2026/05/18 by Peter Bárány · 1 voice
Medicine · #Blood Pressure and Hypertension Studies #Cardiac, Anesthesia and Surgical Outcomes #Hemodynamic Monitoring and Therapy
paper · doi:10.1111/joim.70107
openalex publication_date 2026/05/18 · openalex created_date 2026/05/19 · openalex updated_date 2026/05/19
Despite progress in controlling hypertension globally, it is still the leading risk factor for early death and poor health [1]. Effective antihypertensive treatment reduces cardiovascular morbidity and mortality and prevents progression of diabetic complications, heart failure, and chronic kidney disease. However, WHO estimates that only 23% of adults with hypertension worldwide have it under control. Based on randomized controlled studies, recent guidelines recommend a blood pressure goal of less than 130/80 mm Hg in patients with cardiovascular disease, diabetes mellitus, and chronic kidney disease [2]. Especially in elderly patients, achieving such a strict blood pressure target carries a risk of hypotension, syncope, and acute kidney injury (AKI) episodes [3]. Hypotension and hemodynamic instability during acute illness are common events leading to temporary withholding of antihypertensive medication. Aspects of inhospital management of patients with hypertension have been studied and debated recently. A meta-analysis found a decreased risk of perioperative hypotension when renin-angiotensin-aldosterone system inhibitors (RAASi) were discontinued up to 10–48 h before surgery [4]. The risk of postoperative atrial fibrillation increased, but no effect on mortality was observed. In hospitalized patients with elevated blood pressure, it is necessary to distinguish between asymptomatic hypertension and emergencies with target-organ damage requiring immediate intervention [5]. Patients with asymptomatic hypertension should continue their medications but intensified treatment of inpatients, with often transient increase in blood pressure, should be avoided. In the large propensity score–matched cohort study of stable hospitalized patients with hypertension by Ribak et al in this issue of Journal of Internal Medicine [6], clinical outcomes associated with discontinuation of antihypertensive therapy were evaluated. Exclusion criteria included patients admitted with AKI or hypotension as well as patients in the ICU and cardiology wards. Overall, 28.4% of the whole cohort of hypertensive patients discontinued one or more prescribed antihypertensive medications. Discontinuation of diuretics was most common, followed by RAASi, whereas 85.9% of patients on beta-blockers continued treatment. Stopping beta-blockers abruptly preoperatively is not recommended in cardiology guidelines because it may lead to rebound tachycardia and hypertension [7]. Consistent in most subgroups, the main findings were increased inhospital and 90-day mortality when antihypertensive therapy was discontinued. Discontinuation in patients admitted to internal medicine wards and patients with infections was associated with higher rates of AKI, whereas withholding antihypertensives in surgical patients was linked to increased risk of myocardial injury. No benefits of discontinuation were observed in any subgroup. This observational study has several limitations. After the propensity matching, blood pressure was lower and the risk of subsequent AKI was higher in the discontinuation group, indicating that remaining bias exists. We have no information on prehospitalization blood pressure control or doses of medications before and during hospitalization. Reasons for withholding of antihypertensives were not possible to obtain retrospectively. Patients were assigned to the discontinuation group if any of the antihypertensive medications were withheld, with the exemption of RAASi discontinued in patients with AKI. The strength of the study is that it reflects real-life data of a population-based cohort of hypertensive patients with common associated comorbidities. In line with findings in the study cohort, discontinuation of RAASi is common in clinical practice and is associated with worse cardiorenal outcomes [8]. Generally, AKI and hyperkalemia are probably the most common adverse events leading to discontinuation of RAASi. Resuming therapy may be beneficial [9] but is often delayed or not done. In the present study, a significant proportion of the patients may be put at risk when discontinued medications were not restarted after discharge from the hospital. Evidence-based guidance on inpatient management of hypertensive patients is largely lacking. In the perioperative period withholding RAASi is often routinely done because of the risk of hypotension. However, as soon as the patient is hemodynamically stable, restart of discontinued antihypertensives should be advised to avoid future cardiorenal complications [7]. Fluid and electrolyte balance should be strictly controlled, especially in high-risk patients with cardiovascular and kidney disease. When the patient is discharged, planning for future care and transition to the treating physician is essential to secure follow-up. Future research on how blood pressure control can be optimized in the acute setting is needed to develop guidelines protecting vulnerable patients from severe complications. In the long run, personalized precision medicine is of utmost importance to provide best practices to our high-risk hypertensive patients. The author declares no conflicts of interest.