ILLUSTRATIVE CASE
A 48-year-old man is admitted to your family medicine service for cellulitis after failed outpatient therapy. He has presumed community-acquired methicillin-resistant Staphylococcus aureus infection of the left lower extremity and is receiving intravenous (IV) vancomycin. His BP this morning is 176/98 mm Hg, and the reading from the previous shift was 168/94 mm Hg. He is asymptomatic from this elevated BP. Based on protocol, his nurse is asking about treatment in response to the multiple elevated readings. How should you address the patient’s elevated BP, knowing that you will see him for a transition management appointment in 2 weeks?
Elevated BP is common in the adult inpatient setting. Prevalence estimates range from 25% to > 50%. Many factors can contribute to elevated BP in the acute illness setting, such as pain, anxiety, medication withdrawal, and volume status.2,3
Treatment of elevated BP in outpatients is well researched, with evidence-based guidelines for physicians. That is not the case for treatment of asymptomatic elevated BP in the inpatient setting. Most published guidance on inpatient management of acutely elevated BP recommends IV medications, such as hydralazine or labetalol, although there is limited evidence to support such recommendations. There is minimal evidence for outcomes-based benefit in treating acute elevations of inpatient BP, such as reduced myocardial injury or stroke; however, there is some evidence of adverse outcomes, such as hypotension and prolonged hospital stays.4-8
Although the possibility of intensifying antihypertensive therapy for those with known hypertension or those with presumed “new-onset” hypertension could theoretically lead to improved outcomes over the long term, there is little evidence to support this presumption. Rather, there is evidence that intensification of antihypertensive therapy at discharge is linked to short-term harms. This was demonstrated in a propensity-matched veteran cohort that included 4056 hospitalized older adults with hypertension (mean age, 77 years; 3961 men), equally split between those who received antihypertensive intensification at hospital discharge and those who did not. Within 30 days, patients receiving intensification had a higher risk of readmission (number needed to harm [NNH] = 27) and serious adverse events (NNH = 63).9
The current study aimed to put all these pieces together by quantifying the prevalence of hypertension in hospitalized patients, characterizing clinician response to patients’ acutely elevated BP, and comparing both short- and long-term outcomes in patients treated for acute BP elevations while hospitalized vs those who were not. The study also assessed the potential effects of antihypertensive intensification at discharge.
STUDY SUMMARY
Treatment of acute hypertension was associated with end-organ injury
This retrospective, propensity score–matched cohort study (N = 22,834) evaluated the electronic health records of all adult patients (age > 18 years) admitted to a medicine service with a noncardiovascular diagnosis over a 1-year period at 10 Cleveland Clinic hospitals, with 1 year of follow-up data.
Exclusion criteria included hospitalization for a cardiovascular diagnosis; admission for a cerebrovascular event or acute coronary syndrome within the previous 30 days; pregnancy; length of stay of less than 2 days or more than 14 days; and lack of outpatient medication data. Patients were propensity-score matched using BP, demographic features, comorbidities, hospital shift, and time since admission. Exposure was defined as administration of IV antihypertensive medication or a new class of oral antihypertensive medication.
Continue to: Outcomes were defined...
