Beware of Intensifying Antihypertensive Regimen at Hospital Discharge

By Will Boggs MD

NEW YORK (Reuters Health) - Hospitalists often change antihypertensives in patients whose blood pressure is increased during hospitalization, even if their blood pressure was well-controlled before hospitalization - but discharging the patient on the intensified regimen can lead to serious side effects, researchers say.

"Our study adds to others that indicate the few weeks after coming home from the hospital are a particularly high-risk time for medication confusion, error, and harms - so the safest route will always be to check on whether changes to long-term medications are necessary," said Dr. Timothy S. Anderson of Beth Israel Deaconess Medical Center, in Brookline, Massachusetts.

"I think our findings support the notion that when a hospitalized patient is sick, poorly rested, in pain, possibly delirious, and meeting many new doctors, the odds of success with adjusting chronic disease medications are low and, if anything, making multiple medication changes may lead to confusion and an increased risk of medication error and avoidable harms," he told Reuters Health by email.

Dr. Anderson's team used medical records and Medicare claims data to investigate the rates of hospital readmissions, medication-related severe adverse events and cardiovascular events after discharge in older adults with hypertension with intensified antihypertensive regimens versus those without such changes.

In propensity-score-matched comparisons, patients discharged with intensified blood pressure treatment were 23% more likely to be readmitted to the hospital and 41% more likely to have a serious adverse event within 30 days of discharge than were patients whose treatment was not intensified. Both findings were statistically significant.

Cardiovascular events within 30 days of discharge were uncommon but more likely among patients with intensified blood pressure treatment.

The groups did not differ, however, in the rate of cardiovascular events within one year of discharge or in the risk of dying within 30 days of discharge, the researchers reported in JAMA Internal Medicine, online August 19.

Despite intensification of blood pressure treatment, there was no significant difference in the change in blood pressure after hospital discharge between the groups.

"I think it is extremely important for patients with chronic conditions to follow up with their outpatient providers after being hospitalized and to discuss any and all medication changes that were made while being hospitalized," said Dr. Anderson.

"While our findings indicate that hospitalization may not be the right time for increasing older adults' blood pressure medications, I think it is important to note that, at a population level, we have a lot of work to do to improve the blood pressure control in older adults," he said. "Thus, it may be that hospitalization is the right time to identify new blood pressure concerns, or concerns about other chronic conditions, that can be addressed in short-term follow-up after patients have recovered from their acute illness."

Dr. Franz H. Messerli, a professor of medicine at Mount Sinai Icahn School of Medicine in New York City, who was not involved in the study, told Reuters Health by email, "What is done daily in numerous teaching hospitals all over the globe is at best useless and at worst harmful. To utilize these flimsy inpatient blood pressures to adjust a regimen that the patient subsequently will take for months and years is highly inappropriate, particularly in the elderly."

"Hypertension is a lifelong disease; its treatment has to be based as close as possible on everyday blood pressure in real life," said Dr. Messerli, also of the University of Bern, in Switzerland, and Jagiellonian University, in Krakow, Poland.

Dr. Anderson was at the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center while conducting the study.

SOURCE: https://bit.ly/2ZbMhxn

JAMA Intern Med 2019.

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