Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge

Abstract

Importance: Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization.

Objective: To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge.

Design, setting, and participants: In this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019.

Exposures: Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge.

Main outcomes and measures: The primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge.

Results: The propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1.06-1.88; NNH, 63; 95% CI, 34-370). At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, -2.4 to 3.7 mm Hg).

Conclusions and relevance: Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.

Figure.. Cumulative Hazard Plots Comparing Outcomes With Exposure to Antihypertensive Regimen Intensifications at Hospital Discharge

A, Patients were censored at 30 days after index hospitalization discharge. All-cause readmissions were identified through Veterans Affairs and Medicare claims. B, Patients were censored at 30 days after index hospitalization discharge. Serious adverse events were identified through Veterans and Medicare claims and defined as the first emergency department visit or hospitalization for injurious falls, syncope, hypotension, electrolyte abnormalities, or acute kidney injury. C, Patients were censored at 365 days after index hospitalization discharge. Cardiovascular events were identified through Veterans Affairs and Medicare claims and defined as the first emergency department visit or hospitalization for acute myocardial infarction, unstable angina, stroke, heart failure, or hypertension. HR indicates hazard ratio.