Do we treat asymptomatic hypertension in hospitalized patients?

From the Guidelines

Asymptomatic hypertension in hospitalized patients generally does not require immediate treatment unless blood pressure is severely elevated (typically >180/120 mmHg) or the patient has specific conditions like acute coronary syndrome, heart failure, or aortic dissection. For most hospitalized patients with asymptomatic elevated blood pressure, the focus should be on monitoring rather than acute intervention. This approach is supported by the most recent and highest quality study, which found that there is no evidence to suggest that treating asymptomatic hypertension in the inpatient setting improves outcomes 1.

Key Considerations

• The decision to initiate or adjust long-term antihypertensive therapy should be based on outpatient blood pressure measurements rather than inpatient readings, as hospitalization-related stress, pain, and medication effects often cause temporary elevations 1.
• Abrupt lowering of blood pressure in chronically hypertensive patients can potentially reduce perfusion to vital organs, as their autoregulatory mechanisms have adapted to higher pressures.
• The best approach is to continue patients' home antihypertensive medications during hospitalization and address persistent hypertension in the outpatient setting after discharge.
• If treatment is deemed necessary for severely elevated readings, oral medications like amlodipine 5-10 mg, labetalol 100-200 mg, or captopril 25 mg are preferred over IV medications to avoid rapid blood pressure drops.

Evidence-Based Recommendations

• The European guidelines on cardiovascular disease prevention in clinical practice recommend initiating drug therapy promptly in individuals with a sustained systolic blood pressure (SBP) ≥180 mmHg and/or a diastolic blood pressure (DBP) ≥110 mmHg regardless of their total cardiovascular risk assessment 1.
• The Annals of Emergency Medicine clinical policy statement suggests that asymptomatic patients with elevated blood pressures may be screened to identify evidence of end-organ damage, including microvascular injury manifested by retinal changes, left ventricular hypertrophy, and renal injury 1.

Conclusion Not Applicable

Instead, the key points to consider are:

• Monitoring rather than acute intervention is the preferred approach for asymptomatic hypertension in hospitalized patients.
• The decision to initiate or adjust long-term antihypertensive therapy should be based on outpatient blood pressure measurements.
• Continuing patients' home antihypertensive medications during hospitalization and addressing persistent hypertension in the outpatient setting after discharge is the best approach.

From the Research

Treatment of Asymptomatic Hypertension in Hospitalized Patients

• Asymptomatic hypertension in hospitalized patients is a common condition that requires careful evaluation and management 2.
• The decision to treat asymptomatic hypertension in hospitalized patients depends on various factors, including the severity of hypertension, presence of end-organ damage, and underlying medical conditions 3, 4.
• Current evidence-based guidelines do not specifically address inpatient hypertension, but they suggest that asymptomatic patients with severely elevated blood pressure can be managed in the outpatient setting 3, 2.
• However, hospitalized patients with asymptomatic hypertension may require treatment to prevent cardiovascular complications, especially if they have underlying cardiovascular disease or other risk factors 5, 6.

Management Strategies

• The management of asymptomatic hypertension in hospitalized patients involves a gradual reduction of blood pressure over several days to weeks, rather than aggressive lowering of blood pressure 3, 4.
• Oral antihypertensive medications are preferred over intravenous medications, unless there is evidence of end-organ damage or hypertensive emergency 5, 6.
• Commonly used antihypertensives, such as metoprolol and amlodipine, may not be effective in lowering blood pressure in hospitalized patients with severe hypertension 6.
• Intravenous hydralazine, on the other hand, has been shown to be effective in reducing blood pressure in hospitalized patients with severe hypertension 6.

Considerations

• Hospitalized patients with asymptomatic hypertension require close monitoring of their blood pressure and clinical status to prevent cardiovascular complications 2, 5.
• The treatment of asymptomatic hypertension in hospitalized patients should be individualized based on the patient's underlying medical conditions, cardiovascular risk factors, and response to treatment 3, 4.
• Further research is needed to determine the optimal management strategies for asymptomatic hypertension in hospitalized patients and to assess the effect of treatment on clinical outcomes 6.