Severe inpatient hypertension prevalence and blood pressure response to antihypertensive treatment

Ghazi, Lama; Li, Fan; Chen, Xinyuan; Simonov, Michael; Yamamoto, Yu; Biswas, Aditya; Hanna, Jonathan; Shah, Tayyab; Townsend, Raymond R.; Peixoto, Aldo J.; Wilson, F. Perry

doi:10.1111/jch.14431

Cited by 13 publications

(11 citation statements)

References 49 publications

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“…These acute severe BP elevations frequently occur during hospitalization for other reasons. In fact, 10% of nonintensive care unit hospitalized patients, admitted for reasons other than hypertension, have been found to develop incident severe hypertension [ 3 , 4 ]. These high BPs, though often not causing symptoms, usually prompt healthcare providers to administer antihypertensives, commonly intravenous (i.v.)…”

Section: Introductionmentioning

confidence: 99%

“…We have previously shown that treatment with i.v. antihypertensives was associated with a 38% greater risk (hazard ratio [HR]: 1.38 [1.15, 1.67]) of severe BP reduction (mean arterial pressure reduction of ≥30%) compared to no treatment among inpatients who develop severe hypertension [ 3 ]. However, it is unknown whether treatment of acute severe BP elevation might lead to worse clinical outcomes.…”

Section: Introductionmentioning

confidence: 99%

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

Ghazi¹,

Li²,

Simonov³

et al. 2022

Journal of Hypertension

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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.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

Ghazi¹,

Li²,

Simonov³

et al. 2022

Journal of Hypertension

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“…Prior literature examining the immediate effect of BP treatment has documented a potential pathway for the observed harms in which BP immediately declines by greater than 25% over the course of hours, leading to a risk for tissue hypoperfusion. 8,[29][30][31] Intravenous antihypertensives have a greater immediate BP-lowering effect than oral medications, 30 and while both formulations have been associated with immediate BP lowering of greater than 25%, 8 this is more common with intravenous medications, occurring as often as one-third of the time. 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.…”

Section: Discussionmentioning

confidence: 99%

“…Third, the use of antihypertensives may result in overly rapid BP lowering, which has been associated with increased risk of cerebral hypoperfusion and death among patients treated for symptomatic hypertensive emergencies. 8,9 Fourth, clinical trials of inpatient diabetes management have demonstrated that applying outpatient treatment targets to inpatient settings may result in overtreatment and harms. 10 Better evidence to inform clinical decision-making is needed to optimize inpatient BP management, particularly for older adults who endure the highest burdens of hypertension, hospitalization, and frailty.…”

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confidence: 99%

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

et al. 2023

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ImportanceAsymptomatic blood pressure (BP) elevations are common in hospitalized older adults, and widespread heterogeneity in the clinical management of elevated inpatient BPs exists.ObjectiveTo 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 ParticipantsThis 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.InterventionsIntensive 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 MeasuresThe 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.ResultsAmong 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 RelevanceThe 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.

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“…We recently found that among patients hospitalized for reasons other than HTN at a large multi-hospital center, severe HTN was prevalent in 10% of patients and 40% received antihypertensive treatment, primarily oral antihypertensives [ 14 ]. Additionally, we report that excessive BP reduction (drop ≥30%) within 6 hours after severe HTN development was observed in treated and untreated patients.…”

Section: Introductionmentioning

confidence: 99%

Blood pressure response to commonly administered antihypertensives for severe inpatient hypertension

Ghazi

Chen

et al. 2022

PLoS ONE

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Background Blood pressure (BP) elevations are commonly treated in hospitalized patients; however, treatment is not guideline directed. Our objective was to assess BP response to commonly prescribed antihypertensives after the development of severe inpatient hypertension (HTN). Methods This is a cohort study of adults, excluding intensive care unit patients, within a single healthcare system admitted for reasons other than HTN who developed severe HTN (systolic BP>180 or diastolic BP >110 mmHg at least 1 hour after admission). We identified the most commonly administered antihypertensives given within 6 hours of severe HTN (given to >10% of treated patients). We studied the association of treatment with each antihypertensive vs. no treatment on BP change in the 6 hours following severe HTN development using mixed-effects model after adjusting for demographics and clinical characteristics. Results Among 23,147 patients who developed severe HTN, 9,166 received antihypertensive treatment. The most common antihypertensives given were oral metoprolol (n = 1991), oral amlodipine (n = 1812), oral carvedilol (n = 1116), IV hydralazine (n = 1069) and oral hydralazine (n = 953). In the fully adjusted model, treatment with IV hydralazine led to 13 [-15.9, -10.1], 18 [-22.2, -14] and 11 [-14.1, -8.3] mmHg lower MAP, SBP, and DBP in the 6 hours following severe HTN development compared to no treatment. Treatment with oral hydralazine and oral carvedilol also resulted in significantly lower BPs in the 6 hours following severe HTN development (6 [-9.1, -2.1 and -7 [-9.1, -4.2] lower MAP, respectively) compared to no treatment. Receiving metoprolol and amlodipine did not result in a drop in BP compared to no treatment. Conclusion Among commonly used antihypertensives, IV hydralazine resulted in the most significant drop in BP following severe HTN, while metoprolol and amlodipine did not lower BP. Further research to assess the effect of treatment on clinical outcomes and if needed which antihypertensives to administer are necessary.

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Severe inpatient hypertension prevalence and blood pressure response to antihypertensive treatment

Cited by 13 publications

References 49 publications

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

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

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

Blood pressure response to commonly administered antihypertensives for severe inpatient hypertension

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