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

项目总结/摘要 2015年，老年人住院人数超过1200万。住院期间，血压（BP） 可能由于急性疾病、压力和新药物暴露而波动。虽然长期 严格控制血压对老年人心血管风险的好处是众所周知的，但没有研究表明， 治疗住院期间无症状血压升高的短期获益。尽管存在证据缺口， 单中心研究表明，老年人通常在住院期间接受强化BP治疗， 非心脏疾病。老年人在接受药物治疗时发生药物相关不良事件的风险增加 治疗和从急性疾病中恢复，因此，了解密集的好处和危害， 在住院期间治疗血压升高是至关重要的。在住院治疗时， 高血压，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、福尔斯和急性肾损伤。迄今为止，先前的研究尚未评估 加强住院BP治疗对住院期间临床结局的影响。必须解决 先前对住院患者血液的研究突出了围绕住院患者BP管理的知识差距 葡萄糖管理，证明将门诊血糖治疗目标应用于 医院环境导致院内低血糖和死亡的风险增加。的目的 应用是描述老年人中强化治疗血压升高的流行病学和结果， 成人住院期间我们提出了一项回顾性队列研究，所有老年人住院的非- 2013年至2015年期间，国家退伍军人事务卫生系统的心脏疾病。一是 描述住院老年人中血压升高的住院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 回归以获得通过关键患者特征对强化BP治疗的相对风险的直接估计 包括既往门诊血压控制、多种药物治疗、多发病、痴呆和预期寿命有限。 其次，我们将评估强化住院BP治疗对住院临床结局的影响 包括潜在危害（例如福尔斯、急性肾损伤）和潜在获益（急性CV事件减少）。 我们将比较接受和未接受强化BP治疗的老年人的住院结果， 倾向评分与对照组相匹配，用于适应症混杂。我们将进行预先指定的分组 分析以确定患有多种疾病、痴呆或预期寿命有限的患者是否 院内伤害风险增加。这项研究将填补一个重要的知识空白，并提供关键的指导， 老年人的住院BP治疗决策。这些数据将作为未来研究的基础， 设计并测试一项试点干预措施，以指导在治疗期间血压升高治疗决策的个体化。 根据老年人获益的可能性和不良结局的风险，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.