Is a 79-year-old female with uncontrolled hypertension (elevated blood pressure of 190/80 mmHg) and a history of recurring chest pain, on hydralazine, a suitable candidate for discharge home with outpatient cardiology follow-up?

Discharge Recommendation for 79-Year-Old Female with Uncontrolled Hypertension

This patient should NOT be discharged home at this time with a blood pressure of 190/80 mmHg, despite her low cardiac risk profile, because she requires optimization of her antihypertensive regimen and close monitoring before safe discharge can occur.

Key Clinical Context

This patient presents with:

• HEART score of 4 points (12-16% 30-day MACE risk) - placing her in an intermediate-risk category, NOT low-risk 1
• Recent negative stress test (<1 month ago) 1
• Negative troponin on current evaluation 1
• Severely elevated BP (190/80 mmHg) despite being on hydralazine TID PRN 1
• Moderate mitral regurgitation with otherwise normal cardiac function 2

Why Discharge is Inappropriate

1. Inadequate Blood Pressure Control

• A BP of 190/80 mmHg represents severely elevated blood pressure requiring intervention before discharge 1
• Current guidelines recommend follow-up within 1 week for severely elevated BP presentations 1
• The patient is on PRN hydralazine rather than scheduled, long-acting antihypertensive therapy - this represents suboptimal management 3

2. PRN Hydralazine is Inappropriate for Chronic BP Management

• Hydralazine PRN is frequently misused in hospitalized patients for non-urgent hypertension and is associated with unpredictable BP responses and adverse events including hypotension 3, 4
• Studies show that 36% of PRN antihypertensive administrations occur at BP levels <180/110 mmHg, which don't meet criteria for acute severe hypertension 3
• Hydralazine can cause myocardial ischemia and anginal attacks, particularly concerning given her chest pain history 2
• In patients with valvular disease (she has moderate mitral regurgitation), hydralazine may increase pulmonary artery pressure 2

3. Intermediate Cardiac Risk Requires Closer Follow-Up

• Her HEART score of 4 points indicates 12-16% risk of 30-day MACE, which is NOT low-risk (low-risk is defined as <3 points with 0-2% MACE rate) 1
• While her recent negative stress test is reassuring, guidelines recommend 1-2 week follow-up for patients in whom MI has been ruled out 1
• In patients with recurrent low-risk chest pain, guidelines suggest expedited outpatient testing rather than admission, but this patient's BP is not controlled 1

Recommended Management Before Discharge

Optimize Antihypertensive Regimen

• Discontinue PRN hydralazine and transition to scheduled, long-acting antihypertensive therapy 1, 3
• The 2024 ESC guidelines recommend combination therapy with a RAS blocker (ACE inhibitor or ARB) plus a dihydropyridine calcium channel blocker or thiazide diuretic as initial therapy for confirmed hypertension 1
• If already on two-drug combination, escalate to three-drug combination (RAS blocker + CCB + thiazide/thiazide-like diuretic), preferably as a single-pill combination 1
• Avoid rapid BP reduction - target 20-30% reduction from baseline over 24-48 hours, not immediate normalization 1, 5

Monitor for Treatment Response

• Observe BP response to scheduled antihypertensive therapy for at least 24 hours before discharge 1
• Long-acting antihypertensives typically require 1-2 weeks to reach steady state, so inpatient changes should be conservative 1
• Document BP control to <160/90 mmHg before discharge consideration 1

Ensure Appropriate Follow-Up

• Arrange cardiology follow-up within 1 week of discharge given severely elevated BP and intermediate cardiac risk 1
• Provide home BP monitoring instructions and equipment if possible 1
• Ensure medication reconciliation at discharge with clear instructions on new antihypertensive regimen 1

Critical Pitfalls to Avoid

• Do not rely on PRN hydralazine for chronic BP management - it is associated with unpredictable responses and adverse events 3, 4
• Do not discharge with uncontrolled severe hypertension (SBP ≥180 mmHg) without optimization and documented response to therapy 1
• Do not assume low cardiac risk based solely on negative stress test - her HEART score of 4 indicates intermediate risk requiring closer follow-up 1
• Avoid overly aggressive BP reduction in elderly patients with chronic hypertension due to altered autoregulation and risk of hypotension 1, 5
• Do not discharge without confirmed outpatient follow-up - if follow-up is unavailable, consider further testing or extended observation 1