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Intensifying Antihypertensive Medication Regimens in Older Adults
Study Questions:
Does intensification of antihypertensive medications at hospital discharge impact clinical outcomes after discharge?
Methods:
Patients hospitalized in the Veterans Health Administration national health systems facilities between January 2011 and December 2013 for noncardiac conditions (pneumonia, urinary tract infection, or venous thromboembolism) were included in this retrospective cohort study. All patients included were ages ≥65 years and had a diagnosis of hypertension. Antihypertensive intensification was defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive (compared to the medications used before hospitalization). The primary outcomes of interest were hospital readmission, serious adverse events, and cardiovascular events. Secondary outcomes included the change in systolic blood pressure (SBP) within 1 year of hospital discharge.
Results:
A total of 4,056 hospitalized older adults with hypertension (mean age, 77 years; 97.7% men) were included in this analysis. This propensity-matched cohort was equally split between those whose antihypertensive medications were intensified and those who did not have an intensification of their regimen. Within 30 days, patients who had had their antihypertensive medications intensified had an increased risk of readmission (hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.07-1.88); number needed to harm, 63; 95% CI, 34-370). At 1 year, no differences were observed for cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in SBP among those who did versus did not receive intensification (mean SBP, 134.7 vs. 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, -2.4 to 3.7 mm Hg).
Conclusions:
The investigators concluded that among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensive medications at discharge was not associated with reduced cardiac events or improved BP control within 1 year. However, intensification was associated with an increased risk for readmission and serious adverse events within 30 days.
Perspective:
These data support the need to measure BP in the home environment and to treat to control, based on home BP. Additional analysis is warranted to determine if specific BP management plans would assist in the process of BP control with improved continuity between inpatient and outpatient management. Furthermore, these data were in a predominantly male cohort; thus, this question has not been answered among female hypertensive patients.
Clinical Topics: Geriatric Cardiology, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Hypertension
Keywords: Antihypertensive Agents, Blood Pressure, Blood Pressure Monitoring, Ambulatory, Geriatrics, Hypertension, Inpatients, Outcome Assessment, Health Care, Outpatients, Patient Discharge, Patient Readmission, Pneumonia, Primary Prevention, Risk, Urinary Tract Infections, Venous Thromboembolism, Veterans Health
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