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Original Investigation
August 19, 2019

Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge

Author Affiliations
  • 1Division of General Internal Medicine, University of California, San Francisco
  • 2San Francisco Veterans Affairs Medical Center, San Francisco, California
  • 3now with Division of General Medicine, Beth Israel Deaconess Medical Center, Brookline, Massachusetts
  • 4Division of Geriatrics, University of California, San Francisco
  • 5Division of Hospital Medicine, University of California School of Medicine, San Francisco
JAMA Intern Med. Published online August 19, 2019. doi:10.1001/jamainternmed.2019.3007
Key Points

Question  What is the association between the intensification of an antihypertensive regimen at hospital discharge and clinical outcomes of hospitalized older adults with hypertension?

Findings  In this national cohort study of 4056 propensity-matched older adults with hypertension who were hospitalized for noncardiac conditions, discharge with intensified antihypertensive regimens was associated with an increased risk of readmissions and serious adverse events within 30 days and was not associated with a reduction in cardiovascular events or blood pressure at 1 year.

Meaning  The findings suggest that intensification of antihypertensives at hospital discharge is associated with short-term harms without long-term benefits and should generally be avoided in older adults hospitalized for noncardiac conditions.

Abstract

Importance  Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization.

Objective  To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge.

Design, Setting, and Participants  In this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019.

Exposures  Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge.

Main Outcomes and Measures  The primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge.

Results  The propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1.06-1.88; NNH, 63; 95% CI, 34-370). At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, −2.4 to 3.7 mm Hg).

Conclusions and Relevance  Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.

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