When is permissive hypertension (high blood pressure) tolerated?

From the Guidelines

Permissive hypertension is not recommended as a standard approach, but rather permissive hypotension is considered in specific trauma cases, aiming for a reduced systolic blood pressure of 80–90 mmHg in patients without traumatic brain injury (TBI) and/or spinal injury, as supported by the most recent evidence 1.

Clinical Scenarios for Permissive Hypotension

• Trauma-induced hypotension without TBI or spinal injury
• The goal is to achieve a reduced systolic blood pressure of 80–90 mmHg

Important Considerations

• Permissive hypotension is contraindicated in patients with TBI and spinal injuries, as adequate perfusion pressure is crucial for tissue oxygenation of the injured central nervous system
• Elderly patients and those with chronic arterial hypertension should be carefully considered for permissive hypotension

Evidence-Based Recommendations

• The European guideline on management of major bleeding and coagulopathy following trauma supports the concept of permissive hypotension in specific cases 1
• A recent meta-analysis of RCTs found a decrease in mortality when permissive hypotension was used in trauma patients without TBI 1
• Close hemodynamic monitoring is essential during permissive hypotension, with frequent reassessment of the risk-benefit ratio as the patient's condition evolves

Medications and Monitoring

• Medications are not typically used to achieve permissive hypotension, but rather to support the patient's hemodynamic status
• Close monitoring of blood pressure, cardiac output, and organ perfusion is crucial to ensure the patient's safety and adjust the treatment approach as needed

From the Research

Permissive Hypertension

Permissive hypertension refers to the practice of allowing blood pressure to remain elevated in certain clinical situations. The decision to permit hypertension is typically made on a case-by-case basis, taking into account the individual patient's condition and the potential risks and benefits of treating or not treating the elevated blood pressure.

Clinical Scenarios

• Asymptomatic elevated blood pressure in hospitalized patients: According to 2, the risk-benefit ratio of initiating or intensifying antihypertensive medications for asymptomatic elevated inpatient blood pressure is less clear.
• Hypertensive emergency: This condition involves acute target-organ damage and should be treated swiftly, usually with intravenous antihypertensive medications, in a closely monitored setting 2.
• Critically ill patients with pulmonary arterial hypertension: Management of these patients requires a careful balance to maintain perfusion while optimizing right-sided heart function 3.

Considerations

• The lack of evidence-based guidelines for managing elevated blood pressure in the acute care setting contributes to significant practice variation 2, 4.
• Recent observational studies have suggested potential harms associated with treating asymptomatic elevated inpatient blood pressure, which brings current practice into question 2.
• A comprehensive understanding of the underlying physiology and hemodynamics is crucial for the management of patients with complex conditions such as pulmonary arterial hypertension 3.