番茄社区

Treating asymptomatic hypertension in patients admitted for non-cardiac reasons was associated with more end organ damage than if it was left alone, according to an observational study.

Such antihypertensive-treated patients had a higher incidence of subsequent inpatient acute kidney injury (10.3% vs 7.9%, P<0.001) and myocardial injury (1.2 vs 0.6%, P=0.003) compared with non-treated peers in a propensity-matched analysis of 4,520 patient-pairs, reported Michael Rothberg, MD, MPH, of Cleveland Clinic, and colleagues.

"Associated harms were similar for oral and IV treatments and occurred across SBP [systolic blood pressure] intervals. We did not find any group of patients whose outcomes were better with treatment," the authors wrote in the study published online in .

"It's tempting to 'fix' a patient's BP spikes when they are in the hospital (because you can), and this practice, temptation, and even expectation is rampant in just about every hospital setting. There has never been any evidence that it is associated with improved outcomes; and, in the case of hypertension, this study shows it may be associated with long-term harm," commented John Bisognano, MD, PhD, of University of Rochester Medical Center, New York, who was not involved with the study.

"This study provides needed support for avoiding treatment of inpatient BP numbers that would normally prompt outpatient medication intensification," he wrote in an email to 番茄社区.

Notably, acute treatment for high BP in the inpatient setting was not common at the Cleveland Clinic: Despite 78% prevalence of high BP readings during noncardiac admissions in the year 2017, only 8.2% of hypertensive systolic BP readings prompted administration of an IV antihypertensive medication or a new class of an oral drug.

Study investigators added that it was "surprising" that even systolic BPs spikes of 220 mm Hg or greater elicited treatment in only 47% of cases.

"The lower rates of treatment we observed may reflect newer evidence regarding hypertensive urgency in the ambulatory setting, better appreciation of BP lability during acute illness, and growing recognition of the potential harms of IV treatment. The lack of harms among untreated patients appears to support this conservative approach," according to Rothberg's group.

Strokes occurred at the same 0.1% rate whether hypertension was addressed or not during the admission, the authors reported. Post-discharge stroke and MI rates within 30 days were also no different between groups.

In addition, the 9% of people with antihypertensive medication intensification at discharge did not have better BP control in the following year.

There can be valid reasons to add or intensify medication regimens in the hospital setting, such as in the case of getting heart failure patients on guideline-directed medical therapy, argued R. Neal Axon, MD, MSCR, of the Medical University of South Carolina in Charleston.

"With that said, there are also plenty of valid reasons to de-escalate or reduce medications in the inpatient setting, especially in the elderly. The best approach regarding BP medications, this article might support, is to make the fewest changes possible," Axon commented.

Bisognano emphasized that the place to treat BP in the asymptomatic patient is in the outpatient setting with properly performed readings.

The cohort study was based on electronic medical record data from 2017 at 10 Cleveland Clinic hospitals.

Investigators 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.

Systolic BP 140 mm Hg or higher was recorded at least once during admission in 17,821 individuals.

A third of these inpatients underwent acute BP treatment via oral (e.g., calcium channel blockers, β-blockers, and angiotensin-converting enzyme inhibitors) or IV administration (e.g., direct-acting vasodilators, β-blockers, and α-β blockers).

Treated patients tended to be at higher cardiovascular risk, they were older, more were Black patients, and they had higher BP readings.

No differences between hypertensive groups remained after propensity score matching.

"We found that most elevated systolic BPs dropped at least 20 points by the next measurement. Follow-up measurements were taken sooner in patients who remained untreated, suggesting that simply repeating the BP 4 hours later may substitute for treatment," study authors said.

"BP elevations tended to be transient, and fewer than 1 in 3 patients who had their medication intensified were discharged on the new regimen. Mean systolic BP at discharge was less than 140 mm Hg in both treated and untreated patients," they continued.

A limitation of the retrospective cohort study was the exclusion of dose intensification among people already on BP medications. Accordingly, the actual harm of BP treatment for inpatients may be greater than reported in their study, Rothberg and collaborators noted.

In any case, "even if treatment of elevated BP in the hospital does not result in harm, we found no indication that it was beneficial. It was, at best, a waste of time and resources," they concluded.

Axon shared that he recently commiserated about this "everyday issue" with a colleague who had been paged four times in one day by a nurse caring for a patient with asymptomatic elevated BP.

"I know I don't need to treat this, but these pages are just wearing me down," he recalled the colleague complaining.

Comment