Clinical

What drives intensification of antihypertensive therapy at discharge?


 

Background: Transient elevations in blood pressure are common among adult patients, yet there are no data or guidelines that support long-term medication changes based on these readings. Tight control of blood pressure is likely to improve outcomes among patients with heart failure), myocardial infarction, and stroke. Patients with reduced life expectancy, dementia, or metastatic cancer are less likely to benefit from tight control.

Dr. Teddy Holzer

Study design: Retrospective cohort study.

Setting: U.S. Veterans Administration (VA) Health System.

Synopsis: The investigators reviewed data from 14,915 adults over 65 (median age, 76 years) admitted to the VA with a diagnosis of pneumonia, urinary tract infection, or venous thromboembolism. Most patients (65%) had well-controlled blood pressure prior to admission.

A total of 2,074 (14%) patients were discharged with an intensified hypertension regimen (additional medication or higher dose). While both elevated inpatient and outpatient blood pressures were predictive of intensification, the association with elevated inpatient blood pressure was much stronger (odds ratio, 3.66; 95% confidence interval, 3.29-4.08) than it was with elevated outpatient blood pressure (OR, 1.75; 95% CI, 1.58-1.93).

In a multivariate regression analysis, the investigators found no significant differences in intensification by life expectancy (P = .07), diagnosis of dementia (P = .95), or metastatic malignancy (P = .13). There was a small increased probability of intensification among patients with heart failure, but no such difference for patients with history of MI (P = .53), stroke (P = .37), or renal disease (P = .73).

The generalizability of this trial may be limited given the cohort was predominantly male (97%), white (77%), and 53% had at least four major comorbidities.

Bottom line: Intensification of antihypertensive therapy at discharge is often driven by inpatient blood pressure readings rather than the broader context of their disease, such as prior long-term outpatient blood pressure control or major comorbidities.

Citation: Anderson TS et al. Intensification of older adults’ outpatient blood pressure treatment at hospital discharge: A national retrospective cohort study. BMJ. 2018:362:k3503.

Dr. Holzer is an assistant professor of medicine in the division of hospital medicine at Mount Sinai Hospital, New York.

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