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Treatment of Hypertension Among Noncardiac Hospitalized Patients
Quick Takes
- Among adults admitted to the hospital for noncardiac diagnosis, treatment of elevated BP is not associated with improved inpatient or outpatient outcomes.
- Inpatient treatment of BP was associated with higher rates of acute kidney injury and myocardial injury among adults hospitalized for noncardiac diagnoses.
- Intensification of BP medications at discharge was not associated with improved BP control at 1 year among patients admitted for noncardiac etiologies.
Study Questions:
Is intensification of blood pressure (BP) during noncardiac hospitalization associated with improved outcomes?
Methods:
Electronic medical record data from 10 hospitals within the Cleveland Clinic Hospitals health care system were used for the present study. Data were collected on all adults admitted to a medicine service in 2017, except for those who were admitted with cardiovascular diagnoses, who were excluded. Additional exclusion criteria were pregnancy, length of stay <2 days or >14 days, lack of outpatient data on medication, recent admission for a cerebrovascular event, or acute coronary syndrome. This cohort was followed for 1 year after hospitalization. Demographic and BP characteristics were used for propensity matching. The outcome of interest included acute treatment of an elevated BP, defined as the administration of an intravenous antihypertensive medication or a new class of an oral antihypertensive treatment following an elevated BP measurement. Additional outcomes included acute kidney injury, myocardial injury, stroke, or a composite of all three, during hospitalization. Post-discharge outcomes included stroke and myocardial infarction within 30 days and BP control up to 1 year.
Results:
Among 22,834 adults included in this analysis (mean age 65.6 years, 56.9% women, 69.9% White), 17,821 patients had at least one elevated BP recorded during the inpatient stay. Regarding systolic BP reading, 8,692 of 106,097 cases (8.2%) of hypertensive systolic BPs were treated; of these, 5,747 (66%) were treated with oral medications. In a propensity-matched sample controlling for patient and BP characteristics, treated patients had higher rates of subsequent acute kidney injury (466 of 4,520 [10.3%] vs. 357 of 4,520 [7.9%]; p < 0.001). Rates of myocardial injury were also higher among the treated patients (53 of 4,520 [1.2%] vs. 26 of 4,520 [0.6%]; p = 0.003). A total of 1,645 of 17,821 patients (9%) with hypertension were discharged with an intensified antihypertensive regimen. No differences in the outpatient rates or stroke or myocardial infarction were observed between the two groups. Medication intensification at discharge was not associated with better BP control in the following year.
Conclusions:
The investigators concluded that hypertension appears to be common among medical inpatients. Intensification of antihypertensive treatment was uncommon. Among those inpatients without end-organ damage, intensification of antihypertensive medications was associated with worse outcomes.
Perspective:
These data suggest that hypertension management is best performed in the outpatient setting among patients who are hospitalized for noncardiac diagnoses and do not have end-organ damage due to elevated BP. However, it should be noted this was not a randomized clinical trial; although propensity matching was used, biases, measurement error, and potential confounding may be present. Further research is warranted to determine the efficacy of BP management during hospitalization among noncardiac patients.
Clinical Topics: Cardiovascular Care Team, Prevention, Hypertension
Keywords: Acute Kidney Injury, Antihypertensive Agents, Blood Pressure, Blood Pressure Determination, Delivery of Health Care, Electronic Health Records, Hypertension, Inpatients, Length of Stay, Myocardial Infarction, Outpatients, Patient Discharge, Primary Prevention, Stroke, Treatment Outcome
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