How to manage blood pressure in a patient with a viral illness?

Management of Blood Pressure in Patients with Viral Illness

Blood pressure management in patients with viral illness should focus on regular monitoring, maintaining adequate hydration, continuing existing antihypertensive medications, and addressing orthostatic changes through careful fluid management and medication adjustments.

Assessment and Monitoring

• Temperature, respiratory rate, pulse, blood pressure, mental status, and oxygen saturation should be monitored at least twice daily in hospitalized patients with viral illness, and more frequently in those with severe illness 1
• An Early Warning Score system is recommended for convenient monitoring of vital signs in hospitalized patients 1
• For patients with orthostatic blood pressure changes, measure blood pressure both lying/sitting and standing to assess for postural hypotension 1

Management Principles

Fluid Management

• Assess patients for volume depletion and their need for additional intravenous fluids, as dehydration is common in viral illnesses and can contribute to orthostatic hypotension 1
• Ensure adequate oral hydration in patients who can tolerate it, especially those with fever who may have increased insensible losses 1

Medication Management

• Continue existing antihypertensive medications in patients with viral illness, particularly RAAS inhibitors (ACE inhibitors, ARBs) which have shown no harm and potential benefit in viral infections 1
• For patients with pre-existing hypertension who develop orthostatic hypotension during viral illness, temporary dose reduction of antihypertensive medications may be necessary 1
• If systolic blood pressure falls below 90 mmHg for more than 1 hour, consider withdrawing or reducing antihypertensive medications temporarily 1

Special Considerations for COVID-19

• Recent evidence suggests COVID-19 may be associated with new-onset hypertension due to SARS-CoV-2 interaction with ACE2 receptors 2, 3
• Continue RAAS inhibitors in patients with COVID-19 despite theoretical concerns, as clinical evidence supports their continued use 1
• Monitor for potential blood pressure increases during and after COVID-19 infection, as studies have shown both systolic and diastolic BP may be significantly higher post-COVID-19 2, 3

Discharge Criteria and Follow-up

• Before discharge, ensure blood pressure is stable without orthostatic changes 1

• Patients should not be discharged if they have two or more of the following unstable factors 1:

  • Temperature >37.8°C
  • Heart rate >100/min
  • Respiratory rate >24/min
  • Systolic blood pressure <90 mmHg
  • Oxygen saturation <90%
  • Inability to maintain oral intake
  • Abnormal mental status

• Follow-up clinical review should be arranged for all patients who experienced significant complications or worsening of underlying hypertension 1

• Consider virtual care options for follow-up blood pressure monitoring, which has proven effective during the pandemic 4

Common Pitfalls to Avoid

• Do not abruptly discontinue antihypertensive medications in patients with viral illness unless there are specific indications such as prolonged hypotension 1
• For patients with pre-existing COPD and hypertension who develop respiratory complications, oxygen therapy should be guided by repeated arterial blood gas measurements rather than standard protocols 1
• Be aware that viral infections, particularly COVID-19, may cause both hypotension during acute illness and hypertension during recovery, requiring vigilant monitoring throughout the course of illness 5, 2
• Do not overlook the potential for drug interactions between antihypertensive medications and antiviral treatments that may be prescribed for the viral illness 1