Blood Pressure
Olivia C. Welter, PharmD
Despite a body of continually growing evidence against the practice of aggressive BP treatment in hospitalized patients, some health systems still take an intensive approach to managing inpatient BP.
A study published in JAMA on May 30, 2023, adds further confirmation that this practice leads to greater risk of patients experiencing adverse drug events, which could lead to acute kidney injury, elevation of B-type natriuretic peptide or troponin, and transfer to an ICU.
Study background and findings
The study by Anderson and colleagues was conducted within the Veterans Health Administration and focused on older inpatient veterans. Because of this, the gender demographics are not balanced, with women accounting for only 2.6% of the over 66,000 patients included in the study. Patients could be included for review if they were over the age of 65 years, hospitalized for a non-CV diagnosis, and experienced elevated BP within their first 48 hours of hospitalization. The researchers defined intensive BP treatment as receipt of either I.V. or oral antihypertensives in the hospital that the patient had not taken prior to their hospital admission.
Researchers retrospectively evaluated patient data for individuals hospitalized between October 1, 2015, and December 31, 2017, and analyzed the data between October 2021 and January 2023. The primary composite outcome included mortality, ICU transfer, stroke, acute kidney injury, B-type natriuretic peptide elevation, and troponin elevation.
Overall, the study found that patients who received intensive BP treatment were more likely to experience one of the components of the primary composite outcome, with the exception of stroke and mortality. Patients who specifically received I.V. antihypertensives were the most at risk for experiencing any adverse event included in the primary composite outcome.
Other evidence
Over the years, several studies have been published which concluded that treating asymptomatic high BP in the hospital for noncardiac patients can increase risk of negative outcomes.
Ghazi and colleagues measured incidence of mean arterial pressure drop to ≥30% in hospitalized patients with aggressively treated BP, which can indicate potential harm. Their findings, published in the March 2022 issue of the Journal of Clinical Hypertension, found that I.V. antihypertensives were significantly more likely to cause this outcome than oral antihypertensives.
Additionally, a study published December 28, 2020, in JAMA Internal Medicine by Rastogi and colleagues found that when hospitalized patients had their hypertensive episodes treated during their admission and were discharged with intensified BP regimens, they were more likely to experience acute kidney or myocardial injury than untreated patients were. This was in addition to treated patients not having improved BP control a year after their hospitalization.
What’s next?
Authors of the JAMA study suggested that a randomized clinical trial of inpatient BP treatment targets is needed, since most research conducted on rigorous BP management in a hospital setting is studied through retrospective data. While this type of data can still provide valuable insights into treatment practices, there isn’t much control over variables. Randomizing patients for a study such as this is unlikely, however, due to the potential risks that come with randomizing patients to treatment in this setting.
Based on the full body of literature examining the topic, BP management in hospitalized patients without signs of end-organ damage should focus on identifying underlying problems that may be causing secondary elevated BP, such as pain, anxiety, or the stress of being in a hospital setting. Once a potential cause is identified, clinicians can work to treat the underlying cause while avoiding use of medications—especially products given intravenously—that could lower BP. ■