Does aggressive blood pressure (BP) control in inpatients lead to poorer outcomes?

From the Guidelines

Aggressive blood pressure control in hospitalized patients can lead to poorer outcomes and should generally be avoided. The current evidence suggests that intensive inpatient antihypertensive treatment has not been demonstrated to be beneficial, and observational studies have found that receipt of more intensive BP treatment is associated with worse outcomes, including higher rates of acute kidney injury, stroke, and myocardial injury 1. Target blood pressure goals for inpatients should typically be less stringent than outpatient goals, with systolic blood pressure around 140-160 mmHg being reasonable for most hospitalized patients.

Some key points to consider when managing inpatient blood pressure include:

• Medications like labetalol 10-20mg IV, hydralazine 5-10mg IV, or nicardipine infusion can be used for severe hypertension, but rapid, aggressive lowering should be reserved for hypertensive emergencies with end-organ damage.
• Excessive BP reduction can cause cerebral, cardiac, and renal hypoperfusion, particularly in patients whose bodies have adapted to chronic hypertension, leading to increased mortality, acute kidney injury, myocardial ischemia, and cerebral hypoperfusion 1.
• Elderly patients and those with atherosclerotic disease are particularly vulnerable to these complications.
• When treating inpatient hypertension, a gradual approach is preferable, aiming to reduce blood pressure by no more than 25% in the first 24 hours, then gradually working toward target over days.
• Oral medications should be favored over IV when possible, and the patient's outpatient regimen should be considered when planning inpatient management.

The lack of randomized trials on inpatient BP management and the wide variation in practice patterns highlight the need for careful consideration of the potential harms of under or overtreatment of inpatient BP 1. As such, a cautious approach to blood pressure management in hospitalized patients is recommended, prioritizing the prevention of organ damage and minimizing the risk of adverse outcomes.

From the Research

Aggressive Blood Pressure Control in Inpatients

• The evidence suggests that overly aggressive blood pressure (BP) control in inpatients may lead to poorer outcomes, including syncope, renal impairment, polypharmacy, drug interactions, subjective drug side-effects, and non-adherence 2.
• Recent observational studies have emphasized the BP J-curve phenomenon, where low BPs are associated with adverse cardiovascular outcomes, suggesting that overly aggressive BP targets may sometimes be harmful 2.
• A personalized approach to BP drug management, considering individual risks, benefits, and preferences, is recommended when choosing therapeutic targets 2.
• The SPRINT study reported that treating to a systolic BP target of 120 mmHg reduces cardiovascular outcomes in high-risk individuals, but other studies suggest that targets below 130/80 mmHg may not be beneficial for all patients 2, 3.

Risks of Aggressive BP Control

• Aggressive systolic blood pressure control in older subjects may have benefits, but also carries risks, including the J-curve effect, where further reduction of systolic blood pressure (SBP) can lead to increased risk of cardiovascular events if diastolic blood pressure (DBP) is too low 4.
• The optimal SBP control target for older subjects is debated, with some guidelines recommending a reduction to <130 mmHg, while others suggest <140 mmHg or <150 mmHg 4.
• Factors that interfere with or worsen blood pressure control, such as poor adherence to antihypertensive medications, lifestyle changes, secondary causes of hypertension, or ingestion of substances that interfere with BP control, should be identified and managed 5.

Blood Pressure Targets

• Current guidelines on the treatment of hypertension emphasize the need to effectively treat high blood pressure in diabetic individuals, but their recommendations differ in terms of the optimal target blood pressure value to aim for 3.
• The evidence suggests that blood pressure targets will probably have to be lower than <140/90 mmHg, and that values approaching 130/80 mmHg should be recommended, but evidence in favour of even lower systolic values is limited 3.