Cardiology Guidelines

Questioning Antihypertensives for Older Patients

When clinicians find that an older hospitalized patient has elevated blood pressure, their next step is often to initiate antihypertensive treatment, but a new JAMA Internal Medicine study suggests that many of these patients would be better off having their BPs left unmanaged.

Researchers from Beth Israel, UCSF, and the VA analyzed data from 66k older VA patients hospitalized for non-cardiac conditions who experienced elevated BPs during their first 48 hours of hospitalization.

A sizable 21.3% of the patients (14k) received intensive BP treatments within their first 48 hours. 

  • Those patients were far more likely to experience at least one negative outcome (8.7% vs. 6.9%; weighted odds ratio: 1.28)
  • Their risk of negative outcomes was especially high if they received intravenous antihypertensives (weighted odds ratio: 1.90)
  • And the patients showed no clear benefits from receiving early and intensive BP treatments

Early treatment decisions also appeared to have a major impact on patients’ longer-term BP treatment regimens, as those treated within the first 48 hours ended up receiving far more antihypertensive doses than patients whose treatments started after 48 hours (mean additional doses: 6.1 vs. 1.6).

These results join a growing field of retrospective and observational studies that similarly highlighted the risks of intensive BP therapy, prompting the authors to call for the first RCTs on inpatient BP treatment. 

The authors also advised against initiating intensive BP treatments for non-cardiac patients unless there’s evidence of organ damage, and especially avoiding intravenous antihypertensives, while shifting clinical focus to managing the underlying causes of high BP.

Although many seemed to agree that clinicians should rethink how and when they treat elevated BP in these patients, others cautioned that these results might be biased (e.g. sicker patients are more likely to receive early/intense BP treatment) and aren’t strong enough to justify major changes in BP treatment policies on their own.

The Takeaway
One could make the case that this study is both clinically logical and at risk of statistical bias, and although a RCT would help settle both arguments, a BP RCT doesn’t appear to be coming soon.

With that, clinicians might benefit from acknowledging that early and intensive BP treatment appears to be associated with poor outcomes in non-cardiac patients (retrospectively, anyway), and making sure their BP treatment decisions are only as early and intense as each patient specifically requires.

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