A systematic review of clinical practice guidelines for managing inpatient elevated BP was recently published in April 2024 to help address the paucity of evidence to guide a treatment approach for inpatient BP management. Among 14 guidelines developed by organizations in the US, other countries, and multinational organizations, no inpatient BP target or guidance on antihypertensive selection was found in managing asymptomatic elevated BP. Hypertensive urgency was consistently defined as an elevated BP > 180/120 mmHg without evidence of end-organ damage. Noting the lack of inpatient-specific guidance for elevated BP that is not considered an emergency, the authors stated many clinicians reference outpatient guidelines for treatment goals and prescribing decisions. Outpatient guidelines suggest a threshold of > 140-160/90-100 mmHg for immediate pharmacologic treatment with monotherapy for moderate elevations and consideration for combination therapy in those with stage 2 hypertension. Treatment decisions may also follow outpatient guidelines based on patient characteristics, comorbidities, and age. In the final discussions, the authors summarized the lack of robust data to guide non-emergent inpatient BP management with an observed wide pattern of treatment approaches and overall unknown risk versus benefit of intensive BP management. [1]
A 2022 narrative review on treating hypertension among non-cardiac hospitalized patients highlights the paucity of established guidance despite frequent encounters with inpatient hypertension. Existing data, although limited to retrospective studies, indicate that routine or intensified inpatient hypertension control in the absence of end-organ damage may potentially be harmful (see Tables 1-3). [2]
A 2020 review article discusses the available evidence for managing elevated inpatient blood pressure (BP). Despite the lack of evidence, a strong belief exists in controlling BP for hospitalized patients. No guidelines or recommendations are available for managing inpatient elevated BP. The authors’ literature review found that the limited studies and systematic reviews have failed to establish any benefits of anti-hypertensive medications for treating hypertensive urgency or emergency. Of note, this excludes settings like abdominal aortic aneurysms where treatment benefit is clearly represented. There is also a lack of evidence to inform the BP level that may warrant therapy. [3]
In light of these findings, the authors recommend that asymptomatic patients do not require immediate reduction at any BP level. Instead, clinicians should focus on underlying diagnosis for hospitalization and patient recovery. Asymptomatic patients may have their BP reduced over a period of days and withheld home anti-hypertensive regimens that can be resumed with increased dosage or intensity based on an individual basis. If titrated, oral medications should be done conservatively as they may require 2 to 3 days for an effect to be seen. [3]
A 2015 article presented a practical approach for elevated BP management in asymptomatic patients, firstly by assessing whether acute symptoms are contributing to elevated BP (e.g., anxiety, pain, nausea, etc.) prior to BP therapy initiation. Withdrawal from alcohol, benzodiazepines, or illicit drugs can also precipitate hypertension. If volume overload is present, treat accordingly to manage BP. Other inpatient medications may also contribute to hypertension. Unless contraindicated, home BP medications, if on hold, can be restarted. Despite addressing these factors, if BP remains elevated > 20 mmHg above recommended guidelines, then titration of existing BP medications or the addition of new agents can be considered; understanding that the effects may take days to weeks to manifest fully. Proper follow-up in the outpatient setting should be ensured. At the time of the article’s publication, there was no evidence for the efficacy or safety of intravenous (IV) hydralazine or asymptomatic elevated BP. [4]
A 2019 editorial discussed the frequent inappropriate use of IV antihypertensives in inpatient settings, which can lead to adverse events. The authors suggested limiting the use of inpatient IV antihypertensives and considering other underlying causes such as pain, anxiety, or withholding home medications. [5], [6], [7]
Retrospective cohort studies based on the National Veterans Health Administration database examined patients aged 65 years or over with hypertension hospitalized with non-cardiac conditions. Collected data showed approximately 14% of older adults hospitalized for non-cardiac issues had their antihypertensive treatment intensified upon discharge, predominantly those who had previously well-controlled outpatient BP. Most importantly, intensified antihypertensives at discharge neither reduced cardiac events nor improved BP control within 1 year but resulted in an increased risk of readmission and serious adverse events (e.g., first emergency department visit or hospitalization for injurious fall, syncope, hypotension, electrolyte abnormalities, or acute kidney injury) within 30 days. The authors noted the need for increased vigilance to mitigate the risk of over-treating BP in elderly patients transitioning from hospital to home. [8], [9]