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]