2025 Southeastern Residency Conference

Title: Blood Pressure Trajectory Post-Initiation of Eptinezumab Infusions For Migraines


Authors: Ashleigh Neese, Rachel Renwick


Introduction: Calcitonin gene-related peptide (CGRP) is a vasodilatory neuropeptide involved in the pathway responsible for onset of migraines. There are several injectable monoclonal CGRP antagonists approved by the FDA for prevention and treatment of migraines. Post-marketing safety monitoring data for erenumab suggests that CGRP antagonists may place patients at risk for increased blood pressure. Eptinezumab was approved for prevention of migraine in 2020 for the prevention of both episodic as well as chronic migraine. However, it has not undergone evaluation for its effect on blood pressure trajectory post-infusion.


Methods: This retrospective, single-center, multi-site study was performed to determine blood pressure trajectory post-infusion for eptinezumab. Patients selected for inclusion were those who received at least 1 dose of eptinezumab at an infusion center within the VUMC Enterprise. The primary outcome of the study was to assess the incidence of significant blood pressure increases immediately following eptinezumab infusion which was defined as an increase greater than or equal to 20 mmHg or 10 mmHg for systolic or diastolic blood pressure, respectively. The incidence of long-term blood pressure increases at 6 months after eptinezumab infusion and a comparison of increases in blood pressure for the 100 mg versus the 300 mg dose of eptinezumab were investigated.


Results: There were 130 patients who received a total of 512 administrations of eptinezumab during the selected time period. Of these administrations, only 35 (7%), met the criteria for a significant increase in blood pressure immediately following infusion for the primary outcome. The average change in blood pressure was -7.48 mmHg for systolic blood pressure and -4.35 mmHg for diastolic blood pressure immediately following administration. When comparing eptinezumab 100 mg versus 300 mg, 20 (9.1%) and 13 (6.1%) of patients experienced a significant increase in blood pressure, respectively. At six months following infusion, 31 (23.8%) of all patients receiving eptinezumab met the criteria for a significant increase in blood pressure. For patients receiving eptinezumab 100 mg, 28 (25.0%) of patients met criteria for a significant increase in blood pressure at 6 months while 15 (26.3%) of patients receiving eptinezumab 300 mg met criteria.


Conclusions: Many patients were previously on other CGRP agents which may have confounded patients experiencing significant blood pressure increases. Additionally, patients had their blood pressure checked post-infusion which resulted in a more accurate blood pressure reading at rest versus when a patient initially presents for their infusion. There were a limited number of patients with eptinezumab as their original infusion which introduced confounding with the 100 mg patient group. Additionally, there was variability in where the patient's 6-month blood pressure was taken. Overall, it was found that eptinezumab causes low incidences of significant blood pressure increases immediately following infusion but can cause increases over a longer period. Therefore, more research should be performed to compare blood pressure increases in patients undergoing treatment with other CGRP agents to eptinezumab.

Title: Evaluating for racial disparities in intravenous fibrinolytic door-to-needle times at a comprehensive stroke center


Authors: Morgan Daniel, Ashly Lamosek, Olivia Morgan, Katleen Chester


Objective: The purpose of this study was to identify the effect of racial disparities on fibrinolytic door-to-needle (DTN) times.


Self Assessment Question: What factor contributed to the initial racial disparity observed in DTN times for fibrinolytic administration in acute ischemic stroke treatment?


Background: The phrase “time is brain” is a staple in the world of acute ischemic stroke (AIS) as it reflects on the importance of efficient and timely care for patients to preserve neurons and limit the degree of ischemia. In the stroke setting, barriers and negative outcomes are more prevalent in black patients than white patients. Data has shown that non-white patients experiencing signs and symptoms of AIS were less likely to be treated with fibrinolytics, likely due to delay in presentation and not meeting eligibility criteria for administration. Despite this information, there is limited evidence on the relationship between race and fibrinolytic DTN times as most of the literature is focused mainly on the tele-stroke setting or outcomes in mechanical thrombectomies. The patient population that will be evaluated is unique compared to other literature as these patients are presenting to a safety net comprehensive stroke center located in the heart of what is known as the country's stroke belt.


Methods: This was a single-center, retrospective chart review evaluating patients presenting directly to the Grady Memorial Hospital Emergency Care Center receiving intravenous fibrinolytics (alteplase and tenecteplase) for AIS from January 2018 to May 2024.  Patients who received intravenous fibrinolytics via the Mobile Stroke Unit or after hospital admission, were excluded from this study.   Data was obtained from the Institutional Stroke Committee fibrinolytic data reports, which are updated monthly.  The primary outcome was mean DTN time, between whites versus non-white patients.   Secondary outcomes included the percentage of patients who met within 30-, 45-, and 60-minute DTN time goals, means of arrival, presentation time to the Emergency Department (00:01 – 08:00, 08:01 – 16:00, 16:01 – 00:00), and time from last known well to fibrinolytic administration, between white versus non-white patients. 


Results: A total of 893 patients treated with intravenous fibrinolytics were analyzed, including 652 non-white and 241 white patients. Non-white patients were significantly younger (median age 63 years [IQR 54–74] vs. 70 years [IQR 61–80], p = 0.025), with no significant difference in sex distribution (56.2% vs. 60.9%, p = 0.056). Median DTN times were longer for non-white patients (45 vs. 41 minutes, p = 0.014). Non-white patients more often required pre-treatment interventions for blood pressure or glucose control (21% vs. 12%, p = 0.003). When accounting for these interventions, DTN times were similar between groups (59 vs. 55 minutes, p = 0.147). A greater proportion of white patients met DTN time goals at 30, 45, and 60 minutes, though differences were not statistically significant (p = 0.139, p = 0.052, p = 0.108, respectively). Arrival methods and presentation times varied significantly. Non-white patients were more likely to arrive by EMS (85.5% vs. 71.8%, p < 0.001) and less likely by air transport (3.7% vs. 24.9%, p < 0.001). They also presented more frequently between 00:01–08:00 (14.6% vs. 8.7%, p = 0.021). Time from last known well to fibrinolytic administration did not differ significantly between groups (140 vs. 144 minutes, p = 0.160).


Conclusion: Racial disparities in fibrinolytic DTN times were initially observed, but these differences were eliminated after accounting for the higher rates of pre-treatment blood pressure and glucose management in non-white patients. This highlights the need for public health initiatives that address disparities in hypertension and diabetes incidence and management in non-white communities. Further research is essential to promote equitable acute stroke care.