What are the guidelines for managing hypertension (high blood pressure) in hospitalized patients?

From the Guidelines

Hospitalized patients with hypertension should be managed according to the latest clinical practice guidelines, which recommend a tailored approach to blood pressure reduction based on the severity of hypertension and the presence of end-organ damage, as outlined in the 2024 systematic review of clinical practice guidelines published in the Annals of Internal Medicine 1. For severe hypertension (>180/120 mmHg) with end-organ damage:

• Use IV medications like labetalol or nicardipine to reduce blood pressure by no more than 25% within the first hour, then to 160/100-110 mmHg within the next 2-6 hours, as recommended by recent guidelines 1.
• Monitor patients closely for signs of organ hypoperfusion and adjust treatment accordingly. For less severe hypertension:
• Continue or initiate oral antihypertensive medications, such as ACE inhibitors, ARBs, calcium channel blockers, or beta-blockers, to target a blood pressure <140/90 mmHg for most patients 1.
• Consider the patient's underlying medical conditions, medication history, and potential side effects when selecting an antihypertensive agent. Additional considerations:
• Monitor for orthostatic hypotension, especially in elderly patients, and adjust treatment as needed 1.
• Assess and address underlying causes of hypertension, such as pain, anxiety, or medication non-adherence, to improve blood pressure control.
• Ensure proper cuff size and positioning for accurate blood pressure measurements, and consider using automated blood pressure monitoring devices to reduce variability 1.
• Consider home medication reconciliation to improve long-term blood pressure control and reduce the risk of readmission 1. Gradual blood pressure reduction is crucial to prevent organ hypoperfusion, particularly in patients with chronic hypertension who have adapted to higher pressures, as highlighted in the 2024 systematic review 1.

From the FDA Drug Label

Titration 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. For more rapid blood pressure reduction, titrate every 5 minutes. Maintenance Adjust the rate of infusion as needed to maintain desired response. 2.5 Conditions Requiring Infusion Adjustment Hypotension or Tachycardia: In case of hypotension or tachycardia, discontinue infusion. When blood pressure and heart rate stabilize, restart infusion at low doses such as 30 mL/hr to 50 mL/hr (3 mg/hr to 5 mg/hr) and titrate to maintain desired blood pressure.

The guidelines for managing hypertension in hospitalized patients using nicardipine hydrochloride injection are:

• Initiate therapy at a rate of 5 mg/hr for a gradual reduction in blood pressure
• Titrate the infusion rate by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr for desired blood pressure reduction
• Adjust the infusion rate as needed to maintain the desired response
• Monitor and adjust for conditions such as hypotension or tachycardia by discontinuing infusion and restarting at a lower dose when stable 2

From the Research

Guidelines for Managing Hypertension in Hospitalized Patients

• The management of hypertension in hospitalized patients is crucial, with studies suggesting that approximately 1 in 4 patients admitted to US hospitals have hypertension 3.
• There is a lack of guidelines for managing inpatient hypertension, but a proposed pathway provides a definition and clinical assessment of hypertension, as well as an organ/system-based therapeutic approach 3.
• The pathway specifies timing, blood pressure goals, recommended antihypertensive drug therapy, and the sequence of add-on drugs for patients with various conditions, including acute aortic syndrome, acute neurologic syndrome, and congestive heart failure 3.

Treatment Approaches

• Routine inpatient hypertension control in the absence of end-organ damage has not shown to be helpful and may have deleterious effects 4.
• The routine use of intravenous antihypertensives in hospitalized non-cardiac patients has been shown to prolong inpatient stay without benefits and should be avoided for inpatient hypertension control 4.
• Beta-blockers may have a role in treating hypertension, but their use needs to be better targeted, with consideration of underlying mechanisms of hypertension and identification of the right patient and the right beta-blocker 5.

Evaluation and Management

• Elevated blood pressure in hospitalized patients can have many potential causes, including anxiety, post-operative salt and volume overload, and previously unrecognized renal failure 6.
• An algorithm for evaluating hospitalized patients with elevated blood pressure can assist physicians in identifying the true cause of the elevation, treating the identified cause, and giving appropriate drug treatment 6.
• Improving recognition, treatment, and control of hypertension in the inpatient setting is warranted, with studies suggesting that hypertension is highly prevalent among inpatients and a large percentage of those with this condition remain hypertensive at the time of discharge and at follow-up 7.