What is the management approach for inpatient hypertension (HTN)?

Inpatient Management of Hypertension

Current guidelines lack specific recommendations for managing asymptomatic elevated blood pressure in hospitalized patients, which contributes to variable practice patterns in inpatient settings. 1

Classification of Hypertensive States in Hospital Settings

Hypertensive Emergency

• Defined as BP >180/120 mmHg WITH evidence of acute end-organ damage 1
• Requires immediate treatment in intensive care settings with intravenous antihypertensive medications 1
• Management varies by specific type of emergency:
  • Aortic dissection: immediate BP reduction 1
  • Malignant hypertension or acute renal failure: gradual BP reduction over days 1
  • Hypertensive encephalopathy: 20-25% reduction in BP or mean arterial pressure over a couple of hours 1

Hypertensive Urgency

• Defined as BP >180/120 mmHg WITHOUT evidence of end-organ damage 1
• Most guidelines recommend outpatient treatment with oral medications and follow-up within days to weeks 1
• Diagnostic testing for end-organ damage may include:
  • Physical examination 1
  • Fundoscopic examination 1
  • Renal panel 1
  • Electrocardiogram 1
  • Additional imaging (echocardiogram, neuroimaging, chest CT) if indicated by symptoms 1

Management of Hypertensive Emergency

Initial Assessment

• Confirm hypertensive emergency with proper BP measurement and evidence of end-organ damage 1, 2
• Evaluate for specific type of emergency (stroke, aortic dissection, acute coronary syndrome, etc.) 1

Treatment Approach

• Admit to intensive care unit for close monitoring 1, 2
• Use intravenous antihypertensive medications with careful titration 1, 2
• Monitor BP with arterial line when possible 3

Medication Options for Hypertensive Emergency

• Nicardipine (IV):
  • Administer by slow continuous infusion via central line or large peripheral vein 4
  • Initial dose: 5 mg/hr, titrate by 2.5 mg/hr every 15 minutes (max 15 mg/hr) 4
  • For more rapid reduction, can titrate every 5 minutes 4
  • Change infusion site every 12 hours if administered via peripheral vein 4
  • Dilute to concentration of 0.1 mg/mL before administration 4
• Other IV options include:
  • Labetalol: useful for most hypertensive emergencies 2, 5
  • Clevidipine: endorsed for acute ischemic stroke and intracranial hemorrhage 5
  • Sodium nitroprusside: rapid onset and offset but use with caution due to toxicity 2, 3
  • Esmolol: useful when tachycardia is present, avoid in low cardiac output 3
  • Fenoldopam: effective with lower incidence of side effects than nitroprusside 3

Management of Asymptomatic Elevated BP in Hospitalized Patients

Important Caveat

• No guidelines provide specific inpatient BP targets or recommendations for managing asymptomatic moderately elevated BP in hospitalized patients 1
• Observational studies suggest intensive BP treatment in asymptomatic inpatients may be associated with adverse outcomes including acute kidney injury, stroke, and myocardial injury 1

Practical Approach

• Avoid treating asymptomatic BP <180/120 mmHg with IV medications 6
• 84.5% of episodic IV antihypertensive doses are administered for SBP <180 mmHg, which may be inappropriate 6
• Rapid BP reduction >25% within 6 hours occurs in 32.6% of patients receiving IV treatment, which may increase risk of adverse events 6
• Focus on oral medication adjustment rather than IV medications for non-emergency BP elevation 6

Discharge Planning and Transitions of Care

• No specific guidelines exist for BP management during transitions from hospital to home 1
• When switching from IV to oral therapy:
  • If transferring to oral nicardipine, administer first dose 1 hour prior to discontinuation of infusion 4
  • For patients whose oral regimen was adjusted during hospitalization, ensure close outpatient follow-up 6

Common Pitfalls in Inpatient Hypertension Management

• Overtreatment of asymptomatic elevated BP with IV medications 6
• Failure to distinguish between hypertensive emergency and urgency 1, 2
• Excessive BP reduction causing hypoperfusion to vital organs 3
• Lack of adjustment to oral regimens before discharge in patients requiring BP control 6