Evaluating Whether Treating Elevated Blood Pressure in the Inpatient Setting Impacts Patient Outcomes: the ACT-BP pilot

Approximately 50-72% of the 36.2 million individuals admitted to U.S. hospitals are diagnosed with hypertension. Hypertension increases the risk of devastating cardiovascular outcomes, such as strokes, heart attacks, and heart failure. Three-quarters of admitted patients experience at least one elevated blood pressure (BP) (>140/90) during hospitalization. While BP is usually elevated for benign reasons, including pain and anxiety, acutely elevated BP can cause end-organ damage. Currently, no guidelines exist for managing asymptomatically elevated BP in the inpatient setting. There is growing observational evidence that antihypertensive medication intensification for asymptomatically elevated BP can result in adverse outcomes, such as increased readmission. Since observational studies are biased, a large-scale clinical trial is needed to identify whether to treat asymptomatically elevated BPs in the hospital. Yet, it would be unethical and costly to randomize individual patients to receive antihypertensive medication intensification. To overcome these obstacles, we designed ACT-BP, a hospital-unit-level intervention. ACT-BP removes standing orders to call physicians about elevated BPs (which encourages treatment due to social desirability bias), provides education on the potential harm of treating asymptomatically elevated BPs, and suggests alternative procedures (e.g., monitoring BP more frequently). If funded, we will obtain three specific pieces of knowledge needed to conduct a larger, adequately powered randomized clinical trial: 1) how much does ACT-BP reduce antihypertensive medication intensification; 2) what refinements will improve its effectiveness; 3) what is the rate of the composite outcome in the intervention and control units. At the end of the funding period, we will know whether it is feasible to persuade clinicians to reduce antihypertensive medication intensification for asymptomatically elevated BPs in the hospital setting. This information would ensure that our future cluster-randomized trial can test the efficacy of antihypertensive intensification on our composite outcome. Thus, it is scientifically necessary to prove we can change intensification patterns. Then, our future RCT will be the first to provide rigorous evidence on whether intensifying antihypertensive medications to address asymptomatically elevated BPs increases the risk of new onset stroke, acute kidney injury, or myocardial infarction. In sum, this R34 grant will provide the scientific knowledge to understand whether a medical unit-level intervention is effective in changing antihypertensive intensification patterns in preparation for the larger R01-funded clinical trial that would establish the safety and efficacy of reducing the use of antihypertensives for patients with asymptomatically elevated BP. Project Number: 1R34HL173138-01A1 | Fiscal Year: 2025 | NIH Institute/Center: National Heart Lung and Blood Institute (NHLBI) | Principal Investigator: Elizabeth Pfoh | Institution: CLEVELAND CLINIC LERNER COM-CWRU, CLEVELAND, OH | Award Amount: $362,250 | Activity Code: R34 | Study Section: NHLBI Single-Site and Pilot Clinical Trials Study Section[SSPT (OA)] View on NIH RePORTER: https://reporter.nih.gov/project-details/1R34HL17313801A1