Although hospital care plays a key role in the diagnosis and treatment of severe acute disease, patients may have multiple chronic illnesses that are not directly related to the reason for admission. For some patients, admission offers a valuable opportunity to start appropriate management of chronic illnesses and to address preventative health issues. For other patients, however, attempts to intensify therapy for chronic diseases can cause more harm than benefit.
Our interest in this topic was spurred by personal experience working in an academic medical center and an affiliated VA hospital. We observed that patients who had well-controlled blood pressure prior to hospitalization were being discharged with substantially escalated regimens of antihypertensive medications. In a recent example, an 82-year-old man with severe chronic obstructive pulmonary disease and remote coronary artery bypass grafting was admitted for chest pain. Prior to admission, his blood pressure was normal without use of any antihypertensive medications. On hospital day 1, his blood pressure rose to about 160/80 mm Hg, likely owing to the stress of the acute illness. Although acute coronary syndrome was quickly ruled out, the patient was prescribed losartan potassium, 25 mg daily, and low-dose metoprolol tartrate, twice daily; both medications were continued at discharge. At his first outpatient follow-up visit 3 days later, his blood pressure was about 85/45 mm Hg.