Effect of intravenous antihypertensives on outcomes of severe hypertension in hospitalized patients without acute target organ damage

Abstract

Background: Treatment of severe inpatient hypertension (HTN) that develops during hospitalization is not informed by guidelines. Intravenous (i.v.) antihypertensives are used to manage severe HTN even in the absence of acute target organ damage; however they may result in unpredictable blood pressure (BP) reduction and cardiovascular events. Our goal was to assess the association between i.v. antihypertensives and clinical outcomes in this population. Methods: This is a multihospital retrospective study of adults admitted for reasons other than HTN who develop severe HTN during hospitalization without acute target end organ damage. We defined severe HTN as BP elevation of systolic >180 or diastolic >110 mmHg. Treatment was defined as receiving i.v. antihypertensives within 3 h of BP elevation. We used overlap propensity score weighted Cox models to study the association between treatment and clinical outcomes during index hospitalization. Results: Of 224 265 unique, nonintensive care unit hospitalizations, 20 383 (9%) developed severe HTN, of which 5% received i.v. antihypertensives and 79% were untreated within 3 h of severe BP elevation. In the overlap propensity weighted population, patients who received i.v. antihypertensives were more likely to develop myocardial injury (5.9% in treated versus 3.6% in untreated; hazard ratio [HR]: 1.6 [1.13, 2.24]). Treatment was not associated with increased risk of stroke (HR: 0.7 [0.3, 1.62]), acute kidney injury (HR: 0.97 [0.81, 1.17]), or death (HR: 0.86 [0.49, 1.51]). Conclusions: Intravenous antihypertensives were associated with increased risk of myocardial injury in patients who develop severe HTN during hospitalization. These results suggest that i.v. antihypertensives should be used with caution in patients without acute target organ damage.

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

“…31 This association between immediate BP lowering and risk for harms is consistent with our findings of greater risks of adverse outcomes among patients receiving intravenous antihypertensives and an additional observational study of intravenous antihypertensives for severely elevated BPs that found an association with increased risk for myocardial injury. 32 It remains possible that unmeasured confounders, such as requirements for nothing by mouth, could be associated with receipt of intravenous treatment and adverse outcomes. None of these studies found signals of benefit from more intensive treatment of elevated inpatient BPs; however, prospective randomized clinical trials are necessary to overcome the risk of unmeasured confounding inherent in each study.…”

“…21 For patients with asymptomatic elevated BP recordings, increased emphasis on correct measurement, confirmation of elevated BP, and evaluation for reversible factors of transient elevations may reduce the risk of overtreatment. 32 Use of intravenous antihypertensives should be discouraged. Management of elevated inpatient BP might be reenvisioned as similar to the management of inpatient sinus tachycardia, for which the focus is on treating the underlying disorder rather than routinely prescribing antiarrhythmics.…”

“…Distinguishing symptomatic and asymptomatic inpatient hypertension remains the key decision point, as pathways for treatment of specific symptomatic syndromes are more clearly defined and evidence based . For patients with asymptomatic elevated BP recordings, increased emphasis on correct measurement, confirmation of elevated BP, and evaluation for reversible factors of transient elevations may reduce the risk of overtreatment . Use of intravenous antihypertensives should be discouraged.…”

“…Intravenous antihypertensives have a greater immediate BP-lowering effect than oral medications, and while both formulations have been associated with immediate BP lowering of greater than 25%, this is more common with intravenous medications, occurring as often as one-third of the time . This association between immediate BP lowering and risk for harms is consistent with our findings of greater risks of adverse outcomes among patients receiving intravenous antihypertensives and an additional observational study of intravenous antihypertensives for severely elevated BPs that found an association with increased risk for myocardial injury . It remains possible that unmeasured confounders, such as requirements for nothing by mouth, could be associated with receipt of intravenous treatment and adverse outcomes.…”

Effect of intravenous antihypertensives on outcomes of severe hypertension in hospitalized patients without acute target organ damage: Erratum

“…The authors have noted that the calculation of the effect estimate for i.v. antihypertensive use on acute kidney injury (AKI) and the inpatient mortality outcome was incorrect in this paper [1]. While the numerical estimates for AKI have changed, the interpretation does not (i.v.…”