What is a safe blood pressure (BP) level for discharge in an inpatient with hypertension?

From the Guidelines

For safe discharge of patients with inpatient hypertension, blood pressure should generally be less than 140/90 mmHg, with a stable or downward trend for at least 24-48 hours, as per the latest guidelines 1. This target may vary based on individual patient factors such as comorbidities, baseline blood pressure, and presenting symptoms. The initial default systolic BP treatment target is 120 to 129 mm Hg; however, relaxed targets (BP as low as reasonably achievable) are recommended in case of treatment intolerance, adults ≥85 years, symptomatic orthostasis, moderate-to-severe frailty, or limited life expectancy 1. Patients should be discharged with clear medication instructions, including at least one antihypertensive medication if newly diagnosed, or their previous regimen with appropriate adjustments. First-line options include ACE inhibitors (like lisinopril 10-20 mg daily), ARBs (such as losartan 50-100 mg daily), calcium channel blockers (amlodipine 5-10 mg daily), or thiazide diuretics (hydrochlorothiazide 12.5-25 mg daily) 1. Some key points to consider when discharging patients with hypertension include:

• Ensuring patients understand their medication regimen, potential side effects, and have a follow-up appointment scheduled within 1-2 weeks.
• Recommending home blood pressure monitoring with instructions to contact their provider if readings exceed 180/110 mmHg.
• Recognizing that complete blood pressure normalization often occurs gradually in the outpatient setting through medication adjustments and lifestyle modifications. The 2024 European Society of Cardiology guidelines provide a new framework for managing elevated blood pressure and hypertension, and clinicians should be aware of these updates when making treatment decisions 1.

From the Research

Inpatient Hypertension Management

• The management of inpatient hypertension is not well-defined in current evidence-based guidelines, which primarily focus on ambulatory care and hypertensive emergencies 2, 3.
• Elevated blood pressure is common in hospitalized patients, and the risk-benefit ratio of treating asymptomatic elevated inpatient blood pressure is unclear 3, 4.
• Recent observational studies suggest potential harms associated with treating asymptomatic elevated inpatient blood pressure, bringing current practice into question 4.

Blood Pressure Targets for Discharge

• There is no clear consensus on safe blood pressure targets for discharge, but general guidelines for blood pressure control in adults are:
  • SBP/DBP < 130/80 mm Hg for adults < 65 years 5
  • SBP < 130 mm Hg for adults ≥ 65 years 5
• However, these targets are based on outpatient management, and the applicability to inpatient settings is unclear 2, 3, 4.

Treatment Approaches

• Treatment of hypertension typically involves lifestyle modification and pharmacologic therapy, with first-line medications including thiazide diuretics, angiotensin-converting enzyme inhibitors, and calcium channel blockers 5, 6.
• In the inpatient setting, the decision to initiate or intensify antihypertensive medications for asymptomatic elevated blood pressure should be made on a case-by-case basis, considering the individual patient's risk factors and clinical context 4.