No abstract

The high prevalence of uncontrolled hypertension in underserved populations is a major cause of health disparities in the United States and requires innovative health care delivery interventions. We conducted a systematic review of randomized controlled trials and comparative observational studies examining the effectiveness of contemporary systems change and quality improvement interventions aimed at improving blood pressure (BP) control published from 2010 to 2020. We included studies evaluating multicomponent practice improvement interventions conducted in the United States in community health centers. We identified 26 studies including 48 187 patients with hypertension with a high proportion of racial/ethnic minorities, low socioeconomic status, and a high burden of chronic illness. Multicomponent interventions led to an average reduction of 5 to 10 mm Hg in systolic BP. Four studies demonstrated the effectiveness of integrating pharmacists into community health centers for BP management and reduced cardiovascular disparities for at-risk populations. Five studies demonstrated the effectiveness of integrating community health workers into care workflows leading to reduction in BP and high patient satisfaction. Five studies used the electronic medical record as a tool for population management and showed only modest reduction in BP. One study demonstrated the effectiveness of incentivizing clinics with higher payments for uninsured and Medicaid patients meeting performance criteria. Very few studies evaluated treatment complications or medications side effects. Multicomponent quality improvement interventions instituted in community health centers are effective in lowering BP. Several components of the interventions were identified as being associated with higher efficacy.

Takotsubo cardiomyopathy (TTC) is prevalent in 2% of patients who present with symptoms suggestive of acute myocardial infarction. It may be triggered by stressful events, resulting in catecholamine surges, myocardial stunning, and disturbances in contractility. TTC in males has been associated with marijuana use and leads to a fivefold increased risk of cardiac events. Marijuana is thought to generate a similar surge in catecholamines leading to tachycardia and elevation of both systolic and diastolic blood pressure. The question remains whether this catecholamine surge is sufficient enough to cause TTC. It is apparent a correlation between marijuana use and TTC may exist. Exogenous cannabinoid stimulation may lead to myocardial stunning via stimulation seen with hypercatecholaminergic states. Understanding the risk factors involved and increasing awareness of cardiovascular complications related to cannabinoid substances becomes more relevant as its use is increasing both recreationally and medically. We present a case of a 50 year-old African-American male with hypertension and regular marijuana use who presented with chest pain radiating to the back. Due to abnormal electrocardiogram and positive cardiac biomarkers concerning for acute coronary syndrome, the patient underwent subsequent coronary angiography that showed no significant coronary obstruction; however, left ventriculogram showed the characteristic apical ballooning of TTC. Our case highlights the pathophysiological mechanism suspected to trigger TTC.