Clinical question: How should clinicians approach the management of asymptomatic hypertension in inpatients?
Background: There are heterogeneous practices to manage asymptomatic blood pressure (BP) elevations for inpatients with elevated BP and no acute end-organ damage, with no clear data to suggest benefit.
Synopsis: A stepwise approach to the management of inpatients with elevated blood pressure is proposed, with two priorities—to avoid preventable harm and adverse drug effects while improving long-term outcomes and blood pressure control. The first step is to assess for acute hypertension-mediated end-organ damage for patients with severe hypertension (180/120 mmHg or higher); these patients should be treated as a hypertensive emergency. The next step is to ensure appropriate measurement techniques prior to remeasurement. If hypertension is confirmed, the third step is to treat contributing factors associated with or exacerbating hypertension. The fourth step is medication reconciliation, with the goal of restarting antihypertensives that may be held and discontinuing unnecessary hospital medications that may be contributing to hypertension. The fifth step is to consider patient-specific factors that may be contributing, including demographics, functional status, comorbidities, and baseline BP control. Most patients do not warrant antihypertensive medication intensification in the hospital or on discharge, though initiating or titrating a single guideline-directed antihypertensive may be considered in select high-risk patients with readiness to make changes, poor baseline BP control, and/or chronic conditions that may benefit from stricter BP control. The sixth and final step is to develop a transitional care plan ensuring patient education and follow-up.
Bottom line: For inpatients with asymptomatic BP elevations, a stepwise approach to management may help avoid preventable harm and adverse drug effects while improving long-term outcomes and BP control.
Citation: Jacobs ZG, and Anderson TS. Management of elevated blood pressure in the hospital-rethinking current practice. JAMA Intern Med. 2024;184(9):1117-8.
Dr. Moussa
Dr. Moussa is an academic hospitalist in the division of hospital medicine at NYU Langone Tisch Hospital and an assistant professor of medicine at the NYU Grossman School of Medicine, both in in New York.