Reference: Intern Med. 2020 Dec 28
A multitude of guidelines offer detailed treatment plans for outpatients with hypertension, but advice is scarcer for hospitalized patients with high blood pressure, and there is growing evidence of harm from treatment. Driven by the pathophysiologic rationale that treatment of elevated systolic blood pressure (SBP) in the hospital reduces end-organ damage similar to treatment in the outpatient setting, it is nearly a reflex response to treat elevated blood pressure readings in these patients. However, previous studies have found an association between treatment of hypertension in asymptomatic hospitalized patients and longer length of stay and increased rates of adverse events, including hypotension and bradycardia.
A recent retrospective cohort study included medicine patients admitted to 10 different hospitals. Importantly, patients with recent or admission diagnoses of myocardial infarction (MI) or stroke or length of stay < 2 or > 14 days were excluded. Treated and untreated patients had similar rates of common comorbidities. Treated patients were older (70.8 years vs. 66.5 years), more likely to have chronic kidney disease (14.5% vs. 13.5%), and had more SBP > 140, more measurements per day, and higher maximum SBP. A propensity-matched model was built to adjust for these differences, treatment route and interval, and other factors, ultimately including 4,520 in each group. The primary composite outcome was acute kidney injury, MI, and/or stroke during hospitalization after the index elevated SBP value. Treated patients had a higher rate of the composite outcome than untreated patients (11% vs. 8.2%, p < 0.001). This finding was consistent for both oral and IV medications and across rising SBP values.
It is tempting to do something rather than appear to do nothing. This study adds to evidence that treatment of elevated SBP in the hospital may be harmful rather than helpful. One limitation of the data is using markers of end-organ damage derived from a retrospective dataset, which may not be clinically meaningful in some cases. Additionally, the cohort may not be representative of the broader patient population as fewer patients received therapy for elevated SBP than reported in prior studies. It is noteworthy that there were similar rates of decline in SBP by ≥ 20 mm Hg on subsequent readings in both treated and untreated patients with SBP > 160. The blood pressure elevations may be for physiologic reasons, as is the case in patients with acute stroke, and lowering the blood pressure to make clinicians feel better may be counterproductive. If we wish to prevent end-organ damage with treatment, perhaps we should put a hard stop to our PRN orders.
For more information, see the topic Hypertension Medication Selection and Management in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Carina Brown, MD, Assistant Professor at Cone Health Family Medicine Residency. Edited by Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School, Dan Randall, MD, Deputy Editor for Internal Medicine at DynaMed, and Katharine DeGeorge, MD, MS, Associate Professor of Family Medicine at the University of Virginia and Clinical Editor at DynaMed.