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BackgroundHypertensive patients (HTs) are usually attended in primary care (PC). We aimed to assess the diagnostic accuracy and cost-benefit ratio of 24-hour ambulatory blood pressure monitoring (ABPM) in all newly diagnosed hypertensive patients (HTs) attended in PC.MethodsIn a cross-sectional study ABPM was recorded in all 336 never treated HTs (Office BP ≥140 and/or ≥ 90 mm Hg) that were admitted during 16 months. Since benefits from drug treatment in white-coat hypertension (WCH) remain unproven, a cost benefit estimation of a general use of ABPM (vs absence of ABPM) in HTs was calculated comparing the cost of usual medical assistance of HTs only diagnosed in office with that based both on refraining from drug treatment all subjects identified as WCH and on the reduction by half of the frequency of biochemical exams and doctor visits.ResultsWomen were 56%, age 51 ± 14 years and BMI 27 ± 4 Kg/m2. Out of these, 206 were considered as true HTs, daytime ABPM ≥ 135 and/or ≥85 mm Hg and 130 (38,7%) were identified as having white coat hypertension (WCH), daytime ABPM <135/85 mm Hg. Versus HTs, WCH group showed higher percentage of women (68% vs 51%) and lower values of an index composed by the association of cardiovascular risk factors. We estimated that with ABPM total medical expenses can be reduced by 23% (157.500 euros) with a strategy based on ABPM for 1000 patients followed for 2 years.ConclusionsIn PC, the widespread use of ABPM in newly diagnosed HTs increases diagnostic accuracy of hypertension, improves cardiovascular risk stratification, reduces health expenses showing a highly favourable benefit-cost ratio vs a strategy without ABPM.

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A 33-year-old female smoker came to our emergency department complaining of dyspnea, pleuritic left chest pain, and an episode of mild hemoptysis. One week previously, she had experienced left calf pain. There was no history of recent trauma or immobilization. Her only medication was an oral contraceptive. On admission, her heart rate was 110 beats per minute in sinus rhythm, with a normal physical examination and arterial blood gases and without evidence of right ventricular strain on ECG (Figure 1). A chest x-ray showed a wedgeshaped peripheral opacity in the lower half of the left lung field (Hampton's hump; Figure 2, long arrow) and an enlarged right descending pulmonary artery (Palla's sign; Figure 2, short arrow). Plasma D-dimers were elevated (2.3 μg/mL; normal value, <0.5 μg/mL). The patient had a chest computed tomography contrast scan that showed luminal filling defects in the left pulmonary artery (Figure 3, asterisk) and right segmental pulmonary arteries, as well as a consolidation area in the left lower lobe probably associated with lung infarction.The patient had normal cardiac biomarkers and a normal transthoracic echocardiogram. Anticoagulation was initiated, and the patient was admitted to our intermediate care unit.Although contrast-enhanced thoracic computed tomography scan allows a rapid and straightforward diagnosis of pulmonary embolism, older radiological findings should not be forgotten. The Hampton's hump, described in 1940 by the radiologist Aubrey Hampton, consists of a wedge-shaped opacity of the peripheral lung field.1 The Palla's sign was named after the description by Antonio Palla of an association between pulmonary embolism and a chest x-ray sign of right descending pulmonary artery enlargement.2 The simultaneous presence of these findings in chest x-ray is infrequent 3 but is a valuable aid in the diagnosis of pulmonary embolism, especially in patients at risk of complications with contrastenhanced imaging techniques. DisclosuresNone.