What are the target blood pressure ranges for patients with hypertension, heart failure, coronary artery disease, and chronic kidney disease in an inpatient setting?

Target Blood Pressure Ranges for Inpatient Hypertension Management

For patients with hypertension in the inpatient setting, target blood pressure should be <140/90 mmHg for most patients, with a more intensive target of <130/80 mmHg for those with diabetes, chronic kidney disease, coronary artery disease, and heart failure.

General Hypertension Management Targets

• General adult population: <140/90 mmHg 1
• Elderly patients (≥65 years): 130-139/70-79 mmHg 1
  • For very elderly patients (≥80 years): <150/90 mmHg 1

Specific Disease-Based Targets

Chronic Kidney Disease

• Target: <130/80 mmHg 1, 2
• For moderate-to-severe CKD with eGFR >30 mL/min/1.73m²: 120-129 mmHg systolic 1
• For CKD with albuminuria: ACE inhibitors or ARBs should be included in the regimen 1, 2

Diabetes

• Target: <130/80 mmHg 1
• Systolic target should be 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg 1
• For older diabetic patients (≥65 years): 130-139 mmHg systolic 1

Coronary Artery Disease

• Target: <130/80 mmHg 1
• Systolic target should be close to 130 mmHg (or lower if tolerated) with diastolic 70-79 mmHg 1

Heart Failure

• Target: <130/80 mmHg 1, 2
• For heart failure with reduced ejection fraction (HFrEF): Treatment should include ACE inhibitors/ARBs, beta-blockers, and diuretics/MRAs as needed 1
• For heart failure with preserved ejection fraction (HFpEF): Consider SGLT2 inhibitors 1, 2

Post-Stroke/TIA

• Target: 120-130 mmHg systolic 1
• For patients with history of stroke or TIA and confirmed BP ≥130/80 mmHg: Target 120-129 mmHg systolic 1

Implementation Considerations

Monitoring and Adjustment

• Initial BP assessment should be confirmed with multiple readings
• For patients on antihypertensive medications, monitor serum creatinine and potassium within 2-4 weeks of initiation or dose adjustment, especially with ACE inhibitors or ARBs 2
• Follow up every 6-8 weeks until BP goal is safely achieved, then every 3-6 months 2

Special Considerations

• Resistant hypertension: Consider secondary causes and medication adherence issues
• Acute hypertensive emergencies: More aggressive targets may be needed based on end-organ damage
• Orthostatic hypotension risk: Use caution with aggressive BP lowering in elderly or frail patients

Common Pitfalls to Avoid

1. Overly aggressive BP lowering: Reducing BP too quickly or too low (<120/70 mmHg) may cause organ hypoperfusion, especially in elderly patients 3

2. Ignoring diastolic pressure: While systolic targets often receive more attention, maintaining diastolic BP >70 mmHg is important to ensure coronary perfusion 1

3. One-size-fits-all approach: While guidelines provide targets, individual factors such as frailty, comorbidities, and medication tolerance should be considered

4. Neglecting non-pharmacological measures: Even in the inpatient setting, sodium restriction (<2g sodium per day) can be an important adjunct to medication therapy 2

5. Dual RAAS blockade: Combining ACE inhibitors with ARBs increases risk of hyperkalemia and acute kidney injury without additional benefit 2

By following these evidence-based target ranges and considering individual patient factors, clinicians can optimize blood pressure management in the inpatient setting while minimizing adverse effects.