Inpatient hypertension management

Learn how common it is, and when to treat it.


Case

Mr. Jones is a 68-year-old man with a history of diabetes and hypertension who presented to the hospital with a diabetic foot ulcer. He reported pain at the site of the ulcer but had no other symptoms. His home blood pressure (BP) medications included lisinopril, amlodipine, and hydrochlorothiazide. He reported that his home BP remained around 120/70 mm Hg and that he followed up with his primary care clinician every 3 months. A review of the patient's chart indicated similar office BP readings. On the day of admission, his BP was 160/92 mm Hg and all his BP readings during the hospital stay were noted to be higher than his home measurements. Should the patient's home BP medications be up-titrated to achieve better BP control in the hospital?

Definitions

Hypertension is defined as a systolic BP above 140 mm Hg or a diastolic BP above 90 mm Hg (11. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-72. [PMID: 12748199], 22. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-219. [PMID: 23771844] doi:10.1093/eurheartj/eht151). This definition pertains to patients with chronic hypertension in an ambulatory setting (22. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-219. [PMID: 23771844] doi:10.1093/eurheartj/eht151, 33. Herzog E, Frankenberger O, Aziz E, Bangalore S, Balaram S, Nasrallah EJ, et al. A novel pathway for the management of hypertension for hospitalized patients. Crit Pathw Cardiol. 2007;6:150-60. [PMID: 18091404], 44. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311:507-20. [PMID: 24352797] doi:10.1001/jama.2013.284427); hypertension has not been defined in guidelines in the setting of hospitalized patients.

Hypertensive emergency is defined as the presence of very high BP associated with ischemic organ dysfunction, such as hypertensive encephalopathy, intracerebral hemorrhage, acute coronary syndromes, acute pulmonary edema, dissecting aortic aneurysm, and eclampsia. Hypertensive urgency is defined as a severe elevation of BP (diastolic BP >120 mm Hg) in asymptomatic patients with no target organ involvement (11. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-72. [PMID: 12748199], 22. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-219. [PMID: 23771844] doi:10.1093/eurheartj/eht151).

How common is hypertension in hospitalized patients?

In patients admitted to the hospital for reasons other than hypertension, the incidence of hypertension appears to be high, with data suggesting a prevalence of up to 72% (55. Axon RN, Cousineau L, Egan BM. Prevalence and management of hypertension in the inpatient setting: a systematic review. J Hosp Med. 2011;6:417-22. [PMID: 20652961] doi:10.1002/jhm.804). Also, available evidence suggests that a large number of patients who have hypertension while inpatients remain hypertensive at the time of discharge (55. Axon RN, Cousineau L, Egan BM. Prevalence and management of hypertension in the inpatient setting: a systematic review. J Hosp Med. 2011;6:417-22. [PMID: 20652961] doi:10.1002/jhm.804, 66. Weder AB. Treating acute hypertension in the hospital: a Lacuna in the guidelines [Editorial]. Hypertension. 2011; 57:18-20. [PMID: 21079044] doi:10.1161/HYPERTENSIONAHA.110.164194).

Various secondary factors might contribute to an acute BP increase in hospitalized patients (33. Herzog E, Frankenberger O, Aziz E, Bangalore S, Balaram S, Nasrallah EJ, et al. A novel pathway for the management of hypertension for hospitalized patients. Crit Pathw Cardiol. 2007;6:150-60. [PMID: 18091404]), including:

  • pain,
  • anxiety,
  • bladder distention,
  • antihypertensive medication withdrawal,
  • alcohol and narcotic withdrawal,
  • poorly controlled or undiagnosed preexisting hypertension,
  • hypervolemia (saline infusion),
  • postoperative state,
  • medications (e.g., corticosteroids, sympathomimetics, erythropoietin, cyclosporin), and
  • central nervous system disorders (e.g., head injury, stroke, brain tumors).

When should hospitalized patients receive pharmacologic treatment of hypertension?

Although clinical trials have shown that treatment of hypertension reduces incidence of stroke, myocardial infarction, and heart failure (22. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-219. [PMID: 23771844] doi:10.1093/eurheartj/eht151, 44. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311:507-20. [PMID: 24352797] doi:10.1001/jama.2013.284427), this pertains to the ambulatory setting and cannot be extrapolated to patients who are acutely ill and admitted to the hospital (66. Weder AB. Treating acute hypertension in the hospital: a Lacuna in the guidelines [Editorial]. Hypertension. 2011; 57:18-20. [PMID: 21079044] doi:10.1161/HYPERTENSIONAHA.110.164194).

Hypertensive emergencies require immediate BP reduction to prevent or limit target organ damage, as well as intensive care monitoring. Patients with hypertensive emergencies are initially treated with parenteral antihypertensive medications (e.g., nitroprusside, nicardipine, labetalol) with the goal of maximum reduction in BP not exceeding 25% of the initial BP in 2 to 6 hours. More aggressive BP reduction is not recommended because it can lead to ischemic events, which can in turn potentially lead to ischemic stroke or cardiac ischemia (77. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000;356:411-7. [PMID: 10972386]). Once the acutely elevated BP is controlled, patients should be switched to oral therapy.

It is unlikely that acute hypertension in the absence of target organ damage confers any greater risk to the patient, and there is no evidence to support lowering the BP emergently in these cases (22. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-219. [PMID: 23771844] doi:10.1093/eurheartj/eht151, 66. Weder AB. Treating acute hypertension in the hospital: a Lacuna in the guidelines [Editorial]. Hypertension. 2011; 57:18-20. [PMID: 21079044] doi:10.1161/HYPERTENSIONAHA.110.164194). Patients with hypertensive urgency need BP reduction but do not need emergent lowering or intensive care monitoring. These patients are generally treated with oral antihypertensive medications (77. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000;356:411-7. [PMID: 10972386]).

In patients with ischemic stroke who are eligible for thrombolytic therapy, reduction in BP to 185/110 mm Hg or lower is recommended before initiation of lytic therapy. In those who are not treated with thrombolytic therapy, most guidelines recommend that the BP should be allowed to autoregulate unless it exceeds 220/120 mm Hg (88. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, et al; American Heart Association Stroke Council. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870-947. [PMID: 23370205] doi:10.1161/STR.0b013e318284056a). In patients with intracranial hemorrhage, the general recommendation is a more aggressive reduction in BP with a goal systolic BP of 140 to 160 mm Hg (99. orgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly ES Jr, et al; American Heart Association Stroke Council and Council on Cardiovascular Nursing. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41:2108-29. [PMID: 20651276] doi:10.1161/STR.0b013e3181ec611b). In these situations, patients might need intensive care monitoring and reduction in BP by intravenous agents.

Causes of elevated BP in patients admitted to the hospital for reasons other than hypertension, as mentioned, could be multifactorial. Unlike in hypertensive emergencies, evidence does not favor acute lowering of elevated BP in these patients. Moreover, overzealous treatment could lead to harms from acute lowering of the BP itself or from adverse effects of the medications used to do so (66. Weder AB. Treating acute hypertension in the hospital: a Lacuna in the guidelines [Editorial]. Hypertension. 2011; 57:18-20. [PMID: 21079044] doi:10.1161/HYPERTENSIONAHA.110.164194, 77. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000;356:411-7. [PMID: 10972386]). These patients do not need acute reduction of BP and can be managed safely with oral antihypertensive medications.

Conclusions

Evidence suggests that elevated BP is common in hospitalized patients. Those with hypertensive emergencies need immediate pharmacotherapy to lower the BP. However, data are lacking on when and how to treat patients admitted to the hospital for reasons other than hypertension who are found to have elevated BP. Based on current evidence, these patients do not need acute BP reduction.

Further studies are needed to define hypertension in hospitalized patients and to determine long-term outcomes of patients with elevated hospital BP readings. Additional data are also needed to determine how best to follow and manage these patients after hospital discharge.

Case conclusion

It is not necessary to increase Mr. John's home antihypertensive medications since he does not have hypertensive emergency. Also, he has had good BP control based on home BP readings, and his hospital BP might be higher than at home due to pain or to the stress of being hospitalized.

The patient's vital signs were monitored closely while he was in the hospital. His BP remained in the range of 140-150/80-90 mm Hg. Antibiotics and pain medication were started, and his home BP regimen was not changed. At discharge, the patient was advised to monitor his BP at home. At 2 weeks' follow-up with his primary care clinician, his foot ulcer had healed and his office BP reading was 126/72 mm Hg. His primary care clinician made no change in his antihypertensive regimen.