Older vets often leave hospital on increased dose of blood pressure pills

[October 19, 2018]  By Lisa Rapaport

(Reuters Health) - Doctors may be overtreating high blood pressure in U.S. Veterans Administration hospitals, a new study suggests.

One in seven older veterans with hypertension are sent home from hospitals with increased doses of blood pressure medication even though half of those given more medication had well-controlled blood pressure before hospital admission, researchers found.

"Our results show evidence that doctors are treating inpatient blood pressures aggressively, despite there being no evidence to suggest this is beneficial in the short term," said lead author Dr. Timothy Anderson of the University of California San Francisco.

Uncontrolled high blood pressure can cause a range of serious and chronic health problems including heart attacks, heart failure, cognitive impairment and kidney and eye disease. But abnormally low blood pressure can increase the risk of dizziness and falls and reduce blood flow to the brain and vital organs.

The American Heart Association defines hypertension, or high blood pressure, as a systolic reading of 130 mmHg or higher and diastolic readings of 80 mmHg or higher. Systolic pressure reflects the pressure blood exerts against artery walls when the heart beats. Diastolic pressure indicates the pressure when the heart rests between beats.

For the study, researchers examined data on 14,915 patients aged 65 and older treated in the U.S. Veterans Administration Health System between 2011 and 2013 for three common conditions that typically don't require aggressive blood pressure management: pneumonia, urinary tract infections or clots in the deep veins of the legs.

Medical records indicate that 9,636 of these patients, or 65 percent, had well-controlled blood pressure before they were hospitalized.

A total of 2,074 patients were sent home with new prescriptions for drugs to lower their blood pressure or with increased doses of medicines they were taking previously - including 1,082 people who had well-controlled blood pressure before they were hospitalized, according to the results published in The BMJ.

"Decisions to intensify antihypertensives at discharge from hospital seem to be driven by inpatient blood pressure measurements and not the overall context of older adults' health or long-term disease control," Anderson said by email.

It's possible that frequent blood pressure measurements during hospitalization captured fluctuations that might have been missed before, Anderson said. But it's also possible that some people had spikes in blood pressure during hospital stays due to pain, stress, anxiety or exposure to new medications - and that their blood pressure would dip once they were out of the hospital without any changes in their blood pressure medication.

"As there are no guidelines for physicians on how to manage inpatient blood pressures, it appears physicians are applying outpatient blood pressure targets to the inpatient setting," Anderson said. "Because hospitalized older adults are particularly vulnerable to medication harms, this may be quite risky."

In the study, 1,293 people, or 9 percent, were started on one antihypertensive drug, and 300 people, or 2 percent, were given multiple new drugs to lower blood pressure.

An additional 628 patients, or 4 percent, were discharged on an increased dose of at least one antihypertensive medication they were taking before their hospitalization.

People who had elevated blood pressure in the hospital were more likely to get increased doses of drugs than those with well-controlled blood pressure during their hospital stays.

The study wasn't designed to determine whether the increased dosages were unsafe, or if patients had adverse effects from them after leaving the hospital.

"We do not know what the clinical impact of the intensified treatment is," said Dr. Costantino Iadecola, director of the Feil Family Brain and Mind Research Institute at Weill Cornell Medicine in New York City.

"The implication is that it is deleterious, but that remains to be seen," Iadecola, who wasn't involved in the study, said by email.

Ideally, doctors in the hospital would communicate with physicians treating the patients outside the hospital to coordinate treatment and determine whether a new blood pressure medication or a higher dose of an existing prescription is necessary when patients are discharged, Iadecola said.

"Better coordination between inpatient and outpatient care is needed to avoid the prolongation of unnecessary treatments," Iadecola said.

SOURCE: https://bit.ly/2CR36SV The BMJ, online September 12, 2018.

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