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Risks Associated With As-Needed BP Medication
Quick Takes
- In the nonsurgical, nonintensive care hospital setting, patients receiving as-needed BP medications were 23% more likely to develop acute kidney injury (AKI) during the admission and were 1.7 times more likely to have ischemic events compared to patients receiving scheduled BP treatment.
- The risk of AKI was similar whether the as-needed BP medication was ordered as a recurring PRN or one-time dose.
- Elderly patients with underlying CVD were more likely to have ischemic events associated with as-needed BP medication use likely due to rapid BP fluctuations and impaired autoregulation response.
Study Questions:
What are the risks of as-needed blood pressure (BP) medication administration, either as a one-time dose or recurring pro re nata (PRN), in asymptomatic patients in the hospital setting?
Methods:
This retrospective cohort study used target trial emulation and propensity score matching to quantify the effect of as-needed BP medication administration on clinical outcomes of nonsurgical adult veterans (n = 133,760) hospitalized in nonintensive care units for >3 days between October 1, 2015, and September 30, 2020. Patients received ≥1 scheduled BP medication within 24 hours of admission and had ≥1 systolic BP >140 mm Hg event to compare data from patients who did not receive as-needed treatment. The primary outcome, the first acute kidney injury (AKI) occurrence during hospitalization, was defined as an increase in serum creatinine by 0.3 mg/dL from the baseline within 48 hours or an increase by 50% over 7 days. The secondary outcome was a rapid >25% BP drop in systolic BP within 3 hours of as-needed BP medication administration. The composite outcome was the occurrence of myocardial infarction (MI), stroke, or death during hospitalization.
Results:
The mean [SD] eligible patients included: age 71.2 [11.6] years, 96% male, and baseline estimated glomerular filtration rate 75.7 [22.7] mL/min/1.73 m2. A total of 28,526 patients (21%) received as-needed BP medication; 80% were one-time dosage, 18% intravenous (IV) only, 66% orally only, and 15% both IV and orally. As-needed BP medication use was associated with an increased AKI risk (adjusted hazard ratio [HR], 1.23 [95% CI, 1.18-1.29]) compared to nonusers. Patients receiving as-needed BP medications and at a higher AKI risk were more likely Black (24.4%) and had higher baseline systolic BP (mean 157.4 mm Hg), higher diastolic BP (mean 84.4 mm Hg), and higher frequency of previous cardiovascular (CV)-related admissions. Compared to nonusers, IV only as-needed BP medication use was associated with a 64% increased risk of AKI (HR, 1.64 [95% CI, 1.48-1.81]), whereas oral as-needed BP medication use versus no use was associated with a lower risk of AKI (HR, 1.17 [95% CI, 1.11-1.24]), and use of both oral and IV as-needed BP medication was not associated with AKI (HR, 0.9 [95% CI, 0.85-1.10]). Secondary analyses found as-needed BP medication users had a 1.5-fold greater risk of rapid BP reduction (95% CI, 1.39-1.62) and 1.69-fold higher rate of the composite outcome (95% CI, 1.49-1.92) compared to nonusers.
Conclusions:
The use of as-needed BP medications among hospitalized patients is associated with increased risk for AKI, MI, stroke, and death.
Perspective:
Previous research has found that BP elevations can occur in 7 out of every 10 hospitalized patients, many of whom were normotensive in the outpatient setting. Although evidence-based guidelines exist regarding the treatment of chronic hypertension, this study aimed to analyze as-needed treatment of BP elevations in the inpatient setting, which is not usually performed in the outpatient setting, to evaluate the risks. This study found that without a clear indication to lower BP, as-needed BP medication use for asymptomatic BP elevation was associated with a greater risk for AKI and ischemic events. Therefore, in asymptomatic patients, it is suggested that clinicians investigate the source of BP elevation before being compelled to reactively treat transient BP elevation, while collaborating with the nurses administrating the medications to ascertain whether the elevation is related to physical or emotional stressors that may be mitigated by control of pain, lack of sleep, withdrawal, missed home medications, or adverse hemodynamic effects related to concomitant medications.
Clinical Topics: Cardiovascular Care Team, Hypertension, Prevention
Keywords: Acute Kidney Injury, Antihypertensive Agents, Blood Pressure, Patient Care Team
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