Intensified blood pressure control during hospital admission and on discharge: a systematic review and meta-analysis of retrospective cohort studies

Introduction Limited single-center studies suggest that intensified blood pressure (BP) control in patients with asymptomatic elevated BP during non-cardiac admissions may lead to worse outcomes. In this study, we performed a systematic review and meta-analysis exploring the safety of intensified BP control vs. a more conservative approach in patients with asymptomatic elevated BP during non- cardiac admissions and at discharge, focusing on stroke, acute kidney injury (AKI), myocardial infarction (MI), and length of stay (LOS). Methods Four retrospective propensity score-matched cohort studies ( n = 77,448) were included. The intensified BP control group ( n = 38,724) received newly initiated, increased dose, intravenous (IV), or pro re nata (PRN) antihypertensive medication, including PRN with scheduled therapy. The non-intensified group ( n = 38,724) included patients continuing their preadmission regimen, scheduled, or with no PRN antihypertensives. Follow-up began after the first inpatient antihypertensivedose or at discharge and continued until (1) 30 days postdischarge, (2) hospitaldischarge, or (3) both, depending on the study. Patients with hypertensive emergencies, stroke, MI, or aortic dissection at admission were excluded. Results Intensified BP control was associated with increased odds of stroke (OR 3.77; 95% CI 1.38–10.27; p < 0.010), AKI (OR 1.23; 95% CI 1.13–1.33; p < 0.00001), and longer LOS (MD 1.17; 95% CI 1.11–1.93; p < 0.00001). No statistically significant increase of MI was noted (OR 2.04; 95% CI 0.85–4.89, p = 0.11). Intensified BP control during non-cardiac hospitalizations and at discharge was linked to higher odds of stroke, AKI, and prolonged hospitalization. Conclusions A more conservative approach may be safer in the absence of acute indications for BP lowering. Prospective, randomized inpatient BP trials, particularly those distinguishing interventions initiated during hospitalization vs. at discharge are warranted to clarify causal relationships and guide evidence-based inpatient BP management. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/566609 , identifier CRD42024566609.