1
|
Deardorff WJ, Jing B, Growdon ME, Blank LJ, Bongiovanni T, Yaffe K, Boscardin WJ, Boockvar KS, Steinman MA. Impact of Hospitalizations on Problematic Medication Use Among Community-Dwelling Persons With Dementia. J Gerontol A Biol Sci Med Sci 2024; 79:glae207. [PMID: 39155601 PMCID: PMC11419320 DOI: 10.1093/gerona/glae207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Indexed: 08/20/2024] Open
Abstract
BACKGROUND Hospitalizations are frequently disruptive for persons with dementia (PWD) in part due to the use of potentially problematic medications for complications such as delirium, pain, and insomnia. We sought to determine the impact of hospitalizations on problematic medication prescribing in the months following hospitalization. METHODS We included community-dwelling PWD in the Health and Retirement Study aged ≥66 with a hospitalization from 2008 to 2018. We characterized problematic medications as medications that negatively affect cognition (strongly anticholinergics/sedative-hypnotics), medications from the 2019 Beers criteria, and medications from STOPP-V2. To capture durable changes, we compared problematic medications 4 weeks prehospitalization (baseline) to 4 months posthospitalization period. We used a generalized linear mixed model with Poisson distribution adjusting for age, sex, comorbidity count, prehospital chronic medications, and timepoint. RESULTS Among 1 475 PWD, 504 had a qualifying hospitalization (median age 84 (IQR = 79-90), 66% female, 17% Black). There was a small increase in problematic medications from the baseline to posthospitalization timepoint that did not reach statistical significance (adjusted mean 1.28 vs 1.40, difference 0.12 (95% CI -0.03, 0.26), p = .12). Results were consistent across medication domains and certain subgroups. In one prespecified subgroup, individuals on <5 prehospital chronic medications showed a greater increase in posthospital problematic medications compared with those on ≥5 medications (p = .04 for interaction, mean increase from baseline to posthospitalization of 0.25 for those with <5 medications (95% CI 0.05, 0.44) vs. 0.06 (95% CI -0.12, 0.25) for those with ≥5 medications). CONCLUSIONS Hospitalizations had a small, nonstatistically significant effect on longer-term problematic medication use among PWD.
Collapse
Affiliation(s)
- W James Deardorff
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Bocheng Jing
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Leah J Blank
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tasce Bongiovanni
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Kristine Yaffe
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Kenneth S Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama, Birmingham, Alabama, USA
- Birmingham Veterans Affairs Geriatrics Research Education and Clinical Center, Birmingham, Alabama, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| |
Collapse
|
2
|
Thompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR, Ahmad FS, Allen RB, Altin SE, Auerbach A, Berger JS, Chow B, Dakik HA, Eisenstein EL, Gerhard-Herman M, Ghadimi K, Kachulis B, Leclerc J, Lee CS, Macaulay TE, Mates G, Merli GJ, Parwani P, Poole JE, Rich MW, Ruetzler K, Stain SC, Sweitzer B, Talbot AW, Vallabhajosyula S, Whittle J, Williams KA. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024:S0735-1097(24)07611-3. [PMID: 39320289 DOI: 10.1016/j.jacc.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
AIM The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.
Collapse
|
3
|
Liu X, Jing B, Graham LA, Liu CK, Lee SJ, Steinman MA, Dave CV, Manja V, Li Y, Fung K, Odden MC. Complex Patterns of Antihypertensive Treatment Changes in Long-Term Care Residents. J Am Med Dir Assoc 2024; 25:105119. [PMID: 38950584 PMCID: PMC11368635 DOI: 10.1016/j.jamda.2024.105119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 04/19/2024] [Accepted: 05/22/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVES Antihypertensive treatment changes are common in long-term care residents, yet data on the frequency and predictors of changes are lacking. We described the patterns of antihypertensive changes and examined the triggering factors. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS A total of 24,870 Department of Veterans Affairs (VA) nursing home residents aged ≥65 years with long-term stays (≥180 days) from 2006 to 2019. METHODS We obtained data from the VA Corporate Data Warehouse. Based on Bar Code Medication Administration medication data, we defined 2 types of change events in 180 days of admission: deprescribing (reduced number of antihypertensives or dose reduction of ≥30% compared with the previous week and maintained for at least 2 weeks) and intensification (opposite of deprescribing). Mortality was identified within 2 years after admission. RESULTS More than 85% of residents were prescribed antihypertensives and 68% of them experienced ≥1 change event during the first 6 months of the nursing home stay. We categorized residents into 10 distinct patterns: no change (27%), 1 deprescribing (11%), multiple deprescribing (5%), 1 intensification (10%), multiple intensification (7%), 1 deprescribing followed by 1 intensification (3%), 1 intensification followed by 1 deprescribing (4%), 3 changes with mixed events (7%), >3 changes with mixed events (10%), and no antihypertensive use (15%). Treatment changes were more frequent in residents with better physical function and/or cognitive function. Potentially triggering factors differed by the type of antihypertensive change: incident high blood pressure and cardiovascular events were associated with intensification, and low blood pressure, weight loss, and falls were associated with deprescribing. Death occurred in 7881 (32%) residents over 2 years. The highest mortality was for those without antihypertensive medication (incidence = 344/1000 person-years). CONCLUSIONS AND IMPLICATIONS Patterns of medication changes existing in long-term care residents are complex. Future studies should explore the benefits and harms of these antihypertensive treatment changes.
Collapse
Affiliation(s)
- Xiaojuan Liu
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA; Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Bocheng Jing
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Laura A Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA; Stanford-Surgery Policy Improvement Research Education Center, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Christine Kee Liu
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA; Section of Geriatrics, Division of Primary Care and Population Health, Stanford University, School of Medicine, Stanford, CA, USA
| | - Sei J Lee
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michael A Steinman
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chintan V Dave
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA; Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - Veena Manja
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Health Policy, Stanford University, Stanford, CA, USA
| | - Yongmei Li
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Kathy Fung
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michelle C Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA; Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| |
Collapse
|
4
|
Jacobs ZG, Anderson TS. Management of Elevated Blood Pressure in the Hospital-Rethinking Current Practice. JAMA Intern Med 2024; 184:1117-1118. [PMID: 39037784 DOI: 10.1001/jamainternmed.2024.3279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
This Clinical Insight proposes a new framework for managing asymptomatic blood pressure elevation in the hospital setting.
Collapse
Affiliation(s)
- Zachary G Jacobs
- Division of Hospital Medicine, Oregon Health & Science University, Portland
| | - Timothy S Anderson
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, VA Pittsburgh Health System, Pittsburgh, Pennsylvania
- Associate Editor, JAMA Internal Medicine
| |
Collapse
|
5
|
Japelj N, Kerec Kos M, Jošt M, Knez L. Impact of changes in antihypertensive medication on treatment intensity at hospital discharge and 30 days afterwards. Front Pharmacol 2024; 15:1376002. [PMID: 39185310 PMCID: PMC11341450 DOI: 10.3389/fphar.2024.1376002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/12/2024] [Indexed: 08/27/2024] Open
Abstract
Introduction Little is known about the cumulative effect of changes in antihypertensive medications on treatment intensity. This study analyzed how changes in antihypertensive medications affect the intensity of antihypertensive treatment at hospital discharge and 30 days afterwards. Methods A prospective observational study of 299 hospitalized adult medical patients with antihypertensive therapy was conducted. The effect of medication changes on treatment intensity was evaluated by the Total Antihypertensive Therapeutic Intensity Score (TIS). Results At discharge, antihypertensive medications were changed in 62% of patients (184/299), resulting in a very small median reduction in TIS of -0.16. Treatment intensity was reduced more with increasing number of antihypertensive medications at admission, whereas it increased with elevated inpatient systolic blood pressure. Thirty days after discharge, antihypertensive medications were changed in 37% of patients (88/239) resulting in a median change in TIS of -0.02. Among them, 90% (79/88) had already undergone a change at discharge. The change in treatment intensity after discharge was inversely correlated with a change at discharge. Discussion Changes in antihypertensive medication frequently occurred at discharge but had a minimal impact on the intensity of antihypertensive treatment. However, these adjustments exposed patients to further medication changes after discharge, evidencing the need for treatment reassessment in the first month post-discharge.
Collapse
Affiliation(s)
- Nuša Japelj
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Mojca Kerec Kos
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Maja Jošt
- Department of Pharmacy, University Clinic Golnik, Golnik, Slovenia
| | - Lea Knez
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
- Department of Pharmacy, University Clinic Golnik, Golnik, Slovenia
| |
Collapse
|
6
|
Growdon ME, Jing B, Morris EJ, Deardorff WJ, Boscardin WJ, Byers AL, Boockvar KS, Steinman MA. Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid-loop diuretic cascade. J Am Geriatr Soc 2024; 72:1728-1740. [PMID: 38547357 PMCID: PMC11187679 DOI: 10.1111/jgs.18892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/16/2024] [Accepted: 03/03/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Prescribing cascades are important contributors to polypharmacy. Little is known about which older adults are at highest risk of experiencing prescribing cascades. We explored which older veterans are at highest risk of the gabapentinoid (including gabapentin and pregabalin)-loop diuretic (LD) cascade, given the dramatic increase in gabapentinoid prescribing in recent years. METHODS Using Veterans Affairs and Medicare claims data (2010-2019), we performed a prescription sequence symmetry analysis (PSSA) to assess loop diuretic initiation before and after gabapentinoid initiation among older veterans (≥66 years). To identify the cascade, we calculated the adjusted sequence ratio (aSR), which assesses the temporality of LD relative to gabapentinoid initiation. To explore high-risk groups, we used multivariable logistic regression with prescribing order modeled as a binary dependent variable. We calculated adjusted odds ratios (aORs), measuring the extent to which factors are associated with one prescribing order versus another. RESULTS Of 151,442 veterans who initiated a gabapentinoid, there were 1,981 patients who initiated a LD within 6 months after initiating a gabapentinoid compared to 1,599 patients who initiated a LD within 6 months before initiating a gabapentinoid. In the gabapentinoid-LD group, the mean age was 73 years, 98% were male, 13% were Black, 5% were Hispanic, and 80% were White. Patients in each group were similar across patient and health utilization factors (standardized mean difference <0.10 for all comparisons). The aSR was 1.23 (95% CI: 1.13, 1.34), strongly suggesting the cascade's presence. People age ≥85 years were less likely to have the cascade (compared to 66-74 years; aOR 0.74, 95% CI: 0.56-0.96), and people taking ≥10 medications were more likely to have the cascade (compared to 0-4 drugs; aOR 1.39, 95% CI: 1.07-1.82). CONCLUSIONS Among older adults, those who are younger and taking many medications may be at higher risk of the gabapentinoid-LD cascade, contributing to worsening polypharmacy and potential drug-related harms. We did not identify strong predictors of this cascade, suggesting that prescribing cascade prevention efforts should be widespread rather than focused on specific subgroups.
Collapse
Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Bocheng Jing
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Earl J Morris
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, USA
| | - W James Deardorff
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Amy L Byers
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Kenneth S Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| |
Collapse
|
7
|
Uber AM, Han J, Grimm P, Montez-Rath ME, Chaudhuri A. Defining systolic blood pressure normative values in hospitalized pediatric patients: a single center experience. Pediatr Res 2024; 95:1860-1867. [PMID: 38326477 DOI: 10.1038/s41390-024-03059-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/12/2023] [Accepted: 01/15/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND Normative blood pressure (BP) values and definition of hypertension (HTN) in children in outpatient setting cannot be reliably used for inpatient therapy initiation. No normative exists to describe HTN in hospitalized pediatric populations. We aimed to study the prevalence of hypertension and produce normative BP values in hospitalized children. METHODS Cross sectional observational study of all children hospitalized on acute care floors, ≥2 and <18 years age, at Stanford Children's Hospital, from Jan-01-2014 to Dec-31-2018. Cohort included 7468 hospital encounters with a total of 118,423 automated, oscillometric, BPs measured in the upper extremity during a hospitalization of >24 hours. RESULTS Overall prevalence of HTN, defined by outpatient guidelines, was 12-48% in boys and 6-39% in girls, stage 1 systolic HTN in 12-38% of boys and 6-31% of girls, stage 2 systolic HTN in 3-10% of boys and 1-8% of girls. Centile curves were derived demonstrating overall higher BP reading for hospitalized patients compared to the outpatient setting. CONCLUSION Higher blood pressures are anticipated during hospitalization. Thresholds provided by the centile curves generated in this study may provide the clinician with some guidance on how to manage hospitalized pediatric patients based on clinical circumstances. IMPACT Hospitalized children have higher blood pressures compared to patients in the ambulatory setting, hence outpatient normative blood pressure values cannot be reliably used for inpatient therapy initiation. No normative exists to describe hypertension in hospitalized pediatric populations. The thresholds provided by the centile curves generated in this study may provide the clinician with some guidance on how to manage hospitalized pediatric patients based on clinical circumstances.
Collapse
Affiliation(s)
- Amanda M Uber
- Department of Nephrology, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Jialin Han
- Department of Nephrology, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul Grimm
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, Stanford, CA, USA
| | - Maria E Montez-Rath
- Department of Nephrology, Stanford University School of Medicine, Stanford, CA, USA
| | - Abanti Chaudhuri
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, Stanford, CA, USA.
| |
Collapse
|
8
|
Griffin BR, Vaughan-Sarrazin M, Shi Q, Ten Eyck P, Reisinger HS, Kennelty K, Good MK, Swee ML, Yamada M, Lund BC, Jalal DI. Blood Pressure, Readmission, and Mortality Among Patients Hospitalized With Acute Kidney Injury. JAMA Netw Open 2024; 7:e2410824. [PMID: 38739389 DOI: 10.1001/jamanetworkopen.2024.10824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Importance Acute kidney injury (AKI) complicates 20% to 25% of hospital admissions and is associated with long-term mortality, especially from cardiovascular disease. Lower systolic blood pressure (SBP) following AKI may be associated with lower mortality, but potentially at the cost of higher short-term complications. Objective To determine associations of SBP with mortality and hospital readmissions following AKI, and to determine whether time from discharge affects these associations. Design, Setting, and Participants This retrospective cohort study of adults with AKI during a hospitalization in Veteran Healthcare Association (VHA) hospitals was conducted between January 2013 and December 2018. Patients with 1 year or less of data within the VA system prior to admission, severe or end-stage liver disease, stage 4 or 5 chronic kidney disease, end-stage kidney disease, metastatic cancer, and no blood pressure values within 30 days of discharge were excluded. Data analysis was conducted from May 2022 to February 2024. Exposure SBP was treated as time-dependent (categorized as <120 mm Hg, 120-129 mm Hg, 130-139 mm Hg, 140-149 mm Hg, 150-159 mm Hg, and ≥160 mm Hg [comparator]). Time spent in each SBP category was accumulated over time and represented in 30-day increments. Main Outcomes and Measures Primary outcomes were time to mortality and time to all-cause hospital readmission. Cox proportional hazards regression was adjusted for demographics, comorbidities, and laboratory values. To evaluate associations over time, hazard ratios (HRs) were calculated at 60 days, 90 days, 120 days, 180 days, 270 days, and 365 days from discharge. Results Of 237 409 admissions with AKI, 80 960 (57 242 aged 65 years or older [70.7%]; 77 965 male [96.3%] and 2995 female [3.7%]) were included. The cohort had high rates of diabetes (16 060 patients [20.0%]), congestive heart failure (22 516 patients [28.1%]), and chronic lung disease (27 682 patients [34.2%]), and 1-year mortality was 15.9% (12 876 patients). Overall, patients with SBP between 130 and 139 mm Hg had the most favorable risk level for mortality and readmission. There were clear, time-dependent mediations on associations in all groups. Compared with patients with SBP of 160 mm Hg or greater, the risk of mortality for patients with SBP between 130 and 139 mm Hg decreased between 60 days (adjusted HR, 1.20; 99% CI, 1.00-1.44) and 365 days (adjusted HR, 0.58; 99% CI, 0.45-0.76). SBP less than 120 mm Hg was associated with increased risk of mortality at all time points. Conclusions and Relevance In this retrospective cohort study of post-AKI patients, there were important time-dependent mediations of the association of blood pressure with mortality and readmission. These findings may inform timing of post-AKI blood pressure treatment.
Collapse
Affiliation(s)
- Benjamin R Griffin
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Mary Vaughan-Sarrazin
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Qianyi Shi
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, Iowa City, Iowa
| | - Patrick Ten Eyck
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Heather S Reisinger
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Korey Kennelty
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
- The University of Iowa College of Pharmacy, Iowa City
| | - Mary K Good
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, Iowa City, Iowa
| | - Melissa L Swee
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Masaaki Yamada
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Brian C Lund
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, Iowa City, Iowa
| | - Diana I Jalal
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, Iowa City, Iowa
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| |
Collapse
|
9
|
Garg K, Staunton MK, Peixoto AJ, Wilson FP, Ghazi L. Correlates of Spontaneous Blood Pressure Reduction Following Severe Inpatient Hypertension Development. Am J Hypertens 2024; 37:273-279. [PMID: 37988620 DOI: 10.1093/ajh/hpad112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/29/2023] [Accepted: 11/18/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Severe hypertension (sHTN) is prevalent in 10% of hospitalized patients and treatment guidelines are lacking. As such, patients who develop sHTN might unnecessarily receive antihypertensive medications which could lead to worse outcomes. Our goal was to investigate correlates of spontaneous blood pressure (BP) reduction to help guide future treatment decisions and avoid harm associated with aggressive BP treatment. METHODS This is a retrospective cohort study of hospitalized adults between 2016 and 2020 who developed sHTN, SBP >180 or DBP >110 mm Hg, after admission. Spontaneous BP reduction was defined as a SBP <160 and a DBP <100 mm Hg achieved within 3 h of sHTN in the absence of antihypertensive therapy. Multivariable logistic regression was used to identify correlates of spontaneous BP reduction. RESULTS Of the 12,825 patients who developed sHTN, 44.2% had spontaneous BP reduction. After adjustment, we found that patients most likely to experience a BP drop received steroids before onset of sHTN (Odds ratio [OR]: 1.3 [1.09, 1.56]), had higher potassium levels on admission (OR: 1.2 [1.09, 1.24]) and were more likely to have a history of chronic pulmonary disease (OR: 1.1 [1.01, 1.18]) or cardiac arrythmia (OR: 1.1 [1.01, 1.18]). While numerically different, these differences were not clinically relevant. CONCLUSIONS Our findings indicate that almost half the patients who develop sHTN have spontaneous BP reduction. Conventional clinical and demographic characteristics were not strong predictors of spontaneous BP reduction following sHTN development. More research is needed to confirm our findings and help guide treatment of sHTN.
Collapse
Affiliation(s)
- Kanika Garg
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
| | - Mary Kate Staunton
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
| | - Aldo J Peixoto
- Section of Nephrology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Francis Perry Wilson
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
- Section of Nephrology, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Lama Ghazi
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
10
|
Kou M, Wang X, Ma H, Li X, Heianza Y, Qi L. Degree of Risk Factor Control and Incident Cardiovascular Diseases in Patients With Hypertension. Mayo Clin Proc 2024; 99:387-399. [PMID: 38323938 DOI: 10.1016/j.mayocp.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/28/2023] [Accepted: 05/03/2023] [Indexed: 02/08/2024]
Abstract
OBJECTIVE To investigate whether joint risk factor control could reduce the excess risk of cardiovascular disease (CVD) in patients with hypertension. PATIENTS AND METHODS A total of 75,293 patients with diagnosed hypertension from the UK Biobank study were included, matched with 256,619 nonhypertensive controls, and followed up until May 31, 2021. Seven risk factors were measured to define joint risk factor control, including blood pressure, body mass index, low-density lipoprotein cholesterol, hemoglobin A1c, albuminuria, smoking, and physical activity. RESULTS Among hypertensive patients, 14% to 24% lower risks of CVD outcomes were associated with each additional risk factor control. In the Cox proportional hazards models, adjusted hazard ratios for patients with 6 or more risk factor controls compared with patients having 2 or less risk factor controls were 0.49 (95% CI, 0.45 to 0.55) for CVD, 0.51 (95% CI, 0.45 to 0.57) for coronary heart disease, 0.48 (95% CI, 0.38 to 0.60) for stroke, and 0.34 (95% CI, 0.26 to 0.44) for CVD mortality. The excess risks of CVD outcomes in patients with hypertension were diminished to nonsignificant or even lower compared with controls if achieving 6 or more risk factor controls. Men experienced stronger protective associations of joint risk factor control on risks of CVD than women (P<.001 for interaction). CONCLUSION The joint risk factor control is associated with lower risks of CVD, and a high degree of risk factor control may considerably attenuate the excess risk of CVD among patients with hypertension.
Collapse
Affiliation(s)
- Minghao Kou
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Xuan Wang
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Hao Ma
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Xiang Li
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Yoriko Heianza
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Lu Qi
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA.
| |
Collapse
|
11
|
Rachoin JS, Cerceo E, Anderson TS. Things We Do for No Reason™: Intensifying antihypertensive medications for hospitalized patients at the time of discharge. J Hosp Med 2024; 19:219-222. [PMID: 37545427 DOI: 10.1002/jhm.13185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Jean-Sebastien Rachoin
- Department of Medicine, Division of Hospital Medicine, Cooper University Healthcare, Camden, New Jersey, USA
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Elizabeth Cerceo
- Department of Medicine, Division of Hospital Medicine, Cooper University Healthcare, Camden, New Jersey, USA
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
12
|
Kanis E, Gallegos P, Christman K, Vazquez D, Mullen C, Cucci MD. Impact of medication intensification on 30-day hospital readmissions in a geriatric trauma population: A multicenter cohort study. Pharmacotherapy 2024; 44:39-48. [PMID: 37926857 DOI: 10.1002/phar.2890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/08/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Fall-related injuries are a significant health issue that occur in 25% of older adults and account for a significant number of trauma-related hospitalizations. Although medication intensification may increase the risk of hospital readmissions in non-trauma patients, data on a geriatric trauma population are lacking. OBJECTIVE The primary objective was to evaluate the effect of medication intensification on 30-day hospital readmissions in geriatric patients hospitalized for fall-related injuries. METHODS This multicenter, retrospective cohort study included patients with geriatric who presented to one of three trauma centers within a large, health-system between January 1, 2018 and December 31, 2020. Patients at least 65 years old admitted with a fall-related injury were eligible for inclusion. Patients were grouped according to medication changes at discharge, which included intensified and non-intensified groups. Medication intensification included increased dose(s) or initiation of new agents. The primary outcome was the 30-day hospital readmission rate. RESULTS Of the 870 patients included (median [interquartile range, IQR] age, 82 [74-89] years, 522 (60%) female, and 220 (25%) with a previous fall), there were 471 (54%) and 399 (46%) patients in the intensified and non-intensified groups, respectively. The intensified group had a higher 30-day hospital readmission rate (21% intensified vs. 16% non-intensified, p = 0.043; number needed to harm 20) based on an unweighted analysis. According to a weighted propensity score logistic regression, medication intensification was associated with higher 30-day hospital readmissions (24% [95% confidence interval [CI] 19-31%] intensified vs. 15% [95% CI 11-20%] non-intensified, p = 0.018). These results were consistent within competing risk models accounting for death (cause-specific model: hazard ratio [HR] 1.63 [95% CI 1.07-2.49], p = 0.023; Fine-Gray model: HR 1.64 [95% CI 1.07-2.50], p = 0.022). CONCLUSIONS In a geriatric trauma population hospitalized after a fall, intensification of medications may pose an increased risk of 30-day hospital readmission.
Collapse
Affiliation(s)
- Emily Kanis
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Patrick Gallegos
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, Ohio, USA
- Department of Pharmacy Practice, Department of Internal Medicine, Northeast Ohio Medical Center, Rootstown, Ohio, USA
| | - Kailey Christman
- Department of Research, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Daniel Vazquez
- Department of Surgery, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Chanda Mullen
- Department of Research, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Michaelia D Cucci
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, Ohio, USA
| |
Collapse
|
13
|
Shantsila E, Lip GYH, Shantsila A, Kurpas D, Beevers G, Gill PS, Williams NH. Antihypertensive treatment in people of very old age with frailty: time for a paradigm shift? J Hypertens 2023; 41:1502-1510. [PMID: 37432893 DOI: 10.1097/hjh.0000000000003495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
The optimal management of hypertension in individuals aged 80 years or older with frailty remains uncertain due to multiple gaps in evidence. Complex health issues, polypharmacy, and limited physiological reserve make responding to antihypertensive treatments unpredictable. Patients in this age group may have limited life expectancy, so their quality of life should be prioritized when making treatment decisions. Further research is needed to identify which patients would benefit from more relaxed blood pressure targets and which antihypertensive medications are preferable or should be avoided. A paradigm shift is required in attitudes towards treatment, placing equal emphasis on deprescribing and prescribing when optimizing care. This review discusses the current evidence on managing hypertension in individuals aged 80 years or older with frailty, but further research is essential to address the gaps in knowledge and improve the care of this population.
Collapse
Affiliation(s)
- Eduard Shantsila
- Department of Primary Care and Mental Health, University of Liverpool
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Alena Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Donata Kurpas
- Health Sciences Faculty, Wrocław Medical University, Wrocław, Poland
- Primary Care and Risk Factor Management Section, European Association of Preventative Cardiology, European Heart House, Les Templiers, Sophia Antipolis
- International Advisory Board of EURIPA (WONCA) - France
- International Foundation for Integrated Care (IFIC), Schiphol Airport, The Netherlands
| | - Gareth Beevers
- University of Birmingham, Department of Medicine, City Hospital, Birmingham
| | - Paramjit S Gill
- Academic Unit of Primary Care Warwick Medical School, University of Warwick Coventry, UK
| | - Nefyn H Williams
- Department of Primary Care and Mental Health, University of Liverpool
| |
Collapse
|
14
|
Anderson TS, Herzig SJ, Jing B, Boscardin WJ, Fung K, Marcantonio ER, Steinman MA. Clinical Outcomes of Intensive Inpatient Blood Pressure Management in Hospitalized Older Adults. JAMA Intern Med 2023; 183:715-723. [PMID: 37252732 PMCID: PMC10230372 DOI: 10.1001/jamainternmed.2023.1667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/24/2023] [Indexed: 05/31/2023]
Abstract
Importance Asymptomatic blood pressure (BP) elevations are common in hospitalized older adults, and widespread heterogeneity in the clinical management of elevated inpatient BPs exists. Objective To examine the association of intensive treatment of elevated inpatient BPs with in-hospital clinical outcomes of older adults hospitalized for noncardiac conditions. Design, Setting, and Participants This retrospective cohort study examined Veterans Health Administration data between October 1, 2015, and December 31, 2017, for patients aged 65 years or older hospitalized for noncardiovascular diagnoses and who experienced elevated BPs in the first 48 hours of hospitalization. Interventions Intensive BP treatment following the first 48 hours of hospitalization, defined as receipt of intravenous antihypertensives or oral classes not used prior to admission. Main Outcome and Measures The primary outcome was a composite of inpatient mortality, intensive care unit transfer, stroke, acute kidney injury, B-type natriuretic peptide elevation, and troponin elevation. Data were analyzed between October 1, 2021, and January 10, 2023, with propensity score overlap weighting used to adjust for confounding between those who did and did not receive early intensive treatment. Results Among 66 140 included patients (mean [SD] age, 74.4 [8.1] years; 97.5% male and 2.6% female; 17.4% Black, 1.7% Hispanic, and 75.9% White), 14 084 (21.3%) received intensive BP treatment in the first 48 hours of hospitalization. Patients who received early intensive treatment vs those who did not continued to receive a greater number of additional antihypertensives during the remainder of their hospitalization (mean additional doses, 6.1 [95% CI, 5.8-6.4] vs 1.6 [95% CI, 1.5-1.8], respectively). Intensive treatment was associated with a greater risk of the primary composite outcome (1220 [8.7%] vs 3570 [6.9%]; weighted odds ratio [OR], 1.28; 95% CI, 1.18-1.39), with the highest risk among patients receiving intravenous antihypertensives (weighted OR, 1.90; 95% CI, 1.65-2.19). Intensively treated patients were more likely to experience each component of the composite outcome except for stroke and mortality. Findings were consistent across subgroups stratified by age, frailty, preadmission BP, early hospitalization BP, and cardiovascular disease history. Conclusions and Relevance The study's findings indicate that among hospitalized older adults with elevated BPs, intensive pharmacologic antihypertensive treatment was associated with a greater risk of adverse events. These findings do not support the treatment of elevated inpatient BPs without evidence of end organ damage, and they highlight the need for randomized clinical trials of inpatient BP treatment targets.
Collapse
Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - W. John Boscardin
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Kathy Fung
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Edward R. Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Michael A. Steinman
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| |
Collapse
|
15
|
Doumat G, Daher D, Itani M, Abdouni L, El Asmar K, Assaf G. The effect of polypharmacy on healthcare services utilization in older adults with comorbidities: a retrospective cohort study. BMC PRIMARY CARE 2023; 24:120. [PMID: 37237338 DOI: 10.1186/s12875-023-02070-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/17/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Older adults are more prone to increasing comorbidities and polypharmacy. Polypharmacy is associated with inappropriate prescribing and an increased risk of adverse effects. This study examined the effect of polypharmacy in older adults on healthcare services utilization (HSU). It also explored the impact of different drug classes of polypharmacy including psychotropic, antihypertensive, and antidiabetic polypharmacy on HSU. METHODS This is a retrospective cohort study. Community-dwelling older adults aged ≥ 65 years were selected from the primary care patient cohort database of the ambulatory clinics of the Department of Family Medicine at the American University of Beirut Medical Center. Concomitant use of 5 or more prescription medications was considered polypharmacy. Demographics, Charlson Comorbidity index (CCI), and HSU outcomes, including the rate of all-cause emergency department (ED) visits, rate of all-cause hospitalization, rate of ED visits for pneumonia, rate of hospitalization for pneumonia, and mortality were collected. Binomial logistic regression models were used to predict the rates of HSU outcomes. RESULTS A total of 496 patients were analyzed. Comorbidities were present in all patients, with 22.8% (113) of patients having mild to moderate comorbidity and 77.2% (383) of patients having severe comorbidity. Patients with polypharmacy were more likely to have severe comorbidity compared to patients with no polypharmacy (72.3% vs. 27.7%, p = 0.001). Patients with polypharmacy were more likely to visit the ED for all causes as compared to patients without polypharmacy (40.6% vs. 31.4%, p = 0.05), and had a significantly higher rate of all-cause hospitalization (adjusted odds ratio aOR 1.66, 95 CI = 1.08-2.56, p = 0.022). Patients with psychotropic polypharmacy were more likely to be hospitalized due to pneumonia (crude odds ratio cOR 2.37, 95 CI = 1.03-5.46, p = 0.043), and to visit ED for Pneumonia (cOR 2.31, 95 CI = 1.00-5.31, p = 0.049). The association lost significance after adjustment. CONCLUSIONS The increasing prevalence of polypharmacy amongst the geriatric population with comorbidity is associated with an increase in HSU outcomes. As such, frequent medication revisions in a holistic, multi-disciplinary approach are needed.
Collapse
Affiliation(s)
- George Doumat
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Darine Daher
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mira Itani
- Department of Family Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Lina Abdouni
- Department of Family Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Khalil El Asmar
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Georges Assaf
- Department of Family Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
- Division of Academic Internal Medicine & Geriatrics, The University of Illinois at Chicago, Chicago, USA.
| |
Collapse
|
16
|
Russell P, Thompson C, Mangoni AA. Rational Prescribing and Deprescribing of Antihypertensive Medications in Older People, a Three-Part Narrative Review, Part 3. Sr Care Pharm 2023; 38:168-178. [PMID: 37185147 DOI: 10.4140/tcp.n.2023.168] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
What happens when you stop? This is the third of a three-part series on antihypertensive medication use in older people. In the first, we reviewed the importance of better blood pressure (BP) control, even in older people with hypertension. In the second, we discussed the limitations of the evidence favoring intensive therapy for some older people. For older people with advanced frailty or those with a limited life expectancy, medications taken for BP can actually be a source of morbidity. Guidelines encourage clinical judgment and rational prescribing. Sometimes the best action is to stop prescribing. De-prescribing of medical therapy is now considered good practice for a range of medications for suitable patients; should this include antihypertensives? In part three of this three-part series, we will review some of the evidence available thus far, demonstrating de-intensification of antihypertensive medications is not a new idea. We will offer a guide to identifying the most suitable patients for de-prescribing: cognitive impairment, frailty, when circumstances change, or when BP is (too) well-controlled. This is an area of equipoise and needs more research. There is a path forward that we hope to illuminate.
Collapse
Affiliation(s)
- Patrick Russell
- 1 Department of Internal Medicine, Royal Adelaide Hospital, Adelaide, South Australia
| | - Campbell Thompson
- 2 University of Adelaide, Department of Medicine, Royal Adelaide Hospital, Adelaide, South Australia
| | - Arduino A Mangoni
- 3 Department of Clinical Pharmacology, Flinders University and Flinders Medical Centre, Bedford Park, South Australia
| |
Collapse
|
17
|
Wajngarten M. How to Improve Clinical Outcomes and Reduce Cardiovascular Risk in Older People with Cardiovascular Disease: Bridging Evidence Gaps. Eur Cardiol 2023; 18:e17. [PMID: 37405340 PMCID: PMC10316345 DOI: 10.15420/ecr.2022.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/07/2023] [Indexed: 07/06/2023] Open
Abstract
The geriatric population is greatly impacted by cardiovascular disease. Thus, it becomes essential to 'geriatricise' the cardiologist through the dissemination of geriatric cardiology. In the early days of geriatric cardiology, it was discussed whether it was simply cardiology 'well done'. Today, 40 years later, it seems clear that this is indeed the case. Patients with cardiovascular disease usually have several chronic conditions. Clinical practice guidelines often address a single condition and do not provide sufficient guidance for patients with multimorbidity. There are several evidence gaps regarding these patients. Physicians and members ofthe care team need a multidimensional understanding ofthe patient to better promote the optimisation of care. It is important to understand that ageing is inevitable, heterogeneous and increases vulnerability. Caregivers must know how to assess elderly patients in a multidomain practical way and how to recognise the factors that may have implications on treatment.
Collapse
Affiliation(s)
- Mauricio Wajngarten
- Department of Cardiology, Hospital Israelita Albert Einstein São Paulo, Brazil
| |
Collapse
|
18
|
Cicco S, D Abbondanza M, Proietti M, Zaccone V, Pes C, Caradio F, Mattioli M, Piano S, Marra AM, Nobili A, Mannucci PM, Pietrangelo A, Sesti G, Buzzetti E, Salzano A, Cimellaro A. Antihypertensive treatment changes and related clinical outcomes in older hospitalized patients. Eur J Clin Invest 2023; 53:e13931. [PMID: 36453932 DOI: 10.1111/eci.13931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/20/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Hypertension management in older patients represents a challenge, particularly when hospitalized. OBJECTIVE The objective of this study is to investigate the determinants and related outcomes of antihypertensive drug prescription in a cohort of older hospitalized patients. METHODS A total of 5671 patients from REPOSI (a prospective multicentre observational register of older Italian in-patients from internal medicine or geriatric wards) were considered; 4377 (77.2%) were hypertensive. Minimum treatment (MT) for hypertension was defined according to the 2018 ESC guidelines [an angiotensin-converting-enzyme-inhibitor (ACE-I) or an angiotensin-receptor-blocker (ARB) with a calcium-channel-blocker (CCB) and/or a thiazide diuretic; if >80 years old, an ACE-I or ARB or CCB or thiazide diuretic]. Determinants of MT discontinuation at discharge were assessed. Study outcomes were any cause rehospitalization/all cause death, all-cause death, cardiovascular (CV) hospitalization/death, CV death, non-CV death, evaluated according to the presence of MT at discharge. RESULTS Hypertensive patients were older than normotensives, with a more impaired functional status, higher burden of comorbidity and polypharmacy. A total of 2233 patients were on MT at admission, 1766 were on MT at discharge. Discontinuation of MT was associated with the presence of comorbidities (lower odds for diabetes, higher odds for chronic kidney disease and dementia). An adjusted multivariable logistic regression analysis showed that MT for hypertension at discharge was associated with lower risk of all-cause death, all-cause death/hospitalization, CV death, CV death/hospitalization and non-CV death. CONCLUSIONS Guidelines-suggested MT for hypertension at discharge is associated with a lower risk of adverse clinical outcomes. Nevertheless, changes in antihypertensive treatment still occur in a significant proportion of older hospitalized patients.
Collapse
Affiliation(s)
- Sebastiano Cicco
- Department of Biomedical Sciences and Human Oncology (DIMO), Internal Medicine Unit "Guido Baccelli" and Unit of Arterial Hypertension "Anna Maria Pirrelli", University of Bari Aldo Moro, Azienda Ospedaliero-Universitaria Policlinico, Bari, Italy
| | - Marco D Abbondanza
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy; Unit of Internal Medicine, 'Santa Maria' Terni University Hospital, Terni, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Vincenzo Zaccone
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" di Ancona, Ancona, Italy
| | - Chiara Pes
- Internal Medicine Unit, Internal Medicine Department, University Hospital of Sassari, Sassari, Italy
| | - Federica Caradio
- Emergency Department, Madonna del Soccorso Hospital, San Benedetto del Tronto, Italy
| | - Massimo Mattioli
- Department of Emergency Medicine, Azienda Ospedaliera 'Ospedali Riuniti Marche Nord', Pesaro, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Alberto Maria Marra
- Department of Translational Medical Sciences, Interdisciplinary Research Centre in Biomedical Materials (C.R.I.B.), University Federico II of Naples, Naples, Italy
| | - Alessandro Nobili
- Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Antonello Pietrangelo
- Department of Medical and Surgical Sciences for Children and Adults, Internal Medicine and Centre for Hemochromatosis and Heredometabolic Liver disease, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Elena Buzzetti
- Department of Medical and Surgical Sciences for Children and Adults, Internal Medicine and Centre for Hemochromatosis and Heredometabolic Liver disease, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | | | - Antonio Cimellaro
- Department of Medical Specialties, Internal Medicine Unit, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
| | | |
Collapse
|
19
|
Tam JM, McHugh KM. Management of Hypertension in the Older Adult Hospitalized With Community-Acquired Pneumonia. J Nurse Pract 2023. [DOI: 10.1016/j.nurpra.2022.104525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|
20
|
Vasilevskis EE, Shah AS, Hollingsworth EK, Shotwell MS, Kripalani S, Mixon AS, Simmons SF. Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute Care: A Shed-MEDS Randomized Clinical Trial. JAMA Intern Med 2023; 183:223-231. [PMID: 36745422 PMCID: PMC9989899 DOI: 10.1001/jamainternmed.2022.6545] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/04/2022] [Indexed: 02/07/2023]
Abstract
Importance Deprescribing is a promising approach to addressing the burden of polypharmacy. Few studies have initiated comprehensive deprescribing in the hospital setting among older patients requiring ongoing care in a postacute care (PAC) facility. Objective To evaluate the efficacy of a patient-centered deprescribing intervention among hospitalized older adults transitioning or being discharged to a PAC facility. Design, Setting, and Participants This randomized clinical trial of the Shed-MEDS (Best Possible Medication History, Evaluate, Deprescribing Recommendations, and Synthesis) deprescribing intervention was conducted between March 2016 and October 2020. Patients who were admitted to an academic medical center and discharged to 1 of 22 PAC facilities affiliated with the medical center were recruited. Patients who were 50 years or older and had 5 or more prehospital medications were enrolled and randomized 1:1 to the intervention group or control group. Patients who were non-English speaking, were unhoused, were long-stay residents of nursing homes, or had less than 6 months of life expectancy were excluded. An intention-to-treat approach was used. Interventions The intervention group received the Shed-MEDS intervention, which consisted of a pharmacist- or nurse practitioner-led comprehensive medication review, patient or surrogate-approved deprescribing recommendations, and deprescribing actions that were initiated in the hospital and continued throughout the PAC facility stay. The control group received usual care at the hospital and PAC facility. Main Outcomes and Measures The primary outcome was the total medication count at hospital discharge and PAC facility discharge, with follow-up assessments during the 90-day period after PAC facility discharge. Secondary outcomes included the total number of potentially inappropriate medications at each time point, the Drug Burden Index, and adverse events. Results A total of 372 participants (mean [SD] age, 76.2 [10.7] years; 229 females [62%]) were randomized to the intervention or control groups. Of these participants, 284 were included in the intention-to-treat analysis (142 in the intervention group and 142 in the control group). Overall, there was a statistically significant treatment effect, with patients in the intervention group taking a mean of 14% fewer medications at PAC facility discharge (mean ratio, 0.86; 95% CI, 0.80-0.93; P < .001) and 15% fewer medications at the 90-day follow-up (mean ratio, 0.85; 95% CI, 0.78-0.92; P < .001) compared with the control group. The intervention additionally reduced patient exposure to potentially inappropriate medications and Drug Burden Index. Adverse drug event rates were similar between the intervention and control groups (hazard ratio, 0.83; 95% CI, 0.52-1.30). Conclusions and Relevance Results of this trial showed that the Shed-MEDS patient-centered deprescribing intervention was safe and effective in reducing the total medication burden at PAC facility discharge and 90 days after discharge. Future studies are needed to examine the effect of this intervention on patient-reported and long-term clinical outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT02979353.
Collapse
Affiliation(s)
- Eduard E. Vasilevskis
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Avantika Saraf Shah
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Sunil Kripalani
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda S. Mixon
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandra F. Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
21
|
Kou M, Wang X, Ma H, Li X, Heianza Y, Qi L. Degree of Joint Risk Factor Control and Incident Heart Failure in Hypertensive Patients. JACC. HEART FAILURE 2023:S2213-1779(23)00035-5. [PMID: 36892491 DOI: 10.1016/j.jchf.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/17/2022] [Accepted: 01/04/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Heart failure (HF) is a major complication in patients with hypertension. OBJECTIVES This study aimed to investigate the extent to which joint risk factor control could attenuate hypertension-related excess risk of HF. METHODS The study included a total of 75,293 participants with diagnosed hypertension from the UK Biobank and matched with 256,619 nonhypertensive control subjects, followed up until May 31, 2021. The degree of joint risk factor control was assessed on the basis of the major cardiovascular risk factors, including blood pressure, body mass index, low-density lipoprotein cholesterol, hemoglobin A1c, albuminuria, smoking, and physical activity. The Cox proportional hazards models were used to estimate associations between the degree of risk factor control and risk of HF. RESULTS Among hypertensive patients, joint risk factor control showed an association with a stepwise reduction of incident HF risk. Each additional risk factor control was related to a 20% lower risk, and the optimal risk factor control (controlling ≥6 risk factors) was associated with a 62% lower risk (HR: 0.38; 95% CI: 0.31-0.45). In addition, the study found that the hypertension-related excess risk of HF among participants jointly controlling ≥6 risk factors were even lower than in nonhypertensive control subjects (HR: 0.79; 95% CI: 0.67-0.94). The protective associations of joint risk factor control and risk of incident HF were broadly stronger among men than women and among medication users than nonusers (P for interaction < 0.05). CONCLUSIONS The joint risk factor control is associated with a lower risk of incident HF in an accumulative and sex-specific manner. Optimal risk factor control may eliminate hypertension-related excess risk of HF.
Collapse
Affiliation(s)
- Minghao Kou
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Xuan Wang
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Hao Ma
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Xiang Li
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Yoriko Heianza
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Lu Qi
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
| |
Collapse
|
22
|
Marshall RC, Thiel DJ, Samar H. Noncardiac inpatient has acute hypertension: Treat or not? THE JOURNAL OF FAMILY PRACTICE 2022; 71:314-316. [PMID: 36179135 PMCID: PMC9531623 DOI: 10.12788/jfp.0470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
A retrospective study found more harm than benefit from treating elevated blood pressure in hospitalized noncardiac patients.
Collapse
Affiliation(s)
| | | | - Haroon Samar
- Madigan Army Medical Center, Joint Base Lewis-McChord, WA
| |
Collapse
|
23
|
Asymptomatic hypertension in the hospital setting: primum non nocere. J Hum Hypertens 2022; 36:781-784. [PMID: 35322179 DOI: 10.1038/s41371-022-00676-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/23/2022] [Accepted: 03/09/2022] [Indexed: 11/08/2022]
|
24
|
Shin J, Kim KI. A clinical algorithm to determine target blood pressure in the elderly: evidence and limitations from a clinical perspective. Clin Hypertens 2022; 28:17. [PMID: 35701854 PMCID: PMC9199158 DOI: 10.1186/s40885-022-00202-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/22/2022] [Indexed: 01/14/2023] Open
Abstract
As the elderly population is growing rapidly, management of hypertension in South Korea faces major challenges because the proportion of elderly hypertension patients is also increasing. The characteristics of this population are also much more complex than younger patients. Elderly hypertension is characterized by wide variations in (1) fitness or biological age, (2) white-coat effect, (3) poor functional status or frailty, (4) dependency in activities of daily living or institutionalization, (5) orthostatic hypotension, and (6) multiple comorbidities. All of these should be considered when choosing optimal target blood pressure in individual patients. Recent randomized clinical trials have shown that the benefits of intensive blood pressure control for elderly patients is greater than previously thought. For generalization of these results and implementation of the guidelines based on these studies, defining the clinician's role for individualization is critically important. For individualized decisions for target blood pressure (BP) in the elderly with hypertension, four components should first be checked. These consist of (1) the minimum requirement of functional status and capability of activities of daily living, (2) lack of harmful evidence by the target BP, (3) absence of white-coat hypertension, and (4) standing systolic BP ≥ 110 mmHg without orthostatic symptoms. Risk of decreased organ perfusion by arterial stenosis should be screened before starting intensive BP control. When the target BP differs among comorbidities, the lowest target BP should be given preference. After starting intensive BP lowering therapy, tolerability should be monitored, and the titration should be based on the mean level of blood pressure by office supplemented by out-of-office BPs. Applications of the clinical algorithms will be useful to achieve more standardized and simplified applications of target BP in the elderly.
Collapse
Affiliation(s)
- Jinho Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Department of Internal Medicine, Geriatric Center, Seoul National University Bundang Hospital, 82 Gumi-ro, Bundang-gu, 13620, Seongnam, Korea.
| |
Collapse
|
25
|
Bahat G, İlhan B, Tufan A, Kılıç C, Karan MA, Petrovic M. Hypotension Under Antihypertensive Treatment and Incident Hospitalizations of Nursing Home Residents. Drugs Aging 2022; 39:477-484. [PMID: 35701577 DOI: 10.1007/s40266-022-00951-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Hypertension is the most prevalent chronic disease in older adults. Antihypertensive drug use increases with aging. In some studies, hypotension developing under antihypertensive medication use has been indicated as a potential risk factor for morbidity and mortality in older adults. Our objective was to assess the relationship between hypotension under antihypertensive treatment and incident hospitalization of nursing home residents. METHODS We detailed blood pressure measurements of the previous 1-year period that were noted regularly at 2-week intervals and studied their mean values. The systolic blood pressure (SBP) and diastolic blood pressure (DBP) thresholds to define low SBP (≤ 110 mm Hg) and DBP (≤ 65 mm Hg) were derived from our previous study. We noted demographics, number of co-morbidities and regular medications, mobility status, and nutritional assessment via the Mini Nutritional Assessment Short Form. RESULTS We included 253 participants (66% male, mean age 75.7 ± 8.7 years). The prevalence of low SBP (≤ 110 mmHg) and low DBP (≤ 65 mmHg) was 34.8% and 15.8%, respectively. Among residents, 4% were bedridden, 15.8% wheelchair bound, 14.5% needing assistance for reduced mobility, and 62.7% were ambulatory. At a median of 15 months of follow-up, hospitalization incidence from any cause was 50.8% (n = 134). Incident hospitalization was more common in the group that had low DBP (odds ratio = 3.06; 95% confidence interval 1.02-9.15; p = 0.04) after adjusting for age, number of comorbidities and medications, mobility status, and nutritional status. Low SBP was not associated with hospitalization. CONCLUSIONS The low DBP (≤ 65 mm Hg) during the previous year was associated with incident hospitalization of nursing home residents after adjustment for several factors. These findings indicate that lower DBP may be a causative factor for incident hospitalization. We need further studies to explore whether a correction of diastolic hypotension may decrease the hospitalization risk in this vulnerable population.
Collapse
Affiliation(s)
- Gülistan Bahat
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, Istanbul, 34390, Türkiye.
| | - Birkan İlhan
- Department of Internal Medicine, Division of Geriatrics, Sisli Hamidiye Etfal Teaching and Research Hospital, University of Health Sciences Türkiye, Istanbul, Türkiye
| | - Asli Tufan
- Department of Internal Medicine, Division of Geriatrics, Marmara University Medical School, Istanbul, Türkiye
| | - Cihan Kılıç
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, Istanbul, 34390, Türkiye
| | - Mehmet Akif Karan
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, Istanbul, 34390, Türkiye
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
26
|
Vitto CM, Lykins V JD, Wiles-Lafayette H, Aurora TK. Blood Pressure Assessment and Treatment in the Observation Unit. Curr Hypertens Rep 2022; 24:311-323. [PMID: 35596047 DOI: 10.1007/s11906-022-01196-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW To review the pathophysiology, diagnosis, and the management of hypertension. Given the paucity of literature regarding the role of the observation unit in the management of hypertension, we will provide our recommendations based on our experience working in an observation unit. RECENT FINDINGS Many patients have limited access to primary care, and hypertension diagnosis often relies on office-based measurements. We will describe situations where that is not necessary to make the diagnosis. We will discuss the current non-pharmacologic treatment guidelines, the education of which should be provided to patients both in the emergency department and observation units. We will provide the current recommendations on what anti-hypertension medications can be initiated in the emergency department and observation units. Hypertension is a leading cause of morbidity and mortality in the USA. The utility of an observation unit in the diagnosis and management of patients with hypertension is beneficial particularly for those with risk factors for atherosclerotic disease. An observation unit stay provides the opportunity to diagnosis hypertension, initiate lifestyle education and pharmacologic treatment if indicated, and help to arrange appropriate follow-up for ongoing management and treatment in individuals with limited access to care.
Collapse
|
27
|
Chaganti B, Lange RA. Treatment of Hypertension Among Non-Cardiac Hospitalized Patients. Curr Cardiol Rep 2022; 24:801-805. [PMID: 35524879 PMCID: PMC9288355 DOI: 10.1007/s11886-022-01699-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This review provides a contemporary perspective and approach for the treatment of hypertension (HTN) among patients hospitalized for non-cardiac reasons. RECENT FINDINGS Elevated blood pressure (BP) is a common dilemma encountered by physicians, but guidelines are lacking to assist providers in managing hospitalized patients with elevated BP. Inpatient HTN is common, and management remains challenging given the paucity of data and misperceptions among training and practicing physicians. The outcomes associated with intensifying BP treatment during hospitalization can be harmful, with little to no long-term benefits. Data also suggests that medication intensification at discharge is not associated with improved outpatient BP control. Routine inpatient HTN control in the absence of end-organ damage has not shown to be helpful and may have deleterious effects. Since routine use of intravenous antihypertensives in hospitalized non-cardiac patients has been shown to prolong inpatient stay without benefits, their routine use should be avoided for inpatient HTN control. Future large-scale trials measuring clinical outcomes during prolonged follow-up may help to identify specific circumstances where inpatient HTN control may be beneficial.
Collapse
Affiliation(s)
- Bhanu Chaganti
- Department of Cardiovascular Medicine, Texas Tech University Health Science Center El Paso, 4800 Alberta Avenue, El Paso, TX, USA
| | - Richard A Lange
- Department of Cardiovascular Medicine, Texas Tech University Health Science Center El Paso, 4800 Alberta Avenue, El Paso, TX, USA.
| |
Collapse
|
28
|
Ambulatory diastolic blood pressure: a marker of comorbidity in elderly fit hypertensive individuals? J Geriatr Cardiol 2022; 19:254-264. [PMID: 35572223 PMCID: PMC9068589 DOI: 10.11909/j.issn.1671-5411.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Masked diastolic hypotension is a new blood pressure (BP) pattern detected by ambulatory blood pressure monitoring (ABPM) in elderly hypertensives. The aim of this study was to relate ABPM and comorbidity in a cohort of fit elderly subjects attending an outpatient hypertension clinic. METHODS Comorbidity was assessed by Charlson comorbidity index (CCI) and CHA2DS2VASc score. All subjects evaluated with ABPM were aged ≥ 65 years. CCI and CHA2DS2VASc score were calculated. Diastolic hypotension was defined as mean ambulatory diastolic BP < 65 mmHg and logistic regression analysis was carried out in order to detect and independent relationship between comorbidity burden and night-time diastolic BP < 65 mmHg. RESULTS We studied 174 hypertensive elderly patients aged 72.1 ± 5.2 years, men were 93 (53.4%). Mean CCI was 0.91 ± 1.14 and mean CHA2DS2VASc score of 2.68 ± 1.22. Subjects with night-time mean diastolic values < 65 mmHg were higher in females [54.7% vs. 45.3%, P = 0.048; odds ratio (OR) = 1.914, 95% CI: 1.047-3.500]. Logistic regression analysis showed that only CHA2DS2VASc score was independently associated with night-time mean diastolic values < 65 mmHg (OR = 1.518, 95% CI: 1.161-1.985; P = 0.002), but CCI was not. CONCLUSIONS ABPM and comorbidity evaluation appear associated in elderly fit subjects with masked hypotension. Comorbid women appear to have higher risk for low ambulatory BP.
Collapse
|
29
|
Ghazi L, Li F, Chen X, Simonov M, Yamamoto Y, Biswas A, Hanna J, Shah T, Townsend R, Peixoto A, Wilson FP. Severe inpatient hypertension prevalence and blood pressure response to antihypertensive treatment. J Clin Hypertens (Greenwich) 2022; 24:339-349. [PMID: 35174627 PMCID: PMC8925013 DOI: 10.1111/jch.14431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/20/2021] [Accepted: 12/27/2021] [Indexed: 12/15/2022]
Abstract
Severe hypertension (HTN) that develops during hospitalization is more common than admission for HTN; however, it is poorly studied, and treatment guidelines are lacking. Our goal is to characterize hospitalized patients who develop severe HTN and assess blood pressure (BP) response to treatment. This is a multi-hospital retrospective cohort study of adults admitted for reasons other than HTN who developed severe HTN. The authors defined severe inpatient HTN as the first documented BP elevation (systolic BP > 180 or diastolic BP > 110) at least 1 hour after admission. Treatment was defined as receiving antihypertensives (intravenous [IV] or oral) within 6h of BP elevation. As a measure of possible overtreatment, the authors studied the association between treatment and time to mean arterial pressure (MAP) drop ≥ 30% using the Cox proportional hazards model. Among 224 265 hospitalized adults, 10% developed severe HTN of which 40% were treated. Compared to patients who did not develop severe HTN, those who did were older, more commonly women and black, and had more comorbidities. Incident MAP drop ≥ 30% among treated and untreated patients with severe HTN was 2.2 versus 5.7/1000 person-hours. After adjustment, treated versus. untreated patients had lower rates of MAP drop ≥ 30% (hazard rate [HR]: 0.9 [0.8, 0.99]). However, those receiving only IV treatment versus untreated had greater rates of MAP drop ≥ 30% (1.4 [1.2, 1.7]). Overall, the authors found that clinically significant MAP drop is observed among inpatients with severe HTN irrespective of treatment, with greater rates observed among patients treated only with IV antihypertensives. Further research is needed to phenotype inpatients with severe HTN.
Collapse
Affiliation(s)
- Lama Ghazi
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Xinyuan Chen
- Department of Mathematics and Statistics, Mississippi State University, Mississippi State, Mississippi, USA
| | - Michael Simonov
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
| | - Yu Yamamoto
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
| | - Aditya Biswas
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
| | - Jonathan Hanna
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Tayyab Shah
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Raymond Townsend
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aldo Peixoto
- Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, and the Hypertension Program, Yale New Haven Hospital Heart and Vascular Center, New Haven, Connecticut, USA
| | - F Perry Wilson
- Department of Internal Medicine, Clinical and Translational Research Accelerator, Yale University, New Haven, Connecticut, USA
| |
Collapse
|
30
|
Yao W, Li J. Risk factors and prediction nomogram model for 1-year readmission for major adverse cardiovascular events in patients with STEMI after PCI. Clin Appl Thromb Hemost 2022; 28:10760296221137847. [PMID: 36380508 PMCID: PMC9676288 DOI: 10.1177/10760296221137847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/09/2022] [Accepted: 10/18/2022] [Indexed: 04/13/2024] Open
Abstract
To identify risk factors and develop a risk-prediction nomogram model for 1-year readmission due to major adverse cardiovascular events (MACEs) in patients with acute ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PCI). This was a single-center, retrospective cohort study. A total of 526 eligible participants were enrolled, which included 456 non-readmitted and 70 readmitted patients. Multivariate logistical regressions were performed to identify the independent risk factors for readmission, and a prediction nomogram model was developed based on the results of the regression analysis. The receiver operating characteristic curve, Hosmer-Lemeshow test, calibration plot, and decision curve analysis (DCA) were used to evaluate the performance of the nomogram. Female (OR = 2.426; 95% CI: 1.395-4.218), hypertension (OR = 1.898; 95% CI: 1.100-3.275), 3-vessel disease (OR = 2.632; 95% CI: 1.332-5.201), in-hospital Ventricular arrhythmias (VA) (OR = 3.143; 95% CI: 1.305-7.574), peak cTnI (OR = 1.003; 95% CI: 1.001-1.004) and baseline NT-proBNP (OR = 1.001; 95% CI: 1.000-1.002) were independent risk factors for readmission (all P < 0.05). The nomogram exhibited good discrimination with the area under the curve (AUC) of 0.723, calibration (Hosmer-Lemeshow test; χ2 = 15.396, P = 0.052), and clinical usefulness. Female gender, hypertension, in-hospital VA, 3-vessel disease, baseline NT-proBNP, and peak cTnI were independent risk factors for readmission. The nomogram helped clinicians to identify the patients at risk of readmission before their hospital discharge, which may help reduce readmission rates.
Collapse
Affiliation(s)
- Wensen Yao
- Department of Cadre's Ward, The First Hospital of Jilin University, Changchun, China
| | - Jie Li
- Department of Cadre's Ward, The First Hospital of Jilin University, Changchun, China
| |
Collapse
|
31
|
Older Adults' Persistence to Antihypertensives Prescribed at Hospital Discharge: a Retrospective Cohort Study. J Gen Intern Med 2021; 36:3900-3902. [PMID: 33469765 PMCID: PMC8642581 DOI: 10.1007/s11606-020-06401-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
|
32
|
Penmatsa KR, Teki P, Gupta A. Hypertension in the hospitalized patient: An update. Nefrologia 2021; 41:605-611. [PMID: 36165149 DOI: 10.1016/j.nefroe.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/13/2020] [Indexed: 06/16/2023] Open
Abstract
In-patient hypertension is a common problem seen in the hospital setting. Current evidence-based guidelines define and address management of hypertension in ambulatory care and hypertensive emergencies in the hospital setting. However, they lack guidance for the management of acute asymptomatic/non-emergent hypertension in the hospitalised patient. The risk-benefit of treating inpatient asymptomatic hypertension is largely unknown. In this narrative review, we discuss current evidence-based perspectives to address this clinical entity.
Collapse
Affiliation(s)
| | | | - Ankur Gupta
- Consultant, Department of Medicine, Whakatane Hospital, New Zealand.
| |
Collapse
|
33
|
McCoy RG, O'Connor PJ. Overcoming Therapeutic Inertia in Type 2 Diabetes Care-Timing, Context, and Appropriateness of Treatment Intensification. JAMA Netw Open 2021; 4:e2130926. [PMID: 34673968 PMCID: PMC8764972 DOI: 10.1001/jamanetworkopen.2021.30926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Rozalina G McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | | |
Collapse
|
34
|
Grubbs C, Morris L. This is not the time to modify a HTN regimen. THE JOURNAL OF FAMILY PRACTICE 2021; 70:293-295. [PMID: 34431775 PMCID: PMC8407227 DOI: 10.12788/jfp.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Intensifying hypertension regimens at discharge increases risk in older patients.
Collapse
|
35
|
Kleipool EEF, Rozendaal ES, Mahadew SKN, Kramer MHH, van den Born BJH, Serné EH, Peters MJL, Muller M. The value of ambulatory blood pressure measurement to detect masked diastolic hypotension in older patients treated for hypertension. Age Ageing 2021; 50:1229-1235. [PMID: 33454734 DOI: 10.1093/ageing/afaa287] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE assess how many patients with low ambulatory diastolic blood pressure (DBP) are not identified when relying on office DBP alone, and thus have 'masked diastolic hypotension'. DESIGN cross-sectional, retrospective cohort study. SETTING academic hospital. SUBJECTS 848 patients treated for hypertension who received ambulatory blood pressure monitoring (ABPM). METHODS cut-off value between on- and off-target systolic blood pressure (SBP): 140 mmHg. Cut-off for low office and/or ambulatory DBP: DBP ≤ 70 mmHg. 'Masked diastolic hypotension' was defined as office DBP > 70 mmHg and mean ambulatory DBP ≤ 70 mmHg. RESULTS mean age of the sample was 60 ± 13 years, 50% was female, 37% had diabetes, 42% preexisting cardiovascular disease (CVD), mean office blood pressure (BP) was 134/79 mmHg. In all patients (n = 848), low office DBP was present in n = 84(10%), while n = 183(22%) had low ambulatory DBP. In all patients with normal-to-high office DBP (n = 764), n = 122(16%) had 'masked diastolic hypotension'. In this group, ambulatory DBP was 14-19 mmHg lower than office DBP. Patients with low ambulatory DBP were older, had more (cardiovascular) comorbidities, and used more (antihypertensive) drugs. Antihypertensive drugs were lowered or discontinued in 30% of all patients with 'masked diastolic hypotension' due to side effects. CONCLUSIONS 'masked diastolic hypotension' is common among patients treated for hypertension, particularly in older patients with CVD (e.g. coronary artery disease, diabetes), patient groups in which the European Society of Cardiology/Hypertension guideline advises to prevent low DBP. Although it remains to be examined at which BP levels the harms of low DBP outweigh the benefits of lowering SBP, our observations are aimed to increase awareness among physicians.
Collapse
Affiliation(s)
- Emma E F Kleipool
- Department of Geriatric/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Eva S Rozendaal
- Department of Geriatric/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Shaya K N Mahadew
- Department of Geriatric/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Mark H H Kramer
- Department of Geriatric/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Bert-Jan H van den Born
- Department of Vascular/Internal Medicine, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Erik H Serné
- Department of Vascular/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Mike J L Peters
- Department of Geriatric/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
- Department of Vascular/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - Majon Muller
- Department of Geriatric/Internal Medicine, Amsterdam UMC, Location VUmc, 1081 HV Amsterdam, The Netherlands
| |
Collapse
|
36
|
Penmatsa KR, Teki P, Gupta A. Hypertension in the hospitalized patient: An update. Nefrologia 2021; 41:S0211-6995(21)00082-5. [PMID: 34074571 DOI: 10.1016/j.nefro.2020.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/08/2020] [Accepted: 12/13/2020] [Indexed: 11/28/2022] Open
Abstract
In-patient hypertension is a common problem seen in the hospital setting. Current evidence-based guidelines define and address management of hypertension in ambulatory care and hypertensive emergencies in the hospital setting. However, they lack guidance for the management of acute asymptomatic/non-emergent hypertension in the hospitalised patient. The risk-benefit of treating inpatient asymptomatic hypertension is largely unknown. In this narrative review, we discuss current evidence-based perspectives to address this clinical entity.
Collapse
Affiliation(s)
| | | | - Ankur Gupta
- Consultant, Department of Medicine, Whakatane Hospital, New Zealand.
| |
Collapse
|
37
|
Sharp LK, Biggers A, Perez R, Henkins J, Tilton J, Gerber BS. A Pharmacist and Health Coach-Delivered Mobile Health Intervention for Type 2 Diabetes: Protocol for a Randomized Controlled Crossover Study. JMIR Res Protoc 2021; 10:e17170. [PMID: 33688847 PMCID: PMC7991981 DOI: 10.2196/17170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 07/17/2020] [Accepted: 01/21/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Aggressive management of blood glucose, blood pressure, and cholesterol through medication and lifestyle adherence is necessary to minimize the adverse health outcomes of type 2 diabetes. However, numerous psychosocial and environmental barriers to adherence prevent low-income, urban, and ethnic minority populations from achieving their management goals, resulting in diabetes complications. Health coaches working with clinical pharmacists represent a promising strategy for addressing common diabetes management barriers. Mobile health (mHealth) tools may further enhance their ability to support vulnerable minority populations in diabetes management. OBJECTIVE The aim of this study is to evaluate the impact of an mHealth clinical pharmacist and health coach-delivered intervention on hemoglobin A1c (HbA1c, primary outcome), blood pressure, and low-density lipoprotein (secondary outcomes) in African-Americans and Latinos with poorly controlled type 2 diabetes. METHODS A 2-year, randomized controlled crossover study will evaluate the effectiveness of an mHealth diabetes intervention delivered by a health coach and clinical pharmacist team compared with usual care. All patients will receive 1 year of team intervention, including lifestyle and medication support delivered in the home with videoconferencing and text messages. All patients will also receive 1 year of usual care without team intervention and no home visits. The order of the conditions received will be randomized. Our recruitment goal is 220 urban African-American or Latino adults with uncontrolled type 2 diabetes (HbA1c ≥8%) receiving care from a largely minority-serving, urban academic medical center. The intervention includes the following: health coaches supporting patients through home visits, phone calls, and text messaging and clinical pharmacists supporting patients through videoconferences facilitated by health coaches. Data collection includes physiologic (HbA1c, blood pressure, weight, and lipid profile) and survey measures (medication adherence, diabetes-related behaviors, and quality of life). Data collection during the second year of study will determine the maintenance of any physiological improvement among participants receiving the intervention during the first year. RESULTS Participant enrollment began in March 2017. We have recruited 221 patients. Intervention delivery and data collection will continue until November 2021. The results are expected to be published by May 2022. CONCLUSIONS This is among the first trials to incorporate health coaches, clinical pharmacists, and mHealth technologies to increase access to diabetes support among urban African-Americans and Latinos to achieve therapeutic goals. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/17170.
Collapse
Affiliation(s)
- Lisa Kay Sharp
- Department of Pharmacy Systems, Outcomes & Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, United States
| | - Alana Biggers
- Department of Medicine, Section of Academic Internal Medicine & Geriatrics, University of Illinois at Chicago, Chicago, IL, United States
| | - Rosanne Perez
- Department of Medicine, Section of Academic Internal Medicine & Geriatrics, University of Illinois at Chicago, Chicago, IL, United States
| | - Julia Henkins
- Department of Medicine, Section of Academic Internal Medicine & Geriatrics, University of Illinois at Chicago, Chicago, IL, United States
| | - Jessica Tilton
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, United States
| | - Ben S Gerber
- Department of Medicine, Section of Academic Internal Medicine & Geriatrics, University of Illinois at Chicago, Chicago, IL, United States
| |
Collapse
|
38
|
Rastogi R, Sheehan MM, Hu B, Shaker V, Kojima L, Rothberg MB. Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions. JAMA Intern Med 2021; 181:345-352. [PMID: 33369614 PMCID: PMC7770615 DOI: 10.1001/jamainternmed.2020.7501] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Despite high prevalence of elevated blood pressure (BP) among medical inpatients, BP management guidelines are lacking for this population. The outcomes associated with intensifying BP treatment in the hospital are poorly studied. OBJECTIVES To characterize clinician response to BP in the hospital and at discharge and to compare short- and long-term outcomes associated with antihypertensive treatment intensification. DESIGN, SETTING, AND PARTICIPANTS This cohort study took place from January 1 to December 31, 2017, with 1 year of follow-up at 10 hospitals within the Cleveland Clinic Hospitals health care system. All adults admitted to a medicine service in 2017 were evaluated for inclusion. Patients with cardiovascular diagnoses were excluded. Demographic and BP characteristics were used for propensity matching. EXPOSURES Acute hypertension treatment, defined as administration of an intravenous antihypertensive medication or a new class of an oral antihypertensive treatment. MAIN OUTCOMES AND MEASURES The association between acute hypertension treatment and subsequent inpatient acute kidney injury, myocardial injury, and stroke was measured. Postdischarge outcomes included stroke and myocardial infarction within 30 days and BP control up to 1 year. RESULTS Among 22 834 adults hospitalized for noncardiovascular diagnoses (mean [SD] age, 65.6 [17.9] years; 12 993 women [56.9%]; 15 963 White patients [69.9%]), 17 821 (78%) had at least 1 hypertensive BP recorded during their admission. Of these patients, 5904 (33.1%) were treated. A total of 8692 of 106 097 cases (8.2%) of hypertensive systolic BPs were treated; of these, 5747 (66%) were treated with oral medications. In a propensity-matched sample controlling for patient and BP characteristics, treated patients had higher rates of subsequent acute kidney injury (466 of 4520 [10.3%] vs 357 of 4520 [7.9%]; P < .001) and myocardial injury (53 of 4520 [1.2%] vs 26 of 4520 [0.6%]; P = .003). There was no BP interval in which treated patients had better outcomes than untreated patients. A total of 1645 of 17 821 patients (9%) with hypertension were discharged with an intensified antihypertensive regimen. Medication intensification at discharge was not associated with better BP control in the following year. CONCLUSIONS AND RELEVANCE In this cohort study, hypertension was common among medical inpatients, but antihypertensive treatment intensification was not. Intensification of therapy without signs of end-organ damage was associated with worse outcomes.
Collapse
Affiliation(s)
- Radhika Rastogi
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Megan M Sheehan
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Bo Hu
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Victoria Shaker
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
| | - Lisa Kojima
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | | |
Collapse
|
39
|
Ailabouni NJ, Marcum ZA, Schmader KE, Gray SL. Medication Use Quality and Safety in Older Adults: 2019 Update. J Am Geriatr Soc 2021; 69:336-341. [PMID: 33438206 PMCID: PMC11057223 DOI: 10.1111/jgs.17018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 11/29/2022]
Abstract
Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2019. We selected high-quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to aspects of suboptimal prescribing and medication safety. The first study used a nationally representative sample of Medicare beneficiaries to examine the continuation of medications with limited benefit in patients admitted for cancer and non-cancer diagnoses in hospice (domain: potentially inappropriate medications). The second study, a retrospective cohort study of older adults in Ontario, Canada, assessed the association between prescribing oral anticoagulants in an emergency department relative to not prescribing anticoagulants in the emergency department and their persistence at 6 months (domain: underuse of medications). The third study, a cluster randomized trial in Quebec, Canada, evaluated the effect of conducting electronic medication reconciliation on several outcomes including adverse drug events and medication discrepancies (domain: medication safety). Lastly, the fourth study, a retrospective study using national inpatient and outpatient Veteran Health Administration combined with clinical and Medicare Claims data, examined the effects of intensification of antihypertensive medications on older adults' likelihood for hospital re-admission and other important clinical outcomes (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.
Collapse
Affiliation(s)
- Nagham J. Ailabouni
- Quality Use of Medicine and Pharmacy Research Centre, UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, Australia
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Zachary A. Marcum
- Quality Use of Medicine and Pharmacy Research Centre, UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, Australia
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Kenneth E. Schmader
- Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, North Carolina
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Shelly L. Gray
- Department of Pharmacy, University of Washington, Seattle, Washington
| |
Collapse
|
40
|
Min L, Ha JK, Hofer TP, Sussman J, Langa K, Cushman WC, Tinetti M, Kim HM, Maciejewski ML, Gillon L, Larkin A, Chan CL, Kerr E. Validation of a Health System Measure to Capture Intensive Medication Treatment of Hypertension in the Veterans Health Administration. JAMA Netw Open 2020; 3:e205417. [PMID: 32729919 PMCID: PMC9374172 DOI: 10.1001/jamanetworkopen.2020.5417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
IMPORTANCE Blood pressure (BP) targets are the main measure of high-quality hypertension care in health systems. However, BP alone does not reflect intensity of pharmacological treatment, which should be carefully managed in older patients. OBJECTIVES To develop and validate an electronic health record (EHR) data-only algorithm using pharmacy and BP data to capture intensive hypertension care (IHC), defined as 3 or more BP medications and BP less than 120 mm Hg, and to identify conditions associated with greater IHC, either through greater algorithm false-positive IHC, or by contributing clinically to delivering more IHC. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was conducted among 319 randomly selected patients aged 65 years or older receiving IHC from the Veterans Health Administration (VHA) from July 1, 2011, to June 30, 2013. Data were collected from a total of 3625 primary care visits. Data were analyzed from January 2017 to March 2020. EXPOSURES Calibration and measurement of the algorithm for IHC (algorithm IHC). MAIN OUTCOMES AND MEASURES For each primary care visit, the reference standard, clinical IHC, was determined by detailed review of free-text clinical notes. The correlation in BP medication count between the EHR-only algorithm vs the reference standard and the sensitivity and specificity of the algorithm IHC were calculated. In addition, presence vs absence of contributing conditions acting in combination with hypertension management were measured to examine incidence of IHC associated with contributing conditions, including an acute condition that lowered BP (eg, dehydration), another condition requiring a BP target lower than the standard 140 mm Hg (eg, diabetes), or the patient needing a BP-lowering medication for a nonhypertension condition (eg, β-blocker for atrial fibrillation) resulting in low BP. RESULTS Among 319 patients with 3625 visits (mean [SD] age, 75.6 [7.2] years; 3592 [99.1%] men), 911 visits (25.1%) had clinical IHC by the reference standard. The algorithm for determining medication count was highly correlated with the reference standard (r = 0.84). Sensitivity of detecting clinical IHC was 92.2% (95% CI, 89.3%-95.1%), and specificity was 97.2% (95% CI, 96.1%-98.3%), suggesting that clinical IHC can be identified from routinely collected data. Only 75 visits (2.1%) were algorithm IHC false positives, 55 visits (1.5%) involved IHC with contributing conditions, and 125 visits (3.5%) involved either false-positive or IHC with contributing conditions. Among select contributing conditions, congestive heart failure (37 patients [5.2%]) was most associated with a prespecified combined false-positive or IHC with contributing conditions rate higher than 5%. CONCLUSIONS AND RELEVANCE These findings suggest that health system data can be used reliably to estimate IHC.
Collapse
Affiliation(s)
- Lillian Min
- VA Ann Arbor Medical Center VA Geriatric Research, Education, and Clinical Center (GRECC)
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
- Institute of Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor, Michigan
| | - Jin-Kyung Ha
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan
| | - Timothy P. Hofer
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
- Institute of Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor, Michigan
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan
| | - Jeremy Sussman
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
- Institute of Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor, Michigan
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan
| | - Kenneth Langa
- VA Ann Arbor Medical Center VA Geriatric Research, Education, and Clinical Center (GRECC)
- Institute of Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor, Michigan
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan
- University of Michigan, Institute for Social Research
| | - William C. Cushman
- Preventive Medicine Section, Memphis VA Medical Center
- Department of Preventive Medicine, University of Tennessee Health Science Center
| | - Mary Tinetti
- Yale School of Medicine, Department of Medicine, Section of Geriatrics
| | - Hyungjin Myra Kim
- Consulting for Statistics, Computing & Analytics Research (CSCAR), University of Michigan, Ann Arbor
- Department of Biostatistics, University of Michigan Medical School
| | - Matthew L. Maciejewski
- ADAPT Center of Innovation Durham, VA Health Care System
- Department of Population Health Sciences, Duke University
| | - Leah Gillon
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
| | - Angela Larkin
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
| | - Chiao-Li Chan
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan
| | - Eve Kerr
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
- Institute of Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor, Michigan
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan
| |
Collapse
|
41
|
de Simone G, Mancusi C. Primum non nocere. J Hum Hypertens 2020; 34:547-550. [PMID: 32546775 DOI: 10.1038/s41371-020-0366-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Giovanni de Simone
- Hypertension Research Center and Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy.
| | - Costantino Mancusi
- Hypertension Research Center and Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| |
Collapse
|
42
|
Ouslander JG. Improving Drug Therapy for Patients With Life‐Limiting Illnesses: Letʼs Take Care of Some Low Hanging Fruit. J Am Geriatr Soc 2020; 68:682-685. [DOI: 10.1111/jgs.16395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 02/03/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Joseph G. Ouslander
- Clinical Biomedical Science Charles E. Schmidt College of Biomedical Science Boca Raton Florida
| |
Collapse
|
43
|
Anderson TS, Lee S, Jing B, Fung K, Ngo S, Silvestrini M, Steinman MA. Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals. JAMA Netw Open 2020; 3:e201511. [PMID: 32207832 PMCID: PMC7093767 DOI: 10.1001/jamanetworkopen.2020.1511] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/24/2020] [Indexed: 01/08/2023] Open
Abstract
Importance Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home. Objective To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications. Design, Setting, and Participants This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013. Main Outcomes and Measures Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics. Results Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels. Conclusions and Relevance In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.
Collapse
Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sei Lee
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Bocheng Jing
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Kathy Fung
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Sarah Ngo
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Molly Silvestrini
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Michael A. Steinman
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| |
Collapse
|
44
|
Vu M, Schleiden LJ, Harlan ML, Thorpe CT. Hypertension Management in Nursing Homes: Review of Evidence and Considerations for Care. Curr Hypertens Rep 2020; 22:8. [PMID: 31938958 DOI: 10.1007/s11906-019-1012-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW We sought to summarize recent evidence regarding optimal blood pressure (BP) treatment targets and antihypertensive regimen intensity for nursing home (NH) residents and similar older, complex patients with hypertension. RECENT FINDINGS Recent trials have demonstrated cardiovascular benefits from more intensive BP targets among ambulatory, less complex older adults, but generalizability to NH residents is questionable. Other trials have demonstrated that de-intensifying antihypertensives in frail, older patients is feasible, with no or modest increases in BP, but most have not assessed effects on patient-centered outcomes. Observational studies with patients more representative of NH residents suggest harms associated with more intensive BP treatment and reduction in fall risk associated with deintensification, but findings and potential for bias vary across studies. Randomized trials and rigorous observational studies examining effects of deintensified BP management on patient-centered outcomes in complex, older populations are needed to inform improved guidelines and treatment for NH residents.
Collapse
Affiliation(s)
- Michelle Vu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Center for Medication Safety, Veterans Affairs Pharmacy Benefits Management, Hines, IL, USA
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Michelle L Harlan
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Kerr Hall Suite 2204, Campus Box 7573, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA.,Elon University, Elon, NC, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA. .,Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Kerr Hall Suite 2204, Campus Box 7573, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA.
| |
Collapse
|
45
|
Anderson TS, Steinman MA. Highlighting the Need for Action Regarding Persistent Sex Bias in Research-Reply. JAMA Intern Med 2020; 180:165. [PMID: 31904791 DOI: 10.1001/jamainternmed.2019.5676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael A Steinman
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| |
Collapse
|
46
|
Affiliation(s)
- Kimberly E Lind
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| |
Collapse
|
47
|
[Not Available]. MMW Fortschr Med 2019; 161:3. [PMID: 31773631 DOI: 10.1007/s15006-019-1093-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
|
48
|
Gorelick PB, Qureshi S, Farooq MU. Management of blood pressure in stroke. INTERNATIONAL JOURNAL CARDIOLOGY HYPERTENSION 2019; 3:100021. [PMID: 33447751 PMCID: PMC7803067 DOI: 10.1016/j.ijchy.2019.100021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 10/09/2019] [Indexed: 01/01/2023]
Abstract
Objective In this review and opinion piece, we discuss recent United States (US)-based guidance statements on the management of BP in stroke according to stroke type and stage of stroke. Methods We reviewed the most recent guidance statements on BP control from United States (US)-based organizations such as the American Heart Association/American Stroke Association (AHA/ASA) and American College of Cardiology (ACC), and articles available to the authors in their personal files. Results The key BP target before starting alteplase (t-PA) is < 185/110 mm Hg, and the maintenance BP after tPA administration is < 180/105 mm Hg. For IPH patients with systolic BP between 150 and 220 mm Hg and no contraindication to acute BP reduction therapy, acute lowering to 140 mm Hg systolic BP is safe. For persons with small vessel or lacunar cerebral ischemia, a reasonable BP lowering target is < 130 mm Hg systolic. For primary stroke prevention, the target BP for those with hypertension is < 140/90 mm Hg and self-measured BP is recommended to assist in BP control. Recent study and guidance suggest a BP target of <130/80 mm Hg for both primary and recurrent stroke prevention. BP control is reasonable for the prevention of cognitive decline or dementia. Conclusions BP targets for the proper management of stroke vary by chronological stage of stroke and by stroke subtype. Furthermore, consideration should be given to control of BP variability, especially in the acute phases of stroke, as it may play a role in conferring longer term outcomes. Stroke is an important cause of morbidity and mortality worldwide, and is well suited for prevention and acute treatment with proper BP management. BP targets in acute ischemic stroke vary whether intravenous alteplase is administered or an endovascular intervention is implemented or not. In acute intraparenchymal hemorrhage of the brain (IPH), it is reasonable to lower BP to a systolic level of 140–150 or up to 160 mm Hg. For both first and recurrent stroke prevention it is reasonable to aim for a BP target of <130/80 mm Hg based on the recent data. The revised BP target has been lowered to <130/80 mm Hg for prevention of major cardiovascular outcomes including stroke. Intensive BP control potentially preserves cognition, brain health, and brain structural integrity. Blood pressure variability is a new target for study in the acute treatment and prevention of stroke.
Collapse
Affiliation(s)
- Philip B Gorelick
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Translational Neuroscience, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Shakaib Qureshi
- Hauenstein Neurosciences, 220 Cherry Street SE, Grand Rapids, MI 49503, USA
| | - Muhammad U Farooq
- Hauenstein Neurosciences, 220 Cherry Street SE, Grand Rapids, MI 49503, USA
| |
Collapse
|