Impact of Intensive Blood Pressure Treatment on Clinical Outcomes of Hospitalized Older Adults

项目摘要/摘要 2015年，老年人住院人数超过1200万。住院期间，血压(BP) 可能会因急性疾病、压力和新的药物暴露而波动。虽然从长远来看 严格控制血压对老年人心血管风险的好处是众所周知的，没有研究表明 住院期间治疗无症状性血压升高的短期益处。尽管存在这种证据差距， 单中心研究表明，老年人通常在住院期间接受强化的BP治疗 非心脏疾病。老年人发生与药物有关的不良事件的风险增加 急性疾病的治疗和康复，因此，深入了解 住院期间血压升高的治疗至关重要。在住院期间，病情与 对于高血压来说，老年人可能特别容易受到BP过度治疗造成的伤害，包括 有症状的直立、摔倒和急性肾损伤。到目前为止，先前的研究还没有评估过 住院期间强化的住院BP治疗对临床结果的影响。解决这些问题的重要性 先前对住院患者血液的研究突显了围绕住院患者血压管理的知识差距 血糖管理表明，将门诊血糖治疗目标应用于 医院环境会增加住院期间低血糖和死亡率的风险。这样做的目的是 应用于描述强化治疗老年人血压升高的流行病学和结果 住院期间的成人。我们建议对所有因非糖尿病住院的老年人进行回顾性队列研究。 2013至2015年间，国家退伍军人事务健康系统的心脏状况。首先，我们将 描述住院老年人中血压升高的患者接受强化治疗的频率，并评估 与强化BP管理相关的患者特征。我们将使用对数二项式或泊松 根据关键患者特征直接估计强化BP治疗的相对风险的回归分析 包括既往门诊血压控制、多药联用、多种疾病、痴呆症和有限的预期寿命。 第二，我们将评估住院强化BP治疗对住院临床结果的影响。 包括潜在的危害(如跌倒、急性肾损伤)和潜在的益处(减少急性心血管事件)。 我们将比较接受和没有接受强化BP治疗的老年人的住院结果 倾向评分与对照相匹配，用于指征混淆。我们将进行预先指定的小组 分析以确定患有多种疾病、痴呆症或预期寿命有限的患者是否 增加住院伤害的风险。这项研究将填补一个重要的知识空白，并提供关键的指导，以告知 老年人的住院BP治疗决定。这些数据将作为未来研究的基础 设计和测试一项试点干预措施，以指导在治疗期间血压升高的个体化治疗决策 根据老年人受益的可能性和不良后果的风险确定围住院期。

PROJECT SUMMARY/ABSTRACT Older adults accounted for over 12 million hospitalizations in 2015. During hospitalization, blood pressure (BP) may fluctuate as a result of acute illness, stress, and new medication exposures. Though the long-term benefits of strict BP control on older adults’ cardiovascular risk are well established, no research has shown a short-term benefit to treating asymptomatic elevated BPs during hospitalization. Despite this evidence gap, single-center studies indicate older adults commonly receive intensive BP treatments during hospitalization for non-cardiac conditions. Older adults are at increased risk of medication-related adverse events while being treated for and recovering from acute illness, therefore, understanding the benefits and harms of intensively treating elevated BPs during hospitalization is critically important. While hospitalized for conditions unrelated to hypertension, older adults may be particularly susceptible to harms resulting from BP overtreatment, including symptomatic orthostasis, falls, and acute kidney injury. To date, prior studies have not assessed the effect of intensive inpatient BP treatment on clinical outcomes during hospitalization. The importance of addressing the knowledge gaps surrounding inpatient BP management is highlighted by prior research on inpatient blood glucose management which demonstrated that applying outpatient blood glucose treatment targets to the hospital setting results in increased risks of in-hospital hypoglycemia and mortality. The objective of this application is to characterize the epidemiology and outcomes of intensively treating elevated BPs in older adults during hospitalization. We propose a retrospective cohort study of all older adults hospitalized for non- cardiac conditions in the national Veteran’s Affairs Health System between 2013 and 2015. First, we will describe how often elevated inpatient BPs are treated intensively among hospitalized older adults and evaluate patient characteristics associated with intensive BP management. We will use log binominal or Poisson regression to obtain direct estimates of relative risks of intensive BP treatment by key patient characteristics including prior outpatient BP control, polypharmacy, multi-morbidity, dementia, and limited life expectancy. Second, we will evaluate the impact of intensive inpatient BP treatment on in-hospital clinical outcomes including potential harms (e.g. falls, acute kidney injury) and potential benefits (reduction in acute CV events). We will compare in-hospital outcomes of older adults who did and did not receive intensive BP treatment using propensity score matching to control for confounding by indication. We will conduct pre-specified subgroup analyses to determine whether patients with multi-morbidity, dementia, or limited life expectancy have increased risk of in-hospital harms. This study will fill a vital knowledge gap and provide key guidance to inform inpatient BP treatment decisions for older adults. These data will serve as the foundation for future studies to design and test a pilot intervention to guide the individualization of elevated BP treatment decisions during the peri-hospitalization period based upon older adults’ likelihood to benefit and risk of adverse outcomes.