What are the guidelines for managing hypertension (High Blood Pressure) in inpatients?

From the Guidelines

For inpatient blood pressure management, a cautious approach is recommended, avoiding intensive antihypertensive treatment unless there is evidence of end-organ damage, due to the potential risks of overtreatment, including acute kidney injury, stroke, and myocardial injury, as suggested by observational studies 1. When managing inpatient blood pressure, it's crucial to assess the situation's urgency and the patient's overall clinical context.

• For hypertensive emergencies, where blood pressure exceeds 180/120 mmHg with evidence of end-organ damage, immediate intervention with intravenous medications such as labetalol, nicardipine, or clevidipine is warranted to lower blood pressure by no more than 25% in the first hour.
• In non-emergent situations, the preference is for oral medications, starting with the patient's home regimen if it has been effective, and adjusting as necessary based on the patient's response and comorbid conditions. Key considerations include:
• The choice of medication should be guided by the patient's comorbidities, such as using ACE inhibitors or ARBs for patients with diabetes or heart failure, and calcium channel blockers for those at risk of stroke.
• Monitoring for orthostatic hypotension, particularly in elderly patients, is essential by checking blood pressure in different positions.
• The goal is to maintain a blood pressure below 140/90 mmHg for most patients, although targets may be adjusted for certain populations, such as the elderly, to prevent falls and other adverse events, as indicated by recent clinical practice guidelines 1.

From the FDA Drug Label

Lowering blood pressure lowers the risk of fatal and non-fatal cardiovascular events, primarily strokes and myocardial infarctions Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than one drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)

The management of inpatient blood pressure involves lowering blood pressure to reduce the risk of cardiovascular events. Comprehensive cardiovascular risk management is essential and may include multiple interventions such as:

• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake It is also noted that many patients will require more than one drug to achieve blood pressure goals, and guidelines such as those from the National High Blood Pressure Education Program’s Joint National Committee should be consulted for specific advice on goals and management 2 3.

From the Research

Inpatient Blood Pressure Management

• Inpatient hypertension is a common issue, with nearly one third of the US adult population affected by hypertension, and elevated blood pressure observed in a majority of hospitalized patients 4.
• The management of inpatient blood pressure is crucial, as hypertensive emergencies can be life-threatening and require urgent treatment under close monitoring 5.
• Current evidence-based hypertension guidelines do not specifically address inpatient hypertension, making it essential to develop best practices for diagnosing and managing nonemergent hypertension in the inpatient setting 4.

Treatment Options

• Nicardipine and nitroglycerin are two commonly used agents for treating hypertensive emergencies, including acute heart failure syndrome 5, 6.
• A study comparing nicardipine and nitroglycerin for hypertensive acute heart failure syndrome found that nicardipine may be more effective than nitroglycerin in achieving optimal blood pressure control and reducing the need for additional antihypertensive agents 6.
• Intravenous nitroglycerin is also a well-known treatment for acute decompensated heart failure, with benefits including rapid onset of action, reduced LV and RV filling pressures, and improved survival 7.

Asymptomatic Elevated Blood Pressure

• There is limited evidence to support the treatment of asymptomatic elevated blood pressure in the inpatient setting, and potential harm may outweigh benefits 8.
• A review of available literature found no evidence that asymptomatic elevated blood pressure progresses to lead to end-organ damage, but clear instances of hypertensive emergency where treatment is indicated 8.
• Conscientious adjustment of an anti-hypertensive regimen should be undertaken during episodes of elevated blood pressure associated with end-organ damage 8.