How should asymptomatic hypertension be managed in the hospital?

Case

A 62-year-old man with diabetes mellitus and hypertension presents with painful erythema of the left lower extremity and is admitted for purulent cellulitis. During the first evening of admission, he has increased left lower extremity pain and nursing reports a blood pressure of 188/96 mm Hg. He denies dyspnea, chest pain, visual changes, confusion, or severe headache.

Background

The prevalence of hypertension in the outpatient setting in the United States is estimated at 29% by the National Health and Nutrition Examination Survey.¹ Hypertension generally is defined in the outpatient setting as an average blood pressure reading greater than or equal to140/90 mm Hg on two or more separate occasions.² There is no consensus on the definition of hypertension in the inpatient setting; however, hypertensive urgency often is defined as a sustained blood pressure above the range of 180-200 mm Hg systolic and/or 110-120 mm Hg diastolic without target organ damage, and hypertensive emergency has a similar blood pressure range, but with evidence of target organ damage.³

In general, the guidelines for the treatment of hypertension are focused on management of chronic hypertension in the outpatient setting and/or hypertensive emergency in the inpatient setting. However, there is no consensus on the treatment of nonemergent, asymptomatic hypertension, or hypertensive urgency in the inpatient setting. This is alarming since the prevalence of inpatient hypertension may be as high as 72%, which roughly equates to 26.2 million encounters per year.^4,5 It is hypothesized that the stress and complications of being acutely ill and 24-hour blood pressure monitoring likely contribute to the elevated prevalence.⁴ Overall, the available evidence indicates that the recognition and appropriate treatment of hypertension in the inpatient setting is suboptimal due to the lack of guidelines and inconsistent management.^4,6

The evidence

There are several clinical trials to suggest that the ambulatory treatment of chronic hypertension reduces the incidence of myocardial infarction, cerebrovascular accident (CVA), and heart failure^7,8; however, these trials are difficult to extrapolate to acutely hospitalized patients.⁶ Overall, evidence on the appropriate management of asymptomatic hypertension in the inpatient setting is lacking.

Some evidence suggests we often are overly aggressive with intravenous antihypertensives without clinical indications in the inpatient setting.^3,9,10 For example, Campbell et al. prospectively examined the use of intravenous hydralazine for the treatment of asymptomatic hypertension in 94 hospitalized patients.¹⁰ It was determined that in 90 of those patients, there was no clinical indication to use intravenous hydralazine and 17 patients experienced adverse events from hypotension, which included dizziness/light-headedness, syncope, and chest pain.¹⁰ They recommend against the use of intravenous hydralazine in the setting of asymptomatic hypertension because of its risk of adverse events with the rapid lowering of blood pressure.¹⁰

Lipari et al. found similar results in their analysis of 172 hospitalized patients who received intravenous antihypertensives for hypertension.⁹ The majority who received an intravenous antihypertensive were asymptomatic and did not have a clinical indication.⁹ Further, they reported that approximately 56 patients demonstrated blood pressure reductions of more than 25% within 6 hours of antihypertensive administration.⁹ Of those, two suffered from a hypotensive event and six had a subsequent scheduled oral antihypertensive held.⁹ They echoed similar recommendations of Campbell et al. that intravenous antihypertensive use in patients with asymptomatic hypertension should be avoided because of the risk of adverse events.⁹

Weder and Erickson performed a retrospective review on the use of intravenous hydralazine and labetalol administration in 2,189 hospitalized patients.³ They found that only 3% of those patients had symptoms indicating the need for IV antihypertensives and that the length of stay was several days longer in those who had received IV antihypertensives.³