Treating Early Hospitalization Blood Pressure Deemed a No-No for Patient Safety

For older people hospitalized with noncardiovascular diagnoses, intensive lowering of asymptomatic inpatient blood pressures (BPs) may constitute overtreatment and lead to harm, observational data suggested.

U.S. veterans acutely treated for elevated systolic BP in the first 48 hours of hospitalization -- without evidence of acute end organ damage -- suffered more adverse events when counting combined inpatient mortality, ICU transfer, stroke, acute kidney injury, B-type natriuretic peptide (BNP) elevation, and troponin elevation (8.7% vs 6.9% for untreated peers, weighted OR 1.28, 95% CI 1.18-1.39), according to a group led by Timothy Anderson, MD, MAS, of Beth Israel Deaconess Medical Center in Brookline, Massachusetts.

A particularly high risk of adverse events among patients receiving IV antihypertensives was identified (weighted OR 1.90, 95% CI 1.65-2.19), they reported in JAMA Internal Medicine.

The investigators said their findings were consistent across subgroups stratified by age, frailty, preadmission BP, early hospitalization BP, and history of cardiovascular disease. The worse outcomes associated with intensive BP treatment persisted when endpoints were assessed individually, except for stroke and mortality.

"In the absence of randomized trial data, our findings suggest that the safest path forward may be to rethink the underlying reason for inpatient BP measurement and reorient clinical practice. Distinguishing symptomatic and asymptomatic inpatient hypertension remains the key decision point, as pathways for treatment of specific symptomatic syndromes are more clearly defined and evidence based," Anderson and colleagues wrote.

"Management of elevated inpatient BP might be reenvisioned as similar to the management of inpatient sinus tachycardia, for which the focus is on treating the underlying disorder rather than routinely prescribing antiarrhythmics," they cited as an example.

Asymptomatic BP elevations are common during hospitalization and may be related to factors such as pain, fever, delirium, anxiety, new medications, and imprecise measurement.

In this setting, the standard outpatient recommendations to drive down BP do not necessarily apply. Antihypertensive medications may confer too much BP lowering too fast, ultimately leading to cerebral hypoperfusion and death.

Indeed, Anderson's team reported that intensively treated patients were more likely to experience a hypotensive episode with systolic BP less than 100 mm Hg (14.8% vs 14.0%, weighted OR 1.22, 95% CI 1.15-1.30). These patients were also less likely to be discharged home (84.9% vs 87.1%, weighted OR 0.89, 95% CI 0.83-0.94).

Moreover, there has yet to be any signal of benefit suggested by the limited literature on treating asymptomatic inpatient BPs, the authors said.

"In combination, these findings suggest that pharmacologic treatment of asymptomatic elevated inpatient BP should be the exception rather than the rule. Instead, concerns of persistently elevated inpatient BPs should be communicated to patients and their outpatient clinicians for close follow-up, and if uncontrolled hypertension is confirmed in the outpatient setting, a decision to intensify antihypertensive treatment can be made after recovery from acute illness," they concluded.

Their retrospective study was based on Veterans Health Administration (VHA) records and Medicare claims for people age 65 and older hospitalized in 2015-2017.

The authors selected the 66,140 individuals (mean age 74.4, 97.5% men) who had noncardiovascular admissions yet several measurements of systolic BP ≥140 mm Hg in the first 48 hours of hospitalization.

Of this cohort, 21.3% received intensive BP treatment, defined as receipt of new IV antihypertensives or oral BP-lowering medications (not used prior to admission) in early hospitalization. Within this group, 17.8% received IV antihypertensives.

Propensity score overlap weighting was used to adjust for confounding between those who did and did not receive early intensive treatment. Before weighting, patients receiving intensive treatment had higher systolic BPs prior to hospitalization (mean 140.4 vs 135.2 mm Hg) and were more likely to have a systolic BP reading greater than 180 mm Hg in the first 48 hours (37.9% vs 15.2%).

The treatment group had slightly lower systolic BPs after the first 48 hours of hospitalization (average 138.0 vs 139.4 mm Hg) and went on to receive more additional antihypertensives during the remainder of their hospitalization (mean additional doses 6.1 vs 1.6).

Anderson and colleagues acknowledged that their reliance on the VHA database meant results may not be generalizable beyond a predominately male study population with greater multimorbidity. Similar to prior studies on this topic, the observational study design also left room for unmeasured confounding despite attempts at statistical adjustment.

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