In recent years, most physicians have become far more aggressive when it comes to intensive blood pressure control. That’s largely because the American College of Cardiology (ACC) and the American Heart Association (AHA) have created strict guidelines for blood pressure management. To be “normal” you now have to be below 120/80. There’s one place where adhering to those parameters could pose a problem. Surprisingly, it’s in the hospital!
Beware Intensive Blood Pressure Control in the Hospital:
This research will make many cardiologists uncomfortable. It was published in JAMA Internal Medicine (May 30, 2023). The results defy conventional wisdom.
Here is what the investigators did. They analyzed the medical records of 66,140 patients admitted to Veterans Health Administration hospitals between October 1, 2015 and December 31, 2017. These were older people (65 and up). They did not have heart problems or a “hypertensive emergency” at the time they were admitted to a VA hospital.
When patients are hospitalized it is common for them to have their blood pressure monitored. That is primarily to detect bouts of HYPOtension. If blood pressure drops too low it could signal low fluid volume, sepsis or internal bleeding. Not infrequently, though, such monitoring detects elevated blood pressure. After all, hospitalization can be a stressful experience. Pain, anxiety, fever and lack of sleep can all raise blood pressure (BP).
Should Asymptomatic Hypertension Lead to Intensive Blood Pressure Control?
That is the question these investigators were trying to answer. They point out that blood pressure is often measured many times daily during hospitalization.
They go on to note that:
“…the majority of hospitalized patients, including those with normal home BPs, will experience elevated BPs (>140/90 mmHG) without signs of acute end organ damage, often termed asymptomatic BP elevation.”
When doctors detect such elevations they often administer oral or even intravenous medications to bring down blood pressure. Is that a good idea? Surprisingly, there has not been a lot of research to answer that question.
The authors reveal:
“To our knowledge, there are no clinical trials or professional society recommendations to guide treatment decisions for asymptomatic elevated BPs in the hospital, and as a result, clinical practice varies widely.”
That is typical doctorspeak. What it means is that doctors are flying blind when it comes to intensive blood pressure control in the hospital. This research attempts to determine if such treatment is beneficial. And the envelope please!
Beware Intensive Blood Pressure Control in the Hospital:
Here are the surprising conclusions of this study:
“In this cohort study using VHA data of a predominately male population with multiple morbidities, we found that 21% of older adults with elevated inpatient BP recordings received intensive antihypertensive treatment in the first 48 hours of hospitalization and that receipt of intensive treatment was associated with a greater odds of adverse events, including cardiac injury, AKI [acute kidney injury], and ICU transfer.”
In other words, intensive blood pressure control in these hospitalized patients led to heart and kidney problems. As a result, more of these individuals had to be transferred to intensive care units. The authors conclude that patients diagnosed with elevated blood pressure in the hospital should probably not automatically receive intensive blood pressure control unless there is a compelling reason to do so.
When Less Is More:
The article in JAMA Internal Medicine (May 30, 2023) was published under the “LESS Is MORE” heading. It only applies to hospitalized patients. What about people who are not in the hospital?
How low should you get blood pressure to go? That is a question that has been challenging both doctors and patients for many years. If you asked most American physicians a decade ago when to start prescribing drugs for hypertension, you might have been told that 145/95 should trigger treatment. Now, though, intensive blood pressure control is the norm to prevent a MACE (Major Adverse Cardiovascular Event).
Readings greater than 120/80 are likely to lead to a diagnosis of hypertension. And that can easily lead to a prescription. How effective is intensive blood pressure control in preventing heart attacks, strokes or death from cardiovascular causes?
Is Intensive Blood Pressure Control Worth the Effort?
The Systolic Blood Pressure Intervention Trial (SPRINT) showed that lowering systolic pressure below 120 was better at preventing heart disease, complications and premature death than aiming for 140. However, the scientists running SPRINT were very careful about selecting patients who would get the most benefit from intensive blood pressure control.
In addition, questions remain about whether the difficulties of achieving such low blood pressure and the potential side effects people might suffer would make this intervention too costly. In many cases, volunteers needed to take several medications in order to get systolic blood pressure even close to 120.
An Analysis of Intensive Blood Pressure Control:
A meta-analysis of six trials of intensive blood pressure control was also published under the “LESS IS MORE” category in JAMA Internal Medicine (May 9, 2022). The authors point out that older people are highly variable when it comes to their risk of cardiovascular disease. Pre-existing conditions like diabetes and poor kidney function can impact outcomes.
Doctors need to weigh the benefits of intensive blood pressure control against the downsides of such treatment. BP meds can cause episodes of low blood pressure (hypotension) which can cause fainting, falls and broken bones. Kidneys can be damaged by too many powerful blood pressure drugs. Diuretics can deplete the body of crucial minerals such as potassium, magnesium and zinc.
That is why this study is important. It asks the question: How long does it take to achieve a meaningful benefit with intensive blood pressure control?
The Results, Please:
Let’s cut right to the chase. Here are the findings:
“In this analysis of 6 randomized clinical trials consisting of 27 414 individuals with hypertension aged 60 years and older, 19.1 months and 34.4 months were needed to avoid 1 cardiovascular event for 100 and 200 patients, respectively.”
OK, that might be hard to understand. Here is our take on the data:
Getting systolic blood pressure below 130 significantly reduced the chance of a heart attack or stroke. It took a long time, however, to see the benefits. To prevent one serious cardiovascular event, 500 people would have to take high doses of one or more types of blood pressure lowering medication for at least nine months. After approximately three years of treatment, one person out of 100 would benefit from intense blood pressure management.
Put another way, after three years, 99 people out of 100 would not have received benefit from intense blood pressure control. If you are the 1 person in 100 that would benefit, this is good news. If you are part of the 99 people who would not have benefitted, it’s not such good news.
The authors conclude:
“In this analysis, we found that treating 100 older patients (≥60 years) with hypertension for approximately 3 years would prevent 1 MACE [major adverse cardiovascular event]. These findings suggests that intensive SBP control may be most appropriate for older adults with a life expectancy of greater than 3 years.”
What Does All This Mean?
When life expectancy is less than 1 year, the harms of intensive BP control may outweigh the benefits. From our perspective, though, even with life expectancy beyond 1 year, a person should consider benefits vs. harms carefully.
The authors point out that intensive blood pressure control carries risks. Clinicians should consider “each patient’s values and preferences” when determining the best treatment program. And patients should not be afraid to ask their health care providers how likely the treatment is to benefit them. We’d also encourage them to ask whether there are worrisome risks to weigh.
To learn more about proper blood pressure measurement, natural approaches and the pros and cons of many BP medications, you may wish to read our eGuide to Blood Pressure Solutions. It can be found under the Health eGuides tab.
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