

Case Discussion

A 70-year-old female with a history of uterine cancer previously treated with pembrolizumab (discontinued in January) presented to the emergency department with acute onset nausea and vomiting. On arrival, she was afebrile, tachycardic, normotensive, and saturated well in room air. Labs were notable for troponin of 20, normal TSH, elevated proBNP, ESR and CRP. EKG revealed atrial fibrillation with rapid ventricular response and subtle ST changes in leads II, aVF, V4-V6. She was started on diltiazem infusion for rate control and was subsequently transitioned to oral amiodarone. Given the concern for pericarditis, NSAIDs were initiated. Transthoracic echocardiogram was notable for an ejection fraction of 58% with moderate circumferential pericardial effusion without tamponade. Given her recent ICI exposure and evolving clinical course, she was diagnosed with pembrolizumab- induced pericarditis with associated atrial fibrillation and pericardial effusion. High-dose corticosteroids and colchicine were initiated for stabilization and symptomatic improvement.

Discussion

IRAEs usually occur within 3 months of therapy but may develop later. They are classified as low-grade (1-2), high-grade (3-4), or lethal (5). Anti- PD1 therapy is frequently associated with minor IRAEs, which develop in ~70% of patients; dermatologic IRAEs are most common. Major IRAEs develop in 10-15% of patients, and lethal IRAEs may develop in up to 3%. Cardiac IRAEs are infrequent but significant. Presentation is variable and may involve the myocardium, pericardium, or conductive system. In the case of pericardial disease, high-dose IV methylprednisolone with oral steroid taper should be considered. Re-challenge with ICI therapy should only be considered if clinically stable and pericarditis or myocarditis are excluded.

Conclusions

Our patient illustrates a rare but significant IRAE associated with ICI with improvement following immunosuppressive and rate-control therapy.

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