Use of Intravenous Antihypertensives in Adults Hospitalized for Noncardiac Causes

In adults hospitalized for noncardiac diagnoses, does treatment of hypertension with intravenous (IV) antihypertensives improve outcomes?

Multiple retrospective, cohort studies have shown that use of IV antihypertensives in adults with hypertensive blood pressure (BP) measurements who have been hospitalized for noncardiac causes is associated with significant harm. Use of IV antihypertensives in these patients increases the risk of acute kidney injury (AKI) by approximately 1.5 times and doubles the risks of myocardial injury and inpatient mortality. (Strength of Recommendation [SOR]: B, cohort studies.) It may also increase the risks of stroke and intensive care unit (ICU) transfer and length of hospital stay. (SOR: B, cohort studies.) Risks of end-organ damage and death increase with a higher number of IV antihypertensive doses. (SOR: B, single cohort study.)

A 2023 retrospective, cohort study included 66,140 patients 65 years and older hospitalized for noncardiac diagnoses who had elevated BP in the first 48 hours after hospitalization.¹ The study compared patients who were treated with IV antihypertensives or new oral antihypertensives with patients who did not receive these treatments.

IV antihypertensives were used in 2,504 patients and were associated with increased risks of inpatient mortality (weighted odds ratio [OR] = 1.79; 95% CI, 1.26–2.53), transfer to the ICU (weighted OR = 2.54; 95% CI, 2.08–3.11), AKI (weighted OR = 1.63; 95% CI, 1.34–1.97), stroke (weighted OR = 2.67; 95% CI, 1.02–7.04), troponin elevation (weighted OR = 1.67; 95% CI, 1.22–2.31), and hypotension with systolic BP less than 100 mm Hg (weighted OR = 1.27; 95% CI, 1.12–1.44) vs patients who received no hypertension treatment. IV anti-hypertensives were also associated with an increased risk of the primary composite outcome, which included mortality, transfer to the ICU, AKI, stroke, B-type natriuretic peptide elevation, and troponin elevation (weighted OR = 1.90; 95% CI, 1.65–2.19).

A 2023 retrospective, cohort study investigated the use of IV antihypertensives in 20,383 patients 18 years and older admitted for diagnoses other than hypertension who developed severe hypertension (systolic BP greater than 180 mm Hg or diastolic BP greater than 110 mm Hg) while hospitalized.² Patients with severe hypertension in the emergency department or at admission were excluded. The 1,059 patients given IV antihypertensives within 3 hours of developing severe hypertension had increased rates of troponin elevation (hazard ratio = 1.6; 95% CI, 1.13–2.24) but not increased rates of AKI, stroke, or mortality compared with the 16,204 patients not treated with IV antihypertensives in this time frame.

A 2021 prospective, propensity-matched, cohort study followed 22,834 patients older than 18 years admitted for non-cardiac conditions.³ Of these patients, 5,904 received a new treatment for hypertension during their hospitalization, and 1,516 were treated with IV medications with or without oral medications. Patients treated with IV antihypertensives had a higher risk of myocardial injury (OR = 2.27; 95% CI, 1.17–4.68) and AKI (OR = 1.47; 95% CI, 1.16–1.87) compared with those who received no treatment. Stroke was rare in the cohort and rates were not different between the groups.

A 2021 prospective, cohort study included 42,771 adult patients with noncardiac diagnoses who received BP medications after hospital admission.⁴ It compared a cohort of 4,219 patients who received as-needed antihypertensives in addition to scheduled antihypertensives with an equal number of propensity-matched patients who received only scheduled anti-hypertensives. The authors did not specify whether the scheduled medication regimen included home medications or agents initiated at time of admission. Among the patients who received as-needed antihypertensive agents, 93% of medications were administered intravenously, but both IV and oral as-needed medications were included in the statistical analysis.