Key points What is the association between intensive treatment of elevated blood pressure in hospitalized patients and clinical outcomes of hospitalized older veterans? Findings In this cohort study using propensity score overlap weighting in 66,140 older adults hospitalized for noncardiac conditions , receipt of intensive inpatient antihypertensive treatment was associated with an increased risk of adverse events, with even higher risks for patients. who receive intravenous antihypertensives. Meaning The findings do not support inpatient treatment of elevated blood pressure in hospitalized older adults without evidence of end-organ damage and highlight the need for randomized clinical trials of inpatient blood pressure treatment targets. |
Importance
Asymptomatic elevations in blood pressure (BP) are common in hospitalized older adults, and there is widespread heterogeneity in the clinical management of elevated BP in hospitalized patients.
Aim
To examine the association of intensive treatment of elevated BP in hospitalized patients with in-hospital clinical outcomes of older adults hospitalized for non-cardiac conditions.
Design, environment and participants
This retrospective cohort study examined data from the Veterans Health Administration between October 1, 2015 and December 31, 2017, for patients aged 65 years or older hospitalized for non-cardiovascular diagnoses and who experienced elevated BP in the first 48 hours of hospitalization.
Interventions
Intensive BP treatment after the first 48 hours of hospitalization, defined as receipt of intravenous antihypertensives or oral classes not used before admission.
Main result and measures
The primary outcome was a composite of in-hospital mortality, intensive care unit transfer, stroke, acute kidney injury, B-type natriuretic peptide elevation, and troponin elevation. Data were analyzed between October 1, 2021 and January 10, 2023, and propensity score overlap weighting was used to adjust for confounding between those who did and did not receive early intensive treatment.
Results
Among the 66,140 patients included (mean [SD] age, 74.4 [8.1] years; 97.5% men and 2.6% women; 17.4% black, 1.7% Hispanic, and 75.9% Whites), 14,084 (21.3%) received intensive treatment for BP within the first 48 hours of hospitalization.
Patients who received early intensive treatment vs. those who did not continued to receive a greater number of additional antihypertensive drugs during the rest of their hospitalization (mean additional doses, 6.1 [95% CI, 5.8-6.4] vs. 1.6 [95% CI, 1.5- 1.8], respectively).
Intensive treatment was associated with an increased risk of the primary composite outcome (1220 [8.7%] vs 3570 [6.9%]; weighted odds ratio [OR], 1.28; 95% CI, 1.18 -1.39), with the highest risk among patients receiving intravenous antihypertensives (weighted OR, 1.90; 95% CI, 1.65-2.19).
Intensively treated patients were more likely to experience each component of the composite outcome except stroke and mortality.
Findings were consistent across subgroups stratified by age, frailty, pre-admission BP, early hospitalization BP, and history of cardiovascular disease.
Conclusions and relevance
Study findings indicate that among hospitalized older adults with elevated BP, intensive pharmacological antihypertensive treatment was associated with an increased risk of adverse events.
These findings do not support treatment of elevated blood pressure in hospitalized patients without evidence of end-organ damage, and highlight the need for randomized clinical trials of blood pressure treatment targets in hospitalized patients.
