Evaluation of mean arterial pressure as a risk factor for missed ophthalmoscopic findings in the emergency department Público
Bruce, Beau Benjamin (2010)
Published
Abstract
Background: The objective of this study was to examine
risk factors for the failure
to diagnose acute ophthalmoscopic findings in patients presenting
to the emergency
department (ED).
Methods: Consecutive, adult patients presenting to the Emory
University ED with
a chief complaint of headache, acute focal neurologic deficit,
visual changes, or a diastolic blood pressure ≥120 were
included. Photographs of the ocular fundus (optic
disc and macula) were obtained from both eyes using a commercially
available non-
mydriatic ocular fundus camera. ED physicians were masked to the
results of the
photographs during their care of these patients and were asked to
proceed with their
routine evaluation of patients. Photographs were reviewed by
experts for the presence or absence of ocular fundus abnormalities.
The outcome of interest was missed findings defined as the
presence of relevant findings not identified during routine care of
patients. Presenting complaints, systolic and diastolic blood
pressure, heart rate, height, weight, age, race, gender, and the
patients ED diagnoses were recorded. Systolic blood pressure (SBP),
diastolic blood pressure (DBP), and heart rate (HR)
were used to calculate mean arterial pressure (MAP). MAP≥125
was the exposure of
interest. Univariate, stratified, and logistic regression analyses
were performed.
Results: 350 were enrolled in the study. Forty-four patients
(13%) had an relevant
abnormality and 27 (61%) of these were missed. Stratified analyses
indicated evidence
of interaction between MAP and age, BMI, black race, and sex.
Logistic regression
analyses showed that MAP≥125 was the primary, independent
risk factor for missed
fundus abnormalities after controlling for age, BMI, race, and
sex.
Conclusions: There is a substantial burden of relevant
ophthalmoscopic findings in
the ED and the majority of these findings are missed. Mean arterial
pressure was the
most important determinant of whether a patient would have a missed
ophthalmoscopic finding during the ED evaluation, and our findings
suggest that defining the
blood pressure threshold for hypertensive emergency as
DBP≥120 is too high to be
used as a screening criteria for end organ damage and that a lower
threshold may be
more appropriate.
Table of Contents
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . .1
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 2
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 7
Hypothesis . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 7
Study Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . 7
Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 9
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 10
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 16
References . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 19
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 24
About this Master's Thesis
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