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Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions

Educational Objective: To characterize clinician response to blood pressure in the hospital and at discharge and to compare short-term and long-term outcomes associated with antihypertensive treatment intensification.
1 Credit CME
Key Points

Question  Among adults with noncardiac admissions, is treatment of hypertension during the admission or antihypertensive treatment intensification at discharge associated with better outcomes?

Findings  In this cohort study of 22 834 adults, inpatient hypertension treatment, both oral and intravenous, was associated with higher rates of subsequent acute kidney and myocardial injury. There was no blood pressure interval in which treatment was associated with better outcomes, and medication intensification at discharge was not associated with improved blood pressure control.

Meaning  In this study, in the absence of evidence of end-organ damage, conservative management of inpatient hypertension was associated with improved outcomes compared with more intensive management.

Abstract

Importance  Despite high prevalence of elevated blood pressure (BP) among medical inpatients, BP management guidelines are lacking for this population. The outcomes associated with intensifying BP treatment in the hospital are poorly studied.

Objectives  To characterize clinician response to BP in the hospital and at discharge and to compare short- and long-term outcomes associated with antihypertensive treatment intensification.

Design, Setting, and Participants  This cohort study took place from January 1 to December 31, 2017, with 1 year of follow-up at 10 hospitals within the Cleveland Clinic Hospitals health care system. All adults admitted to a medicine service in 2017 were evaluated for inclusion. Patients with cardiovascular diagnoses were excluded. Demographic and BP characteristics were used for propensity matching.

Exposures  Acute hypertension treatment, defined as administration of an intravenous antihypertensive medication or a new class of an oral antihypertensive treatment.

Main Outcomes and Measures  The association between acute hypertension treatment and subsequent inpatient acute kidney injury, myocardial injury, and stroke was measured. Postdischarge outcomes included stroke and myocardial infarction within 30 days and BP control up to 1 year.

Results  Among 22 834 adults hospitalized for noncardiovascular diagnoses (mean [SD] age, 65.6 [17.9] years; 12 993 women [56.9%]; 15 963 White patients [69.9%]), 17 821 (78%) had at least 1 hypertensive BP recorded during their admission. Of these patients, 5904 (33.1%) were treated. A total of 8692 of 106 097 cases (8.2%) of hypertensive systolic BPs were treated; of these, 5747 (66%) were treated with oral medications. In a propensity-matched sample controlling for patient and BP characteristics, treated patients had higher rates of subsequent acute kidney injury (466 of 4520 [10.3%] vs 357 of 4520 [7.9%]; P < .001) and myocardial injury (53 of 4520 [1.2%] vs 26 of 4520 [0.6%]; P = .003). There was no BP interval in which treated patients had better outcomes than untreated patients. A total of 1645 of 17 821 patients (9%) with hypertension were discharged with an intensified antihypertensive regimen. Medication intensification at discharge was not associated with better BP control in the following year.

Conclusions and Relevance  In this cohort study, hypertension was common among medical inpatients, but antihypertensive treatment intensification was not. Intensification of therapy without signs of end-organ damage was associated with worse outcomes.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: October 24, 2020.

Published Online: December 28, 2020. doi:10.1001/jamainternmed.2020.7501

Corresponding Author: Michael B. Rothberg MD, MPH, Cleveland Clinic, 9500 Euclid Ave, Mail Code G10, Cleveland, OH 44195 (rothbem@ccf.org).

Author Contributions: Dr Rastogi and Ms Sheehan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Dr Rastogi and Ms Sheehan contributed equally and are considered co-first authors of this work.

Concept and design: Rastogi, Rothberg.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Rastogi, Sheehan, Hu.

Critical revision of the manuscript for important intellectual content: Rastogi, Sheehan, Shaker, Kojima, Rothberg.

Statistical analysis: Rastogi, Sheehan, Hu.

Administrative, technical, or material support: Shaker, Rothberg.

Supervision: Rothberg.

Conflict of Interest Disclosures: None reported.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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