An Update on Inpatient Hypertension Management

Abstract

Hypertension is highly prevalent affecting nearly one third of the US adult population. Though generally approached as an outpatient disorder, elevated blood pressure is observed in a majority of hospitalized patients. The spectrum of hypertensive disease ranges from patients with hypertensive emergency including markedly elevated blood pressure and associated end-organ damage to asymptomatic patients with minimally elevated pressures of unclear significance. It is important to note that current evidence-based hypertension guidelines do not specifically address inpatient hypertension. This narrative review focuses primarily on best practices for diagnosing and managing nonemergent hypertension in the inpatient setting. We describe examples of common hypertensive syndromes, provide suggestions for optimal post-acute management, and point to evidence-based or consensus guidelines where available. In addition, we describe a practical approach to managing asymptomatic elevated blood pressure observed in the inpatient setting. Finally, arranging effective care transitions to ensure optimal ongoing hypertension management is appropriate in all cases.

Association of Final Discharge Blood Pressure with Post-discharge Outcomes Using Electronic Medical Record Data: a Retrospective Study

“…Currently, there are no guidelines as to what constitutes a Bsafe^discharge SBP. 1,3,4 In our study, a discharge SBP of 110-140 mmHg was associated with the lowest odds of adverse events in the 30 days post-hospitalization. The odds of 30-day mortality/readmission increased at SBPs < 110 mmHg-with the highest odds observed at SBP values < 80 mmHg.…”

Conditional prescriptions of oral antihypertensive drugs for the management of hypertension urgencies in the inpatient setting: An observational study

“…Furthermore, OCA initiation may also be associated with modifications of the ambulatory antihypertensive treatment at the time of discharge from the hospital (intensification of the antihypertensive regimen). Such modifications depend on the outpatient setting . This point requires further investigation, as we were unable to evaluate therapeutic modifications transferred at discharge with our local clinical data warehouse.…”

“…33 In this context, Axon et al proposed to establish a blood pressure cut point and to notify some symptoms with a 'red flag' whose association trigger a call to the physician. 33 Furthermore, some blood pressure thresholds were even lower ( Figure 2). They were considered to be drafting errors, as they do not correspond to the usual values for acute hypertension.…”

“…Such modifications depend on the outpatient setting. 33,34 This point requires further investigation, as we were unable to evaluate therapeutic modifications transferred at discharge with our local clinical data warehouse. Besides, OCA prescriptions are frequently given for patients admitted for reasons other than hypertension 35 and initiated for a patient with no history of hypertension at the time of hospitalization.…”

Acute Treatment of Hypertensive Urgency

“…In hospitalized patients, these include missed or held doses of outpatient medications, pain, nausea, alcohol and/or benzodiazepine withdrawal, delirium, and obstructive sleep apnea. 22 If no remediable cause is identified, patients should be allowed to rest for at least 30 minutes without the administration of additional antihypertensive medications, after which time the blood pressure should be measured using the correct technique. 2 Clinical trials have shown that rest is effective at lowering blood pressure in patients with hypertensive urgency.…”