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Intensive treatment of elevated blood pressure in hospitalized patients associated with adverse events
Clinical Question
Should clinicians treat elevated blood pressure in asymptomatic hospitalized patients?
Bottom line
Intensive treatment of elevated BP in asymptomatic hospitalized older adults may be associated with an increased risk of adverse events, specifically acute kidney injury, transfer to intensive care, and elevation of troponin and BNP levels. This association was not seen in the subgroup of patients with a maximum BP of 180 mmHg or greater during initial hospitalization. Given the observational design and the use of administrative data, the study results may be affected by unmeasured confounding factors, misclassification of antihypertensive exposure, and inadvertent inclusion of symptomatic patients. Although more research is needed, this data suggests that knee-jerk treatment of elevated BP in the hospital may not be warranted. 2b
Reference
Study design: Cohort (retrospective)
Funding: Government
Setting: Inpatient (ward only)
Synopsis
These investigators used data from the Veterans Health Administration system to identify hospitalized adults 65 years or older who had 2 or more elevated blood pressure (BP) measurements in the first 48 hours of hospitalization (N = 66,140). Admitting diagnoses were used to exclude patients who were hospitalized for cardiovascular disease and those with possible hypertensive emergencies. The study cohort was further divided into patients who received early intensive BP treatment during the first 48 hours (n = 14,084; 21% of cohort) and those who did not. Early intensive BP treatment was defined as exposure to one or more doses of a new oral antihypertensive medication and/or one or more doses of any intravenous antihypertensive. The primary outcome was a composite of death, stroke, acute kidney injury, troponin level elevation, B-type natriuretic peptide (BNP) elevation, and transfer to intensive care unit from 48 hours after hospitalization through discharge. Propensity score methods were used to balance covariates, resulting in 2 groups with a mean age of 74 years. Each group comprised 97% men, 75% White persons, and 18% Black persons. Compared with those who did not receive early intensive treatment, patients in the treatment group received a greater number of additional doses of antihypertensives during their hospital stay (mean additional doses 6.1 vs 1.6). Overall, receiving early intensive BP treatment was associated with an increased likelihood of the primary composite outcome (8.7% vs 6.9%; odds ratio 1.28; 95% CI 1.18 - 1.39). This was true for all individual components of the composite outcome, except for stroke and death. This was also true for subgroup analyses, including older age, frailty, elevated outpatient BP, and history of cardiovascular disease, but was not true for patients with severe BP elevation (180 mmHg or greater) in the first 48 hours of hospitalization. Of note, the association with adverse outcomes was more pronounced in the patients who received intravenous antihypertensives than in those who received only oral antihypertensives.
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL
Comments
Intensive treatment of elevated blood pressure in hospitaliz
Couldn't agree with this more. Extrapolating this to the ED, one should avoid the urge to "urgently treat" patients with BP at these levels who don't have any evidence of a hypertensive urgency. Typically these are patients who have taken their BP at home and are worried. The best "treatment" we can offer is to reassure the patient that there is nothing urgent that needs to be done in the ED. This paper provides a hint that doing otherwise could actually be harmful.
Impact assessment
Excellent
intensive treating blood pressure adverse effects
good to know