Upping Hypertension Meds in Hospital Can Harm Older Patients

Fran Lowry

May 02, 2019

The intensification of antihypertensive regimens during hospitalization poses more risks to older adults than benefits, according to new research.

Transient elevations of blood pressure, common in hospitalized older adults, often lead clinicians to up antihypertensive meds, said investigator Timothy Anderson, MD, from the University of California, San Francisco.

About one in seven older adults admitted to the hospital for a common medical condition, such as pneumonia or a urinary tract infection, is discharged with an intensified regimen of blood pressure medications, he added.

But the practice might actually cause more harm than good "and is something that we should rethink in the clinical community," he told Medscape Medical News.

In fact, when patients were sent home with an increase in antihypertensive medications, "they suffered short-term harms, both an increased risk of being readmitted to the hospital and of having serious adverse events related to medications," he explained. However, there was no reduction in blood pressure a year later.

Anderson presented results from a retrospective cohort study of veterans hospitalized for noncardiac conditions at the American Geriatrics Society 2019 Annual Scientific Meeting in Portland, Oregon.

He and his colleagues used national data from the Veterans Health Administration and Medicare to identify patients 65 years and older who were admitted to a VA hospital for pneumonia, urinary tract infection, or venous thromboembolism from 2011 to 2013.

About half the 4056 patients in the study cohort were discharged with an intensified regimen and about half were not. Mean age was 77 years, and 3% were women.

At 30 days, the risk for readmission because of serious adverse events — like falls, fainting episodes, and acute kidney injury — was significantly higher when the regimen was intensified than when it was not (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.06 - 1.88).

The all-cause readmission rate was also higher with intensification (HR, 1.23; 95% CI, 1.07 - 1.42).

At 1 year, there was no difference in admissions for cardiovascular events — such as heart attack, stroke, or heart failure — between the two groups (HR, 1.18; 95% CI, 0.99 - 1.40), and no difference in change in systolic blood pressure.

In addition, for the 2244 patients with systolic blood pressure below 140 mm Hg before hospitalization, risk for readmission at 30 days because of serious adverse events was significantly higher with intensification (P < .05), as was risk for readmission because of a cardiovascular event at 1 year (P < .05).

Blood pressure control is more of a marathon than a foot race.

"I think we should be trying to move away from the practice of viewing blood pressure in the hospital as a marker of long-term blood pressure control," Anderson said. "Blood pressure control is more of a marathon than a foot race. We'd like to see communication between inpatient and outpatient doctors" noting the elevated blood pressure during hospitalization and advising monitoring.

The main take-home of this study "is that the inpatient setting is not the appropriate venue for adjusting blood pressure medications," said Mark Supiano, MD, from the University of Utah School of Medicine in Salt Lake City.

"That should be left to the patient's primary care provider in an outpatient setting," he told Medscape Medical News.

Although the intensification of blood pressure control in the hospital is not appropriate, this should not be interpreted to mean that attempts to intensify blood pressure management to a systolic blood pressure target of 130 mm Hg are not, he cautioned.

"The hospital is not the right place to be doing this. People are very sick and have other things going on that are accounting for their elevated blood pressure," Supiano said. Decreasing blood pressure is "crucial," but "the time to adjust the meds" is when the patient is back home.

The study was funded by the National Institute on Aging. Anderson and Supiano have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2019 Annual Scientific Meeting: Abstract P6. Presented May 2, 2019.

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