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. 2025 Jan 1;185(1):52-60.
doi: 10.1001/jamainternmed.2024.6213.

As-Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals

Muna Thalji Canales  1   2 , Seonkyeong Yang  3   4 , Anders Westanmo  5 , Xinping Wang  6 , Dexter Hadley  3   7 , Areef Ishani  8 , Rajesh Mohandas  9 , Ronald Shorr  6   10 , Weihsuan Lo-Ciganic  11   12
Affiliations

As-Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals

Muna Thalji Canales et al. JAMA Intern Med. .

Abstract

Importance: Asymptomatic blood pressure (BP) elevations in the hospital are commonly treated with as-needed BP medications, including recurring as-needed and 1-time administration. Veterans represent a population at risk of ischemic events from rapid lowering of BP, but the impact of as-needed BP medication use in this population is unknown.

Objective: To assess the risks of acute kidney injury (AKI) and other outcomes from as-needed BP medication administration in a hospitalized veteran cohort.

Design, setting, and participants: This retrospective cohort study using target trial emulation and propensity score matching included adult veterans, who were hospitalized 3 or more days in Veterans Administration hospitals between October 1, 2015, and September 30, 2020. Participants must have been hospitalized on a non-intensive care unit medical or surgical floor, must not have undergone surgery, and must have received at least 1 scheduled BP medication in the first 24 hours of admission. Participants also must have had at least 1 systolic BP more than 140 mm Hg during hospitalization. Data in this study were analyzed from April 2023 to August 2024.

Main outcomes and measures: The primary outcome was time to first AKI occurrence during hospitalization. Secondary outcomes included greater than 25% reduction in systolic BP within 3 hours of as-needed BP medication administration and the composite outcome of myocardial infarction, stroke, or death during hospitalization.

Results: Of the 133 760 veterans eligible for analysis (mean [SD] age, 71.2 [11.6] years), 96% were male. The mean (SD) baseline estimated glomerular filtration rate was 75.7 (22.7) mL/min/1.73m2. A total of 28 526 patients (21%) received as-needed BP medication. As-needed BP medication use was associated with an increased AKI risk (adjusted hazard ratio, 1.23 [95% CI, 1.18-1.29]) compared to nonusers. Subgroup analyses showed higher AKI risk with intravenous as-needed BP medication use (compared to oral or combined oral and intravenous routes). Secondary analyses indicated as-needed BP medication users had a 1.5-fold greater risk of rapid BP reduction (95% CI, 1.39-1.62) and 1.69-fold higher rate of the composite outcome (95% CI, 1.49-1.92) compared to nonusers.

Conclusions and relevance: The results of this retrospective cohort study showed that as-needed BP medication use among veterans is associated with increased AKI risk. The risks and benefits of this type of BP medication use would best be determined through a prospective trial, and these data suggest that there is the necessary equipoise to conduct such a trial.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Hadley reported grants from the VA Intergovernmental Personnel Act contract during the conduct of the study. Dr Lo-Ciganic reported grants from the VA during the conduct of the study; grants from Merck, Sharp & Dohme, and BMS outside the submitted work; having a patent pending for U1195.70174US00; and consulting fees from Teva Pharmaceuticals. No other disclosures were reported.

References

    1. Axon R, Turner M, Buckley R. An update on inpatient hypertension management. Curr Cardiol Rep. 2015;17(11):94. doi:10.1007/s11886-015-0648-y - DOI - PubMed
    1. Whelton PK, Carey RM, Aronow WS, et al. . 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNa guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71(19):e127-e248. doi:10.1016/j.jacc.2017.11.006 - DOI - PubMed
    1. James PA, Oparil S, Carter BL, et al. . 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427 - DOI - PubMed
    1. Williams B, Mancia G, Spiering W, et al. ; Authors/Task Force Members . 2018 ESC/ESH guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: the task force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens. 2018;36(10):1953-2041. doi:10.1097/HJH.0000000000001940 - DOI - PubMed
    1. Bress AP, Anderson TS, Flack JM, et al. ; American Heart Association Council on Hypertension; Council on Cardiovascular and Stroke Nursing; and Council on Clinical Cardiology . The management of elevated blood pressure in the acute care setting: a scientific statement from the American Heart Association. Hypertension. 2024;81(8):e94-e106. doi:10.1161/HYP.0000000000000238 - DOI - PubMed

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