Things We Do for No Reason™: Intensifying antihypertensive medications for hospitalized patients at the time of discharge

The “Things We Do for No Reason” series reviews practices, which have become common parts of hospital care, may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. A 63-year-old male with essential hypertension, chronic obstructive lung disease (COPD), diabetes, and hyperlipidemia presented to the emergency department (ED) with 2 days of shortness of breath. The ED clinician diagnosed him with a COPD exacerbation and admitted him to the hospital. He has taken hydrochlorothiazide 25 mg daily and lisinopril 20 mg daily for the past 3 years. In his primary care clinic, his blood pressure (BP) typically measures between 125/70 and 140/80 mmHg. Throughout his hospital stay, his BP ranged from 148/79 to 175/102 mmHg. By hospital Day 4, his dyspnea has resolved, and he feels well, but his BP remains 156/91 mmHg. The hospitalist team considers increasing his antihypertensives before discharge. The majority of hospitalized patients have one or more chronic diseases including hypertension, the most common comorbidity.1 Between 24% and 87% of hospitalized patients present with elevated BP.2, 3 Noncardiac hospitalizations often result in intensification of antihypertensives. In a large Veterans Health Administration (VHA) retrospective cohort study, clinicians discharged 14% of older adults with intensified antihypertensives.4 In another retrospective cohort from a large regional health system, clinicians discharge 9% of adults on an augmented BP regimen.5 Intensification of home antihypertensives at discharge may occur for a variety of reasons. First, hospitalists may extrapolate outpatient BP goals to the hospitalized patient. Given the long-term importance of controlling hypertension to improve cardiovascular outcomes, inpatient clinicians may believe that BP elevations in the hospital setting correlate with outpatient readings and warrant treatment. Furthermore, they may worry that inpatient hypertension will produce similar poor outcomes compared to patients with chronic elevations in the outpatient setting.6 Second, the fragmentation of care and poor communication can lead the clinician to change chronic disease medication regimens to “optimize” patients before their next PCP visit. Third, hospitalists may assume that patients elevated inpatient BP reflects their true ambulatory pressures. Fourth, hospitalists frequently perceive that the close monitoring afforded by hospitalization provides an opportunity to optimize BP therapy.7 Last, nurses, consultants, or patients themselves might question hypertensive readings and request that hospitalists intensify treatment. The frequent vital sign monitoring that occurs in the hospital setting and the various nursing alarms and triggers for “abnormal” vital signs can exacerbate this. To understand why routinely intensifying antihypertensives at discharge may harm instead of helping patients, one must examine the basic assumptions that it will lead to improved outpatient adherence and BP control and a reduction in cardiovascular outcomes (e.g., myocardial ischemia or heart failure exacerbation). Many patients whose hospitalists alter their medications have well-controlled BP before hospitalization. As a result, the best available data shows that antihypertensive intensification at discharge does not improve outcomes. In fact, patients commonly face adverse events. While we lack guidelines on the management of asymptomatic BP elevation in the inpatient setting and have little evidence that treating elevated inpatient BP improves outcomes, extant research can inform clinical decisions. A 2018 VHA study reveals the prevalence of this problem. Of the 14,915 older adult veterans (median age 76 years) admitted with a noncardiac condition, 65% had well controlled outpatient BP before hospital admission. Nearly half of the patients with elevated inpatient BP had normotensive BP before admission, highlighting that many variables in the hospital setting can precipitate higher than usual BP.4 These include white coat hypertension, medication and dose interruption, stress, anxiety, nausea, fever, and pain.8 Despite having a controlled outpatient BP, 11.2% of these patients had their BP regimen intensified.4 How providers obtain BP measurements in the hospital should make hospitalists question whether to act on the data. Methods often deviate from current recommendations designed for ambulatory practice, including repeated readings while seated in a quiet environment.9, 10 In a UK hospital, 96% of patients had their BP measured only once, 36% had it measured with the incorrect cuff size, and 41% of patients conversed with staff during measurements.11 Unfortunately, intensifying BP treatment before discharge may not improve outcomes. In a 2019 retrospective cohort study of patients over 65 years old hospitalized for noncardiac diagnoses in the VHA system, investigators reported on outcomes 1 year after intensification of antihypertensive regimens at hospital discharge. They found no differences in mortality, readmissions, or cardiovascular events (defined as ED visits or hospitalization for acute myocardial infarction, unstable angina, stroke, heart failure, or hypertension) among patients who did and did not receive BP regimen intensifications at discharge.12 Another retrospective cohort study of younger hypertensive patients (mean age 66 years) hospitalized for noncardiac conditions in 2017 showed that patients discharged on an intensified regimen did not have better BP control with 1-year follow-up but had higher rates of myocardial infarction and acute kidney injury.5 With the addition of new or intensified medications come potential adverse effects, often seen shortly after hospitalists change the regimen. In the aforementioned VHA study, the authors analyzed rates of serious adverse events (defined as first ED visit or hospitalization for injurious falls, syncope, hypotension, electrolyte abnormalities, or acute kidney injury) and hospital readmission at 30 days.12 The group receiving BP regimen intensifications had a higher risk of serious adverse events (hazard ratio [HR]: 1.41, 95% confidence interval [CI]: 1.06–1.88, number needed to harm [NNH]: 63) and higher risk of readmission (HR: 1.23, 95% CI: 1.07–1.42, NNH: 27) as compared to a matched cohort of patients who did not.12 The 30-day cardiovascular event rate in the group that received BP treatment intensification surpassed that of the control (3.6% vs. 2.2%, HR: 1.65, 95% CI: 1.13–2.40, NNH: 72). When specifically looking at patients with well-controlled prehospitalization BP (office systolic BP < 140 mmHg), the group that had their regimen intensified experienced a higher risk of adverse events at 30 days (HR: 1.65, 95% CI: 1.13–2.40, NNH: 41) and a higher risk of cardiovascular events at 1 year (HR: 1.37, 95% CI: 1.08–1.75, NNH: 30).12 Studies investigating inpatient BP management explicitly exclude admissions for cardiovascular disease.12 Conditions where BP plays an important role, such as congestive heart failure exacerbation, acute stroke, or acute coronary syndrome, likely benefit from intensification of antihypertensives.13, 14 For all other patients, no clear BP cutoffs exist that obligate hospitalists to initiate or intensify BP medications. However, consider intensifying therapy for patients with pre-existing ambulatory hypertension.15 The hospitalist should not react and treat a single elevation of BP but pay attention to the trend, risk factors, and diagnoses. Initiation or intensification of BP medications should occur when the BP is extremely elevated in patients with known cardiovascular risks and the clinical situation presents short-term risks. Outside these situations, the hospitalist should contact the PCP to establish how well the patient's BP is controlled in the ambulatory setting and to understand the patient's previous experience with antihypertensive medications. Before considering antihypertensive intensification, address all contributing conditions. This can include mitigation of anxiety, treatment of pain, diagnosis of urinary retention or withdrawal from nicotine, alcohol, or illicit drugs, or uncovering withheld home medications.7, 16 Do not forget to factor in prescribed medications like intravenous fluids, NSAIDs, steroids, or other treatments that may transiently increase BP. Efforts to optimize the inpatient environment can improve physiologic parameters such as BP.17 Try decreasing the frequency of vital signs measurements and avoid nighttime checks for stable patients. Delay BP measurements for patients with unaddressed pain and/or anxiety. Hospital discharge must include effective patient education and care coordination. To optimize patients' understanding of their existing medication, do not miss the opportunity to counsel patients regarding medication adherence. Many studies reveal patients adhere less often to new medications postdischarge, suggesting that patients benefit from follow-up with a PCP.18 A “warm” handoff to the PCP with a discussion about a potential need for intensification of medications should also include details about the patient's BP trends in the hospital. For patients without a PCP, simply helping to establish outpatient care may benefit them more than starting new medications. Do not routinely intensify BP regimens in patients admitted for noncardiac causes. When available, review prehospitalization BPs and use this to help guide whether to intensify BP treatment. Educate patients on outpatient BP goals, stressing that inpatient BP may not reflect their baseline and that harm can result with overtreatment. Recognize clinical circumstances where inpatient changes to the BP medication regimen are warranted. Returning to our clinical scenario, our patient experienced asymptomatic elevated BP outside of his normal range while in the hospital, possibly worsened by steroid administration. This patient needs close outpatient follow-up with his PCP within 7–14 days of discharge. The hospitalist should prescribe a validated BP cuff to encourage home monitoring. The hospitalist should ensure a discharge summary with all active medications reaches the patient's PCP in advance of his follow-up appointment and, ideally, a “warm handoff” should occur. Timothy S. Anderson was supported by the National Institute on Aging (K76AG074878). Timothy S. Anderson reported receiving grants from the American Heart Association, American College of Cardiology, Boston OAIC Pepper Center, and the US Deprescribing Research Network outside of the submitted work. The remaining authors declare no conflict of interest.