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Low baseline (pre-injury) blood pressure predicts inpatient mortality in elderly trauma patients: A bi-institutional
Jordan D Bohnen1, David C Chang, Elie P Ramly
1From the Division of Trauma, Emergency Surgery and Surgical Critical Care (J.D.B., E.P.R., R.T.L., H.M.A.K., D.D.Y., D.R.K., P.J.F., K.L.B., G.C.V., M.D.M.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Codman Center for Clinical Effectiveness in Surgery (D.C.C., H.M.A.K.), Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery (E.P.R.), Oregon Health & Science University, Portland, Oregon; and Division of Trauma, Burn, and Surgical Critical Care (O.A.O., R.A., A.S.), Brigham and Women's Hospital, Boston, Massachusetts.
Insights
Low baseline systolic blood pressure (SBP) significantly increases inpatient mortality risk in elderly trauma patients. This risk is even higher for those with pre-existing hypertension, warranting further investigation.
Area of Science:
- Geriatric Trauma Care
- Cardiovascular Epidemiology
- Clinical Prognostic Studies
Background:
- The impact of pre-injury blood pressure on trauma outcomes in elderly patients remains unclear.
- Understanding baseline blood pressure's role is crucial for improving geriatric trauma care.
Purpose of the Study:
- To determine the independent association between baseline systolic blood pressure (SBP) and inpatient mortality in elderly trauma patients.
- To identify specific SBP thresholds that may indicate increased mortality risk.
Main Methods:
- Retrospective analysis of trauma registry and electronic health records from 2004-2014.
- Inclusion of patients aged 65 years and older with available baseline vital signs.
- Logistic regression models to assess the impact of baseline SBP on mortality, controlling for confounders.
Main Results:
- Low baseline SBP (<110 mm Hg) was associated with a 3.19-fold increased mortality risk compared to normal SBP.
- The mortality risk was significantly elevated in patients with low baseline SBP, especially when combined with low or normal trauma SBP.
- Patients with low baseline SBP and pre-existing hypertension had a 4.78-fold increased mortality risk.
Conclusions:
- Pre-injury low SBP is an independent predictor of increased inpatient mortality in elderly trauma patients.
- The heightened mortality risk in patients with low baseline SBP and hypertension suggests a complex interaction requiring further study.
- These findings challenge the long-term survival benefits of blood pressure control in the acute trauma setting.
Objective:
The relationship between baseline (i.e., pre-injury) blood pressure and trauma outcomes in elderly patients is unknown. We therefore aimed to identify the independent impact of baseline systolic blood pressure (SBP) on inpatient mortality among elderly trauma patients.
Methods:
The 2004 to 2014 trauma registries of two Level I Trauma Centers were linked to electronic health records then reviewed to identify patients ≥65 years old with available baseline vital signs. Baseline SBP was defined as mean outpatient SBP within 2 years before injury. Trauma SBP was defined as first SBP reading after presentation for trauma. Baseline and Trauma SBP were classified as Low (<110 mm Hg), Normal (110-139 mm Hg), or High (≥140 mm Hg). Logistic multivariable regression models were constructed to assess the independent impact of Baseline SBP on inpatient mortality, controlling for demographics, comorbidities, injury mechanism/severity, and Trauma SBP.
Results:
Of 37,494 patient admissions, 4,233 met inclusion criteria. Median age was 81 years; 63.6% were female. Mortality was 5.39%. In unadjusted analyses, mortality rates were 11.01%, 5.28%, and 4.52% in the Low, Normal, and High Baseline SBP groups, respectively (p = 0.001). In multivariable analyses, patients with Low Baseline SBP had significantly increased mortality risk [OR 3.19 (95% CI 1.62-6.26), p = 0.001] compared to patients with Normal Baseline SBP, in particular when they presented with Low Trauma SBP (<110 mm Hg) [OR 6.14 (2.17-17.36), p = 0.001] or Normal Trauma SBP (110-139 mm Hg) [OR 3.87 (1.43-10.45), p = 0.008]. The mortality risk associated with Low Baseline SBP was particularly elevated among patients with a pre-existing diagnosis of hypertension [OR 4.78 (1.97-11.62), p = 0.001].
Conclusion:
Low baseline pre-injury SBP is independently associated with more than a threefold increase in inpatient mortality among elderly trauma patients and a fivefold increase in mortality risk among patients with pre-existing hypertension. Given that blood pressure control in the elderly offers a long-term survival advantage, the paradoxical finding of decreased survival after trauma warrants further investigation.
Level Of Evidence:
Prognostic/epidemiologic study, level III.
