When should inpatient hypertension be treated?

Management of Inpatient Hypertension

Inpatient hypertension should only be treated if it constitutes a hypertensive emergency (BP >180/120 mmHg with evidence of end-organ damage) or hypertensive urgency (BP >180/120 mmHg without end-organ damage). Asymptomatic elevated blood pressure that does not meet these criteria generally does not require immediate treatment in the inpatient setting 1.

Classification and Assessment

When evaluating inpatient hypertension, categorize it as:

1. Hypertensive Emergency: BP >180/120 mmHg WITH evidence of acute end-organ damage

   • Requires immediate treatment in ICU with IV medications
   • Target: 20-25% reduction in BP over a couple of hours 1

2. Hypertensive Urgency: BP >180/120 mmHg WITHOUT evidence of end-organ damage

   • Most guidelines recommend outpatient treatment with oral medications
   • Follow-up within 1-7 days 1

3. Asymptomatic Elevated BP: Elevated BP without meeting criteria for urgency/emergency

   • No inpatient-specific guidelines exist for management 1
   • Does not require immediate treatment

Diagnostic Evaluation for End-Organ Damage

For BP >180/120 mmHg, assess for end-organ damage:

• Physical examination (including fundoscopic exam)
• Renal panel
• Electrocardiogram
• Additional testing if symptoms indicate: echocardiogram, neuroimaging, chest CT 1

Treatment Approach

For Hypertensive Emergency:

• Admit to ICU
• Use IV antihypertensives (labetalol, nicardipine, clevidipine)
• Target: 20-25% reduction in BP over first few hours 1
• Specific management varies by type of emergency:
  • Immediate BP decrease for aortic dissection
  • Gradual BP decrease over days for malignant hypertension or acute renal failure 1

For Hypertensive Urgency:

• Most guidelines (8 out of 11) recommend outpatient treatment with oral medications 1
• Avoid rapid and excessive BP reduction which could compromise organ perfusion
• If treating inpatient, use oral agents rather than IV medications

For Asymptomatic Elevated BP:

• No inpatient-specific guidelines exist 1
• Confirm BP with repeated measurements
• Focus on outpatient management plan rather than acute inpatient treatment

Important Caveats

1. Avoid overtreatment: Observational studies suggest intensive BP treatment in asymptomatic inpatients may be associated with worse outcomes, including higher rates of acute kidney injury, stroke, and myocardial injury 1.

2. Medication considerations:

   • For patients with renal failure, metoprolol dosing generally doesn't need adjustment 2
   • For patients with hepatic impairment, metoprolol's elimination half-life can be prolonged up to 7.2 hours 2
   • Lisinopril in acute MI patients has shown increased risk of persistent hypotension (9.0% vs 3.7%) and renal dysfunction (2.4% vs 1.1%) 3

3. Transitions of care: No specific guidelines exist for BP management during transitions from hospital to home, even after hypertensive urgency or emergency 1.

Discharge Planning

When discharging patients with elevated BP:

• Outpatient BP goals generally range from <130/80 mmHg to <140/90 mmHg 1
• Arrange follow-up within 1 month for moderately elevated BP and within a week for severely elevated BP 1
• Consider comorbidities when selecting outpatient medications (diabetes, CKD, heart failure, CAD) 1
• For older adults (definitions vary from ≥60 to ≥80 years), slightly higher BP goals (by about 10 mmHg) may be appropriate 1

Remember that while outpatient hypertension management has clear guidelines, there is a notable absence of evidence-based guidance for managing asymptomatic elevated BP in the inpatient setting, which likely contributes to the wide variation in clinical practice.