Management of Hypertension Associated with Fractures
For hypertension associated with fractures, the treatment should focus on careful blood pressure control with close monitoring, using agents that don't compromise bone health, with a target mean arterial pressure reduction of 20-25% within several hours to prevent organ damage while avoiding excessive reduction that could compromise tissue perfusion.
Pathophysiology and Mechanism
Hypertension following fractures can occur due to several mechanisms:
- Pain-induced sympathetic activation
- Stress response to trauma
- Potential fat embolism in long bone fractures
- Pre-existing hypertension exacerbated by trauma
Initial Assessment and Monitoring
- Implement invasive blood pressure monitoring for patients with fractures, particularly those with limited left ventricular function or valvular heart disease 1
- Consider additional monitoring including:
- Central venous pressure monitoring for patients with limited cardiac function
- Cardiac output monitoring (transoesophageal Doppler guided fluid therapy may reduce hospital stay)
- Core temperature monitoring
- Point-of-care hemoglobin analyzers 1
Pharmacological Management
First-line IV Medications (for severe hypertension)
| Medication | Initial Dose | Titration |
|---|---|---|
| Nicardipine | 5 mg/h IV | Increase by 2.5 mg/h every 5-15 min, max 15 mg/h |
| Clevidipine | 1-2 mg/h IV | Double dose every 90 seconds initially |
| Labetalol | 0.3-1.0 mg/kg IV | Slow injection every 10 min or continuous infusion |
| Esmolol | 0.5-1 mg/kg IV bolus | 50-300 μg/kg/min continuous infusion |
Oral Medications (for less severe hypertension)
- Calcium channel blockers are preferred as they have been associated with a lower risk of fractures (HR 0.70; 95% CI 0.49-0.99) 3
- Thiazide diuretics may be beneficial as they have shown reduced fracture risk (HR 0.85,95% CI 0.76-0.97) 4, 5
- Angiotensin receptor blockers have demonstrated reduced fracture risk (HR 0.76,95% CI 0.68-0.86) 4
Medications to Use with Caution
- ACE inhibitors may be associated with increased fracture risk (HR 1.64; 95% CI 1.01-2.66) 3, though some studies show protective effects 6
- Loop diuretics have been associated with higher fracture rates (49.0 per 1000 person-years) compared to other antihypertensives 4
- Any newly initiated antihypertensive carries a 43% increased risk of hip fracture during the first 45 days of treatment (IRR 1.43; 95% CI 1.19-1.72) 7
Blood Pressure Targets
- Reduce mean arterial pressure by 20-25% within several hours 2
- Avoid excessive BP reduction which may precipitate organ hypoperfusion 2
- For patients with thoracolumbar spinal cord injury, consider maintaining mean arterial blood pressures >85 mm Hg to improve neurological outcomes 1
Adjunctive Measures
- Pain management: Implement peripheral nerve blockade (femoral, obturator, lateral cutaneous nerve) to reduce pain-induced hypertension 1
- Temperature regulation: Employ active warming strategies as elderly patients are susceptible to intra-operative hypothermia 1
- Thromboembolism prophylaxis: Use thromboembolism stockings or intermittent compression devices, ensure patient remains warm and well-hydrated 1
Long-term Management
- Schedule follow-up within 1-2 weeks after discharge
- For patients with suboptimally treated hypertension or suspected non-adherence, monthly visits in a specialized setting until target blood pressure is reached 1, 2
- Monitor for regression of hypertension-mediated organ damage (renal function, proteinuria, left ventricular mass) 1
Special Considerations
- When initiating antihypertensive therapy in elderly patients with fractures, start with lower doses and titrate gradually due to increased risk of falls and subsequent fractures 7
- Consider the impact of antihypertensive medications on bone health when selecting agents for long-term management 4, 5, 3, 6