What is the literature recommendation for inpatient hypertension management?

Comment by InpharmD Researcher

For asymptomatic hospitalized patients with elevated blood pressure, there is limited guidance for antihypertensive management and a blood pressure threshold for treatment has not been identified. In general, the acute management of asymptomatic hypertension is not recommended. There were no recommendations for PRN management but patients could resume home blood pressure medications or increase the intensity once underlying issues are controlled or accounted for. A retrospective study did not find benefit, but a greater risk of end-organ damage for treated inpatient hypertension with non-cardiac admissions.

Background

A 2019 review article discusses the available evidence for the management of elevated inpatient blood pressure. Despite the lack of evidence, there is a strong belief that controlling blood pressure for hospitalized patients is important. There are no guidelines or recommendations available for the management of inpatient elevated blood pressure. The author’s review of the literature found that the limited studies and systematic reviews available have failed to establish any benefits for anti-hypertensive medications for the treatment of hypertensive urgency or emergency (this excludes settings like abdominal aortic aneurysm where treatment benefit is clearly represented). There is also a lack of evidence to inform the level of blood pressure that may warrant therapy. [1]

In light of these findings, the authors recommend that asymptomatic patients do not require immediate reduction at any BP level. Clinicians should focus on the reason for hospitalization and patient recovery. Asymptomatic patients may have their blood pressure reduced over a period of days and withheld home anti-hypertensive regimens that can be resumed with increased dosage or intensity considered on an individual basis. Oral medications, if titrated, should be done so conservatively as they may require 2 to 3 days for an effect to be seen. [1]

A 2015 article performed a literature update on the management of inpatient hypertension. They presented a practical approach for elevated BP management in asymptomatic patients, first by assessing whether acute symptoms are contributing to elevated BP (e.g. anxiety, pain, nausea, etc.) and treating prior to starting blood pressure medication. Withdrawal from alcohol, benzodiazepines, or illicit drugs can also precipitate hypertension. If volume overload is present, then treating accordingly may help manage blood pressure. Other inpatient medications may also contribute to hypertension. Unless contraindicated, home BP medication can be restarted if they were on hold. Despite addressing these factors, if BP remains elevated > 20 mmHg above recommended guidelines, then titration of existing BP medications or addition of new agents can be considered; understanding that the effects may take days to weeks to fully manifest. 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 hydralazine or asymptomatic elevated BP. [2]

A 2019 editorial describes two observational studies which determined the frequency of inappropriate intravenous antihypertensive use in an inpatient setting leading to adverse events.. The authors continue to discuss that inpatient hypertension is often treated as a number to fix instead of a potential sign of a new underlying problem such as uncontrolled pain, anxiety, or medication side effects. For these reasons, it is suggested to limit the use of inpatient intravenous antihypertensives and to consider other underlying causes such as pain, anxiety, or withholding home medications. [3], [4], [5]

References:

[1] Stanistreet B, Nicholas JA, Bisognano JD. An Evidence-Based Review of Elevated Blood Pressure for the Inpatient. Am J Med. 2020;133(2):165-169. doi:10.1016/j.amjmed.2019.10.004
[2] Axon RN, Turner M, Buckley R. An Update on Inpatient Hypertension Management. Curr Cardiol Rep. 2015;17(11):94. doi:10.1007/s11886-015-0648-y
[3] Anstey J, Lucas BP. Treatment of Inpatient Asymptomatic Hypertension: Not a Call to Act but to Think. J Hosp Med. 2019;14(3):190-191. doi:10.12788/jhm.3160
[4] Jacobs ZG, Najafi N, Fang MC, et al. Reducing Unnecessary Treatment of Asymptomatic Elevated Blood Pressure with Intravenous Medications on the General Internal Medicine Wards: A Quality Improvement Initiative. J Hosp Med. 2019;14(3):144-150. doi:10.12788/jhm.3087
[5] Pasik SD, Chiu S, Yang J, et al. Assess Before Rx: Reducing the Overtreatment of Asymptomatic Blood Pressure Elevation in the Inpatient Setting. J Hosp Med. 2019;14(3):151-156. doi:10.12788/jhm.3190

Literature Review

A search of the published medical literature revealed 1 study investigating the researchable question:

What is the literature recommendation for inpatient hypertension management?

Level of evidence

C - Multiple studies with limitations or conflicting results  Read more→



Please see Table 1 for your response.


 

Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions

Design

Retrospective cohort study

N= 9,040

Objective

To characterize clinician response to blood pressure (BP) in the hospital and at discharge and to compare short- and long-term outcomes associated with antihypertensive treatment intensification.

Study Groups

Propensity-matched cohort

No treatment (n= 4,520)

Treatment (n= 4,520)

Inclusion Criteria

Age > 18 years, admitted to a medicine service

Exclusion Criteria

Admission for cardiovascular diagnosis or admission within the past 30 days from a cerebrovascular event or acute coronary syndrome, pregnancy, length of stay less than 2 or greater than 14 days, no outpatient medication data

Methods

Patient data along with their medication history were collected for analysis. For patients with multiple admissions, a single admission was chosen at random. Medications were classified based on the 2017 ACC/AHA BP guidelines. Spironolactone and loop diuretics were excluded for the analysis. A propensity model was built to match demographic, individual comorbities, and index BP characteristics between treatment and no treatment groups.

Duration

Data recruitment period: January 1 to December 31, 2017

Outcome Measures

Composite outcome defined as the occurrence of acute kidney injury, myocardial infarction, or stroke

Baseline Characteristics

 

No treatment (n= 4,520)

Treatment (n= 4,520)

 

Age, years

69.8 (16.0%) 69.7 (15.7%)  

Male

1,988 (44%) 1,955 (43.3%)  

Race/ethnicity

White

Black

Other

Unknown

 

3,109 (68.8%)

1,174 (26%)

82 (1.8%)

155 (3.4%)

 

3,052 (67.5%)

1,215 (26.9%)

90 (2%)

163 (3.6%)

 

Body mass index, kg/m(Standard deviation [SD])

29.8 (8.8)

29.9 (8.4)

 

Smoking status

Current smoker

Nonsmoker

Unknown

 

836 (18.5%)

3,538 (78.3%)

146 (3.2%)

 

802 (17.7%)

3,571 (79%)

147 (3.3%)

 

Length of stay, days (SD)

5.01 (2.6)

4.98 (2.6)

 

Comorbidities

Atrial fibrillation

Diabetes

Heart failure

Hypertension

Hyperlipidemia

 

558 (12.3%)

1,208 (26.7%)

420 (9.3%)

2394 (53%)

1455 (32.2%)

 

533 (11.8%)

1,204 (26.6%)

436 (9.6%)

2,369 (52.4%)

1,443 (31.9%)

 

Results

Endpoint

No treatment (n= 4,520)

Treatment (n= 4,520)

p-Value

Occurrence of the composite outcome

Stroke

Acute kidney injury

Myocardial injury

371 (8.2%)

4 (0.1%)

357 (7.9%)

26 (0.6%)

499 (11%)

4 (0.1%)

466 (10.3%)

53 (1.2%)

<0.001

>0.99

<0.001

0.003

Length of stay after index BP, days (SD)

3.56 (2.55) 3.60 (2.27) 0.36

When analyzing separate BP intervals, none of the treated patients had better outcomes compared to the no treatment group. Medication intensification was not associated with better BP control in the following year.

Adverse Events

N/A

Study Author Conclusions

This cohort study found that 78% of adult patients admitted for noncardiovascular diagnoses had at least 1 hypertensive BP measurement, but fewer than 1 in 3 had their medication intensified. More surprisingly, only 8% of hypertensive BP readings prompted medication intensification, and even readings over 220 mm Hg systolic were treated less than half of the time. Paradoxically, treatment, which presumably was meant to prevent end-organ damage, was associated with higher rates of AKI and myocardial injury. In fact, we found no benefit associated with any treatment route or at any BP interval. Our findings suggest that hypertension among medical inpatients should be managed conservatively. Intensification of treatment on discharge also does not appear to be helpful.

InpharmD Researcher Critique

Patients with a recent diagnosis of acute coronary syndrome or cerebrovascular accident were excluded as they typically require specific blood pressure management. It is possible there were unmeasured differences between the treated and untreated group which may influence the clinician to treat those at higher risk of organ damage. 



References:

Rastogi R, Sheehan MM, Hu B, Shaker V, Kojima L, Rothberg MB. Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions. JAMA Intern Med. 2021;181(3):345-352. doi:10.1001/jamainternmed.2020.7501