Conservative therapy for inpatient hypertension bests antihypertensive intensification: JAMA

Previous studies suggest that inpatient practitioners commonly intensify patients' antihypertensive regimens at hospital discharge, including patients with previously well-controlled outpatient BPs. This finding implies that clinical practice may largely be driven by reflexive responses to elevated inpatient recordings being continued at discharge rather than planned adjustment of outpatient regimens. Although evidence-based recommendations exist for outpatient management of hypertension, guidelines for treating inpatients with elevated blood pressure (BP) are lacking. Recent data suggest that a less-intensive approach is best. Because intensification of antihypertensive regimens is common in hospitalized and a subject of debate, understanding the actual benefits and harms of this practice is essential. For this purpose, researchers conducted a study to characterize clinician response to BP in the hospital and at discharge and to compare short- and long-term outcomes associated with antihypertensive treatment intensification.

It was an observational cohort study based on electronic medical record data from 2017 at 10 Cleveland Clinic hospitals. Researchers included 22,834 adults (mean age 65.6 years, 56.9% women, 69.9% White) admitted to a medicine service excluding those with cardiovascular diagnoses, like acute coronary syndrome and cerebrovascular accident, that require specific BP management. They used Demographic and BP characteristics for propensity matching. The major outcome assessed was the association between acute hypertension treatment and subsequent inpatient acute kidney injury, myocardial injury, and stroke. Postdischarge outcomes assessed were stroke and myocardial infarction within 30 days and BP control up to 1 year.

Key findings of the study were:

♦ Systolic BP 140 mm Hg or higher was recorded at least once during admission in 17,821 individuals among which 5904 (33.1%) were treated.

♦ The researchers noted a total of 8692 of 106 097 cases (8.2%) of hypertensive systolic BPs were treated; of these, 5747 (66%) were treated with oral medications.

♦ In a propensity-matched sample controlling for patient and BP characteristics, they found treated patients tended to be at higher cardiovascular risk and subsequent acute kidney injury.

♦ They noted in the article "There was no BP interval in which treated patients had better outcomes than untreated patients"

♦They observed a total of 1645 of 17 821 patients (9%) with hypertension were discharged with an intensified antihypertensive regimen. However, the medication intensification at discharge was found to be not associated with better BP control in the following year.

The authors concluded, " In this cohort study, hypertension was common among medical inpatients, but antihypertensive treatment intensification was not. Intensification of therapy without signs of end-organ damage was associated with worse outcomes".

For further information:

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2774562