Clinical Outcomes of Intensive Inpatient Blood Pressure Management in Hospitalized Older Adults

Abstract

Importance: Asymptomatic blood pressure (BP) elevations are common in hospitalized older adults, and widespread heterogeneity in the clinical management of elevated inpatient BPs exists.

Objective: To examine the association of intensive treatment of elevated inpatient BPs with in-hospital clinical outcomes of older adults hospitalized for noncardiac conditions.

Design, setting, and participants: This retrospective cohort study examined Veterans Health Administration data between October 1, 2015, and December 31, 2017, for patients aged 65 years or older hospitalized for noncardiovascular diagnoses and who experienced elevated BPs in the first 48 hours of hospitalization.

Interventions: Intensive BP treatment following the first 48 hours of hospitalization, defined as receipt of intravenous antihypertensives or oral classes not used prior to admission.

Main outcome and measures: The primary outcome was a composite of inpatient mortality, intensive care unit transfer, stroke, acute kidney injury, B-type natriuretic peptide elevation, and troponin elevation. Data were analyzed between October 1, 2021, and January 10, 2023, with propensity score overlap weighting used to adjust for confounding between those who did and did not receive early intensive treatment.

Results: Among 66 140 included patients (mean [SD] age, 74.4 [8.1] years; 97.5% male and 2.6% female; 17.4% Black, 1.7% Hispanic, and 75.9% White), 14 084 (21.3%) received intensive BP treatment in the first 48 hours of hospitalization. Patients who received early intensive treatment vs those who did not continued to receive a greater number of additional antihypertensives during the remainder of their hospitalization (mean additional doses, 6.1 [95% CI, 5.8-6.4] vs 1.6 [95% CI, 1.5-1.8], respectively). Intensive treatment was associated with a greater risk of the primary composite outcome (1220 [8.7%] vs 3570 [6.9%]; weighted odds ratio [OR], 1.28; 95% CI, 1.18-1.39), with the highest risk among patients receiving intravenous antihypertensives (weighted OR, 1.90; 95% CI, 1.65-2.19). Intensively treated patients were more likely to experience each component of the composite outcome except for stroke and mortality. Findings were consistent across subgroups stratified by age, frailty, preadmission BP, early hospitalization BP, and cardiovascular disease history.

Conclusions and relevance: The study's findings indicate that among hospitalized older adults with elevated BPs, intensive pharmacologic antihypertensive treatment was associated with a greater risk of adverse events. These findings do not support the treatment of elevated inpatient BPs without evidence of end organ damage, and they highlight the need for randomized clinical trials of inpatient BP treatment targets.

Figure 1.. Change in Mean Systolic Blood Pressure (BP) by Treatment Group

Boxes represent median and IQR, with whiskers representing the upper and lower adjacent values. Results reflect overlap-weighted cohorts.

Figure 2.. Clinical Outcomes of Intensive Inpatient Antihypertensive Treatment

Event rates presented for each treatment group are unadjusted, while odds ratios (ORs) are following overlap weighting. Composite outcome includes mortality, intensive care unit (ICU) transfer, any-stage acute kidney injury (AKI), stroke, troponin elevation, or B-natriuretic peptide (BNP) elevation. Hypotension defined as any systolic blood pressure less than 100 mm Hg in the post–48-hour hospitalization period. SNF indicates skilled nursing facility.

Figure 3.. Primary Composite Outcome of Intensive Inpatient Antihypertensive Treatment, Stratified by Age, Frailty, Outpatient Systolic Blood Pressure (BP), History of Cardiovascular Disease, and Maximum Systolic BP in the First 48 Hours

Composite outcome includes mortality, intensive care unit transfer, any-stage acute kidney injury, stroke, troponin elevation, or B-natriuretic peptide elevation. OR indicates odds ratio.