Hypertension hospitalization rises while mortality falls; sex-based disparities remain
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The rate of hospitalization for hypertensive crisis increased in recent years, but the odds of death during hospitalization decreased and was similar for men and women, researchers reported.
According to data published in the Journal of the American Heart Association, the odds of in-hospital mortality were similar between men and women, despite women presenting with fewer comorbidities.
“What we found is that during a time period in which national trends were demonstrating improved overall BP control, the rate of hospitalization for hypertensive crisis was going up for both men and women,” Joseph E. Ebinger, MD, MS, clinical cardiologist and director of clinical analytics at the Smidt Heart Institute of Cedars-Sinai, told Healio. “The important thing to remember, for cardiac physicians, is that improvements in outpatient BP control at a population level are not necessarily translated to reductions in severe hypertensive disorders that may result in hospitalization.”
Using data from the National Inpatient Sample, researchers evaluated sex-specific trends among 918,392 hypertensive crisis hospitalizations (mean age, 60 years; 59% women; 39% white) and 4,377 in-hospital deaths (mean age, 68 years; 60% women; 43% white) during serial time periods (2002-2006, 2007-2011 and 2012-2014).
Hypertensive crisis hospitalization
At hospital admission, women were older (63.7 vs. 55.2 years; P < .001), were more likely to be white (41.1% vs. 36.9%; P < .001) and were more likely to have a history of stroke (11.3% vs. 9.6%; P < .001) compared with men. Conversely, men were more often Black (36.3% vs. 32.9%; P < .001) and more likely to have a history of MI (7.9% vs. 6.7%; P < .001), HF (30.4% vs. 25.3%; P < .001) or renal failure (41.1% vs. 30.6%; P < .001) compared with women.
During the study period, the mean age of patients hospitalized for hypertensive crisis increased from 54.4 years to 56.2 among men (P < .001) and from 63.2 years to 64.2 years among women (P < .001). The comorbidity burden also increased during the study period for both men and women (P for both < .001).
In-hospital mortality
According to the study, the sex-specific demographic and clinical variables among patients who died during hospitalization for hypertensive crisis were similar to those of the admitted population, with women being more often older (P < .001) and white (P = .042) and to have a history of stroke (P < .001) and HF (P < .001) compared with men.
From 2002 to 2014, the researchers observed increased annual admission rates for both men and women, but more so in men, with a 2014 admission rate higher compared with women (0.39% vs. 0.34%; P < .001).
According to the study, the odds of hospitalization for hypertensive crisis increased annually for men (OR per year = 1.084; 95% CI, 1.078-1.09) and women (OR per year = 1.075; 95% CI, 1.07-1.079), with a higher rate of increase observed among men compared with women (P < .001).
After adjusting for age, race/ethnicity, obesity, hypercholesterolemia and diabetes, researchers reported that the likelihood of death during hypertensive crisis hospitalization decreased over time for both men (OR per year = 0.901; 95% CI, 0.874-0.928) and women (OR per year = 0.93; 95% CI, 0.907-0.953); however, the change during specific time periods was not significant for either men or women.
“One of the most interesting factors is when we stratified this by sex, we noticed that the mortality rates declined for both men and women and remained about equal. Yet, for some reason, women had fewer comorbidities. You would expect that if they had fewer comorbidities, they would’ve been dying at a lower rate,” Ebinger told Healio. “The question that needs to be addressed is why we are seeing the same mortality rates between men and women, when based on their CV risk profiles, we would expect women to be dying at a lesser rate than men. Is this due to some underlying biological factor that predisposes women to have a more severe response to high BP? Or are there other health system factors that need to be addressed to help mitigate what would be an inappropriate mortality rate for this condition?”
Moreover, after the researchers included CV conditions to the model, the likelihood of death during hospitalization for hypertensive crisis decreased annually for men (OR, per year = 0.89; 95% CI, 0.863-0.918) and women (OR per year = 0.921; 95% CI, 0.897-0.944); however, the change during specific time periods was not significant for either men or women.
“Since this is a retrospective study, we can’t draw any causal conclusions ... however, things that could be considered are that outpatient control does not necessarily reflect these acute spikes, meaning that people can ‘break through’ hypertensive control,” Ebinger told Healio. “Is it that while the general population has seen BP control, there are subsets that are not experiencing control, and we’re seeing that with an increase in hospitalization?
“We know, for example, men have worse control of BP at younger ages, and women tend to overtake men in that by an older age,” Ebinger told Healio. “Are there hormonal changes that occur over a lifetime? Is it a fact of as people get older, they decide BP isn’t as important to them, and they’re not as adherent to medications? All of these are possible, but future work is needed to discern what exactly is causing it.”
For more information:
Joseph E. Ebinger, MD, MS, can be reached at biodatacore@cshs.org.
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