What are the pharmacological management options for hypertension and hypotension in a hospital setting?

Pharmacological Management of Hypertension and Hypotension in the Hospital Setting

HYPERTENSION MANAGEMENT IN HOSPITAL

Asymptomatic Elevated Blood Pressure (Non-Emergency)

There are no evidence-based guidelines for managing asymptomatic elevated blood pressure in hospitalized patients, and observational data suggest that intensive inpatient BP treatment may cause harm including acute kidney injury, stroke, and myocardial injury. 1

• Do not routinely treat asymptomatic elevated BP in hospitalized patients unless BP meets criteria for hypertensive emergency or urgency 1
• Observational studies show 21-34% of medical inpatients receive IV BP medications despite lack of benefit, and 9-14% are discharged with intensified regimens that may be unnecessary 1
• Focus on optimizing outpatient BP management at discharge rather than aggressive inpatient treatment 1

Hypertensive Emergencies (Target Organ Damage Present)

Hypertensive emergencies require immediate IV antihypertensive therapy in an intensive care setting with continuous BP monitoring. 1

Definition and Initial Approach

• Hypertensive emergency = BP >180/120 mmHg PLUS acute target organ damage (encephalopathy, acute coronary syndrome, pulmonary edema, aortic dissection, stroke, acute renal failure, thrombotic microangiopathy) 1
• Labetalol IV is the first-line agent for most hypertensive emergencies due to its safety profile and effectiveness 1

Specific Clinical Scenarios with BP Targets:

Malignant Hypertension (with or without renal failure):

• Target: Reduce mean arterial pressure (MAP) by 20-25% over several hours 1
• First-line: Labetalol IV 1
• Alternatives: Nitroprusside, nicardipine, urapidil 1

Hypertensive Encephalopathy:

• Target: Reduce MAP by 20-25% immediately 1
• First-line: Labetalol IV (preferred as it maintains cerebral blood flow and doesn't increase intracranial pressure) 1
• Alternatives: Nitroprusside, nicardipine 1

Acute Ischemic Stroke:

• For BP >220/120 mmHg: Reduce MAP by 15% over 1 hour 1
• For thrombolytic candidates: Lower BP to <185/110 mmHg before thrombolysis 1
• First-line: Labetalol IV 1
• Alternatives: Nicardipine, nitroprusside 1

Acute Hemorrhagic Stroke:

• Target: Systolic BP 130-180 mmHg immediately 1
• First-line: Labetalol IV 1
• Alternatives: Urapidil, nicardipine 1

Acute Coronary Syndrome:

• Target: Systolic BP <140 mmHg immediately 1
• First-line: Nitroglycerin IV 1
• Alternatives: Urapidil, labetalol 1

Acute Cardiogenic Pulmonary Edema:

• Target: Systolic BP <140 mmHg immediately 1
• First-line: Nitroprusside or nitroglycerin IV (with loop diuretic) 1
• Alternative: Urapidil (with loop diuretic) 1

Acute Aortic Dissection:

• Target: Systolic BP <120 mmHg AND heart rate <60 bpm immediately 1
• First-line: Esmolol IV plus nitroprusside or nitroglycerin 1
• Alternatives: Labetalol or metoprolol, nicardipine 1

Eclampsia/Severe Pre-eclampsia:

• Target: Systolic BP <160 mmHg and diastolic BP <105 mmHg immediately 1
• First-line: Labetalol or nicardipine IV plus magnesium sulfate 1

Critical Pitfalls in Hypertensive Emergencies:

• Avoid excessive BP reduction (>25% MAP decrease or >50% decrease in MAP) as this is associated with ischemic stroke and death 1
• Never use ACE inhibitors acutely in malignant hypertension—start at very low doses only after initial control, as patients are often volume depleted 1
• Nitroprusside increases intracranial pressure, so avoid in hypertensive encephalopathy if possible 1

Hypertensive Urgency (No Target Organ Damage)

Hypertensive urgency (BP >180/120 mmHg without target organ damage) should be managed with oral antihypertensives and outpatient follow-up in days to weeks, not IV medications. 1

• Start or adjust oral antihypertensive regimen 1
• Arrange outpatient follow-up within days to weeks 1
• Do not admit to hospital or use IV medications unless symptoms develop 1

Initiating Long-Term Antihypertensive Therapy in Hospital

When starting chronic antihypertensive therapy during hospitalization:

For BP ≥140/90 mmHg:

• First-line agents: thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, or long-acting dihydropyridine calcium channel blockers 1, 2
• Target BP <140/90 mmHg for patients without comorbidities 1, 2
• Target BP <130/80 mmHg for patients with existing CVD 1, 2

For BP ≥160/100 mmHg (Stage 2 Hypertension):

• Initiate two-drug combination therapy immediately, preferably as single-pill combination 3, 2
• Preferred combinations: RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker OR RAS blocker + thiazide/thiazide-like diuretic 3, 2
• Achieve target BP within 3 months to reduce cardiovascular risk 3, 2

For BP 130-139/80-89 mmHg with High CVD Risk:

• Start pharmacological treatment if patient has existing CVD (strong recommendation) 1
• Consider treatment if patient has diabetes, CKD, or high CVD risk (conditional recommendation) 1

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HYPOTENSION MANAGEMENT IN HOSPITAL

Orthostatic Hypotension in Hypertensive Patients

Drug-induced orthostatic hypotension occurs in 10.4% of hypertensive patients and is most commonly caused by α-blockers, centrally acting drugs, non-dihydropyridine calcium channel blockers, and diuretics. 4

Prevention Strategies:

• Avoid or use with extreme caution: α-blockers, centrally acting drugs (clonidine), non-dihydropyridine calcium channel blockers (diltiazem, verapamil), and high-dose diuretics 4
• ARBs appear protective against orthostatic hypotension and should be preferred in patients at high risk (elderly, severe uncontrolled hypertension) 4
• Monitor standing BP in all hypertensive patients, especially elderly and those on multiple antihypertensives 4

Management of Drug-Induced Orthostatic Hypotension:

• Discontinue or reduce dose of offending agents (α-blockers, centrally acting drugs, non-dihydropyridine CCBs) 4
• Switch to ARB-based regimen if BP control still needed 4
• Ensure adequate hydration, especially in patients on diuretics who may be volume depleted 1
• Use IV saline infusion to correct precipitous BP falls if necessary 1

Acute Hypotension/Shock

While the provided evidence focuses primarily on hypertension management, general medical knowledge indicates:

• Identify and treat underlying cause (sepsis, cardiogenic shock, hypovolemia, anaphylaxis)
• IV fluid resuscitation as first-line for hypovolemic and distributive shock
• Vasopressors (norepinephrine first-line for septic shock; dopamine or dobutamine for cardiogenic shock) when fluids insufficient
• Avoid aggressive BP lowering in patients with baseline hypotension or those at risk for hypotensive episodes 1, 4

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KEY PRINCIPLES FOR HOSPITAL BP MANAGEMENT

1. Distinguish between hypertensive emergency (treat immediately with IV agents) and urgency (treat with oral agents as outpatient) 1

2. Do not aggressively treat asymptomatic elevated BP in hospitalized patients without clear indication, as this may cause harm 1

3. When initiating chronic therapy, use combination therapy for BP ≥160/100 mmHg 3, 2

4. Labetalol IV is the most versatile first-line agent for hypertensive emergencies 1

5. Avoid excessive BP reduction in emergencies (no more than 20-25% MAP reduction initially) 1

6. Screen for and prevent drug-induced orthostatic hypotension, especially in elderly patients 4