Clinical Question

Does the intensification of antihypertensive regimens at hospital discharge affect clinical outcomes?

Bottom Line

The intensification of antihypertensive regimens on discharge in older adults hospitalized for noncardiac conditions is associated with an increased risk of readmission (number needed to harm [NNH] = 27) and medication-related serious adverse events (NNH = 63) within 30 days. There is no association with a decreased risk of cardiovascular events at one year. (Level of Evidence = 2b)

Synopsis

Using national data from the U.S. Department of Veterans Affairs (VA), the investigators identified adults 65 years or older with hypertension who were admitted within a two-year period to a VA hospital for the common noncardiac conditions of pneumonia, urinary tract infection, or venous thromboembolism. Patients with a secondary diagnosis of atrial fibrillation, acute coronary syndrome, or acute cerebrovascular event were excluded. Using dispensing data from the VA hospital pharmacies, intensifications of antihypertensive regimens were identified by newly prescribed antihypertensive medications on discharge, or an increased dose by more than 20% of a medication that had been prescribed before admission. Patients who received more than 20% of their outpatient care outside the VA, patients admitted from nursing homes, and those who had been hospitalized within the past 30 days were excluded. Out of an initial cohort of 14,915 patients, of which 97% were male, 2,074 (14%) had antihypertensive regimen intensifications at discharge. These patients were more likely to be black and more likely to have higher prehospitalization blood pressures, higher inpatient blood pressures, and heart failure. Using propensity score matching, the investigators then compared 2,028 patients who had antihypertensive regimen intensifications with 2,028 similar patients without such intensifications. Those with intensification were more likely to be readmitted within 30 days of discharge (21% vs. 18%; hazard ratio [HR] = 1.23; 95% CI, 1.07 to 1.42) and were more likely to have an emergency department visit or hospitalization for a medication-related serious adverse event within 30 days (4.5% vs. 3.1%; HR = 1.41; 95% CI, 1.06 to 1.88). There was no difference between the two groups in the rate of cardiovascular events (defined as a composite of emergency department visits and hospitalizations for acute myocardial infarction, unstable angina, stroke, heart failure, or hypertension) at one year.

Study design: Cohort (retrospective)

Funding source: Government

Allocation: Uncertain

Setting: Inpatient (any location) with outpatient follow-up

Reference: Anderson TS, Jing B, Auerbach A, et al. Clinical outcomes after intensifying antihypertensive medication regimens among older adults at hospital discharge [published online August 19, 2019]. JAMA Intern Med. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2747871