Noncardiac inpatient has acute hypertension: Treat or not?
A retrospective study found more harm than benefit from treating elevated blood pressure in hospitalized noncardiac patients.
PRACTICE CHANGER
Manage blood pressure (BP) elevations conservatively in patients admitted for noncardiac diagnoses, as acute hypertension treatment may increase the risk for acute kidney injury (AKI) and myocardial injury.
STRENGTH OF RECOMMENDATION
C: Based on a single, large, retrospective cohort study.1
Rastogi R, Sheehan MM, Hu B, et al. Treatment and outcomes of inpatient hypertension among adults with noncardiac admissions. JAMA Intern Med. 2021;181:345-352.
Outcomes were defined as a temporal association between acute hypertension treatment and subsequent end-organ damage, such as AKI (serum creatinine increase ≥ 0.3 mg/dL or 1.5 × initial value [Acute Kidney Injury Network definition]), myocardial injury (elevated troponin: > 0.029 ng/mL for troponin T; > 0.045 ng/mL for troponin I), and/or stroke (indicated by discharge diagnosis, with confirmation by chart review). Monitored outcomes included stroke and myocardial infarction (MI) within 30 days of discharge and BP control up to 1 year later.
The 22,834 patients had a mean (SD) age of 65.6 (17.9) years; 12,993 (56.9%) were women, and 15,963 (69.9%) were White. Of the 17,821 (78%) who had at least 1 inpatient hypertensive systolic BP (SBP) episode, defined as an SBP ≥ 140 mm Hg, 5904 (33.1%) received a new treatment. Of those receiving a new treatment, 4378 (74.2%) received only oral treatment, and 1516 (25.7%) received at least 1 dose of IV medication with or without oral dosing.
Using the propensity-matched sample (4520 treated for elevated BP matched to 4520 who were not treated), treated patients had higher rates of AKI (10.3% vs 7.9%; P < .001) and myocardial injury (1.2% vs 0.6%; P = .003). When assessed by SBP, nontreatment of BP was still superior up to an SBP of 199 mm Hg. At an SBP of ≥ 200 mm Hg, there was no difference in rates of AKI or MI between the treatment and nontreatment groups. There was no difference in stroke in either cohort, although the overall numbers were quite low.
Patients with and without antihypertensive intensification at discharge had similar rates of MI (0.1% vs 0.2%; P > .99) and stroke (0.5% vs 0.4%; P > .99) in a matched cohort at 30 days post discharge. At 1 year, BP control in the intensification vs no-intensification groups was nearly the same: maximum SBP was 157.2 mm Hg vs 157.8 mm Hg, respectively (P = .54) and maximum diastolic BP was 86.5 mm Hg vs 86.1 mm Hg, respectively (P = .49).
WHAT’S NEW
Previous research is confirmed in a more diverse population
Whereas previous research showed no benefit to intensification of treatment among hospitalized older male patients, this large, retrospective, propensity score–matched cohort study demonstrated the short- and long-term effects of treating acute, asymptomatic BP elevations in a younger, more generalizable population that included women. Regardless of treatment modality, there appeared to be more harm than good from treating these BP elevations.
In addition, the study appears to corroborate previous research showing that intensification of BP treatment at discharge did not lead to better outcomes.9 At the very least, the study makes a reasonable argument that treating acute BP elevations in noncardiac patients in the hospital setting is not beneficial.
CAVEATS
Impact of existing therapy could be underestimated
This study had several important limitations. First, 23% of treated participants were excluded from the propensity analysis without justification from the authors. Additionally, there was no reporting of missing data and how it was managed. The authors’ definition of treatment excluded dose intensification of existing antihypertensive therapy, which would undercount the number of treated patients. However, this could underestimate the actual harms of the acute antihypertensive therapy. The authors also included patients with atrial fibrillation and heart failure in the study population, even though they already may have been taking antihypertensive agents.
CHALLENGES TO IMPLEMENTATION
Potential delays in translating findings to patient care
Although several recent studies have shown the potential benefit of not treating asymptomatic acute BP elevations in inpatients, incorporating that information into electronic health record order sets or clinical decision support, and disseminating it to clinical end users, will take time. In the interim, despite these findings, patients may continue to receive IV or oral medications to treat acute, asymptomatic BP elevations while hospitalized for noncardiac diagnoses.
