What is the treatment for hypertension in an inpatient setting?

From the Guidelines

For inpatient hypertension treatment, a conservative approach is recommended, avoiding intensive antihypertensive treatment unless there is evidence of end-organ damage, as the benefits of intensive treatment have not been demonstrated and may be associated with worse outcomes, including higher rates of acute kidney injury, stroke, and myocardial injury 1. When managing elevated blood pressure in the inpatient setting, it is essential to consider the potential risks of overtreatment, as observational studies have found that more intensive blood pressure treatment is associated with worse outcomes 1.

• The initial approach should focus on assessing the patient's overall clinical condition and identifying any underlying causes of hypertension, such as renal artery stenosis, pheochromocytoma, or medication side effects.
• Monitoring blood pressure regularly, every 4-6 hours, is crucial to adjust treatment accordingly and avoid hypoperfusion, particularly in elderly patients.
• The target blood pressure should be individualized, but generally, a target of <140/90 mmHg is recommended for most patients, although this may be higher (e.g., <160/90 mmHg) in some elderly patients to avoid hypoperfusion.
• A low-sodium diet and limited IV fluids should be encouraged to manage fluid status and avoid volume overload, which can exacerbate hypertension.
• If pharmacological treatment is necessary, oral medications should be preferred over intravenous medications, and the treatment should be tailored to the individual patient's needs, taking into account their medical history, comorbidities, and potential drug interactions.
• The use of multiple drug classes, such as ACE inhibitors, ARBs, diuretics, and calcium channel blockers, may provide better control with fewer side effects than high doses of a single medication, but this should be done with caution and close monitoring of the patient's blood pressure and overall clinical condition 1.

From the FDA Drug Label

Labetalol HCl administered as a continuous intravenous infusion, with a mean dose of 136 mg (27 to 300 mg) over a period of 2 to 3 hours (mean of 2 hours and 39 minutes) lowered the blood pressure by an average of 60/35 mmHg In a clinical pharmacologic study in severe hypertensives, an initial 0. 25 mg/kg injection of labetalol HCl, administered to patients in the supine position, decreased blood pressure by an average of 11/7 mmHg. Nicardipine hydrochloride injection is administered by slow continuous infusion at a concentration of 0. 1 mg/mL. With constant infusion, blood pressure begins to fall within minutes. It reaches about 50% of its ultimate decrease in about 45 minutes For a gradual reduction in blood pressure, initiate therapy at a rate of 5 mg/hr. If desired blood pressure reduction is not achieved at this dose, increase the infusion rate by 2. 5 mg/hr every 15 minutes up to a maximum of 15 mg/hr, until desired blood pressure reduction is achieved.

The treatment for hypertension in an inpatient setting can include:

• Labetalol administered as a continuous intravenous infusion, with a mean dose of 136 mg over 2-3 hours
• Nicardipine administered by slow continuous infusion at a concentration of 0.1 mg/mL, starting at 5 mg/hr and titrating up to 15 mg/hr as needed 2 3 Key considerations include:
• Monitoring blood pressure and heart rate closely during infusion
• Adjusting the infusion rate as needed to maintain desired response
• Being cautious in patients with impaired cardiac, hepatic, or renal function 2 3

From the Research

Treatment of Hypertension in Inpatient Setting

The treatment of hypertension in an inpatient setting depends on the severity of the condition and the presence of end-organ damage.

• Hypertensive emergencies, characterized by elevated blood pressure with acute end-organ damage, require immediate reduction in blood pressure with titratable, short-acting, intravenous antihypertensive agents 4.
• Hypertensive urgencies, characterized by severe hypertension without acute end-organ damage, can usually be managed with oral antihypertensive agents 4, 5.

Intravenous Antihypertensives

Intravenous antihypertensives, such as labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside, are available for the treatment of hypertensive emergencies 4, 5.

• However, sodium nitroprusside is an extremely toxic drug and its use should be avoided 4.
• Newer agents, such as clevidipine and fenoldopam, may have advantages over other available agents in the management of hypertensive crises 4.

Oral Antihypertensives

Oral antihypertensives, such as nifedipine, captopril, clonidine, labetalol, prazosin, and nimodipine, can be effective in managing hypertensive urgencies 5.

Considerations for Inpatient Hypertension Management

When managing hypertension in the inpatient setting, it is essential to consider the patient's clinical presentation and comorbidities 6, 7.

• Intravenous antihypertensives should be used with caution in patients without acute target organ damage, as they may be associated with increased risk of myocardial injury 6.
• Oral antihypertensives may be a safer option for patients with severe hypertension without acute end-organ damage 5, 7.

Best Practices for Inpatient Hypertension Management

Current evidence-based hypertension guidelines do not specifically address inpatient hypertension, but a practical approach to managing asymptomatic elevated blood pressure observed in the inpatient setting is necessary 8.

• Arranging effective care transitions to ensure optimal ongoing hypertension management is crucial in all cases 8.