As-Needed BP Medication and Increased Adverse Outcomes in VA Hospitals
Clinical question: What are the adverse effects of as-needed BP medication on asymptomatic hypertension in hospitalized patients at risk of ischemic events due to high cardiovascular disease burden?
Background: Asymptomatic BP elevations in hospitalized patients are often managed with as-needed medications due to the lack of clear guidelines. Prior studies have suggested potential risks, such as acute kidney injury (AKI), associated with this practice.
Study design: Retrospective cohort study
Setting: Veterans Administration hospitals, excluding intensive care unit settings and surgical floors
Synopsis: Veterans who received at least one as-needed BP medication during hospitalization between October 1, 2015, and September 30, 2020, were compared to those who received only scheduled BP medication. Reasons for admission between the two groups were matched to enhance generalizability. The primary outcome measured was the incidence of AKI, with secondary outcomes including rapid BP drops and a composite of myocardial infarction, stroke, and death. The findings demonstrated that veterans who received as-needed BP medication were 23% more likely to develop AKI (HR, 1.23 [95% CI, 1.18 to 1.29]), with a higher risk associated with IV administration compared to oral treatment. Additionally, in veterans who received as-needed BP medications, there was a 1.5-fold greater risk of rapid BP reduction (95% CI, 1.39 to 1.62) and a 1.7-fold increase in the risk of a composite outcome of MI, stroke, or death (relative risk, 1.69 [95% CI, 1.49 to 1.92]). Limitations include potential residual confounding and focus on a veteran population, limiting generalizability.
Bottom line: As-needed BP medications for asymptomatic hypertension were associated with increased risks of AKI, rapid blood pressure drops, myocardial infarction, stroke, and death in hospitalized veterans.
Citation: Canales MT, et al. As-needed blood pressure medication and adverse outcomes in VA hospitals. JAMA Intern Med. 2025;185(1):52–60. https://doi.org/10.1001/jamainternmed.2024.6213.
Dr. Villaflor is a hospitalist and quality improvement deputy for the hospitalist service at Yale New Haven Hospital, and an assistant clinical professor at Yale School of Medicine, both in New Haven, Conn.