How should asymptomatic hypertension be managed in the hospital?

Other studies have examined the role of oral antihypertensives for management of asymptomatic hypertension in the inpatient setting. A systematic review and meta-analysis by Souza et al. assessed the use of oral pharmacotherapy for hypertensive urgency.¹¹ Sixteen randomized clinical trials were reviewed and it was determined that angiotensin-converting enzyme inhibitors (ACE-I) had a superior effect in treating hypertensive urgencies.¹¹ The most common side effect of using an ACE-I was a bad taste in patient’s mouths, and researchers did not observe side effects that were similar as those seen with the use of IV antihypertensives.¹¹

Further, Jaker et al. performed a randomized, double-blind prospective study comparing a single dose of oral nifedipine with oral clonidine for the treatment of hypertensive urgency in 51 patients.¹² Both the oral nifedipine and oral clonidine were extremely effective in reducing blood pressure fairly safely.¹² However, the rapid lowering of blood pressure with oral nifedipine was concerning to Grossman et al.¹³ In their literature review of the side effects of oral and sublingual nifedipine, they found that it was one of the most common therapeutic interventions for hypertensive urgency or emergency.¹³ However, it was potentially dangerous because of the inconsistent blood pressure response after nifedipine administration, particularly with the sublingual form.¹³ CVAs, acute MIs, and even death were the reported adverse events with the use of oral and sublingual nifedipine.¹³ Because of that, the investigators recommend against the use of oral or sublingual nifedipine in hypertensive urgency or emergency and suggest using other oral antihypertensive agents instead.¹³

Dr. Adam Gray

With this literature in mind, we have developed our own practical approach for the treatment of inpatient asymptomatic hypertension (Figure 1) that is modeled closely to the approach created by Axon et al.¹⁴ Once it is established that a hospitalized patient has elevated blood pressure, providers must assess for symptoms indicative of hypertensive emergency. If the patient has no symptoms of chest pain, dyspnea, altered mental status, severe headache, visual changes, or other evidence of acute end organ damage, then hypertensive emergency is unlikely. Thus, the next step is to assess for common contributing factors to hypertension, including acute pain, nausea, anxiety, or agitation; medication or illicit drug withdrawal; volume overload or depletion; or a new medication that may be contributing to the elevated blood pressure. If the blood pressure remains elevated, the provider should review the patient’s home medication list to ensure that none of their antihypertensives were held on admission to the hospital. Often restarting a patient’s home oral antihypertensive regimen is adequate to control blood pressure.

Typically, if the patient’s blood pressure remains elevated despite these efforts, no urgent treatment is indicated and we recommend close monitoring of the patient’s blood pressure during the hospitalization. If hypertension persists, the next best step would be to titrate a patient’s current oral antihypertensive therapy or to start a long-acting antihypertensive therapy per the JNC 8 (Eighth Joint National Committee) guidelines. It should be noted that, in those patients that are high risk, such as those with known coronary artery disease, heart failure, or prior hemorrhagic CVA, a short-acting oral antihypertensive such as captopril, carvedilol, clonidine, or furosemide should be considered.