Inpatient hypertension is tricky. What’s the best way to answer those overnight nursing phone calls for elevated blood pressures? What’s the role of treating hypertensive urgency in the hospital? Plus, Our nephrology experts put a new issue on the generalist’s radar: are ACE-inhibitors dangerous to give (or hold) during an operation? This NephMadness 2019 episode, features special guests Dr. Pascale Khairallah (@Khairallah_P), Dr. Charlie Wray (@WrayCharles) and Dr. Joel Topf (@kidneyboy) to better understand the role of anti-hypertensives in the inpatient setting and keep your blood pressure down on those overnight calls.
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Written and produced by: Justin Berk MD, MPH, MBA; Pascale Khairallah MD
Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD
Edited by: Matthew Watto, MD
Guest: Pascale Khairallah MD, Charlie Wray DO, Joel Topf MD
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The use of acute antihypertensive agents for hypertensive urgency is a virtually evidence free zone.
Very elevated blood pressures should be evaluated for hypertensive emergency (i.e. end-organ damage).
Per 2017 ACC/AHA guidelines, do not refer hypertensive urgency to the ED. Do not admit hypertensive urgency to hospital. Do not treat hypertensive urgency with IV medications.
IV Hydralazine can have variable response: there is a wide range of effect and 8% of doses are associated with adverse events.
Investigate the cause of inpatient hypertension: anxiety, pain, medication adherence, etc.
Though there is no need to treat asymptomatic hypertension acutely, don’t forget the benefits of chronic hypertension management.
There may be benefits when withholding ACE-inhibitors or ARBs before surgery. Guidelines are split with their recommendations [2014 ACC/AHA; Canadian Cardiovascular Society 2017].
Quote: “Don’t just do something, stand there.” –Dr Charlie Wray (@WrayCharles) teaches his philosophy on hypertensive urgency.
Signs of end-organ damage from elevated blood pressure include: altered mental status, blurred vision, chest discomfort, myocardial infarction, shortness of breath, renal damage
Work-up includes: ophthalmoscope for fundoscopic exam, urinalysis for proteinuria, and seeing the patient.
Causes of inpatient hypertension: pain, anxiety, gratuitous fluid resuscitation, discontinuation or non-adherence to home antihypertensive medications, gratuitous fluid resuscitation, poor measurement.
We don’t need to acutely treat HTN Urgency: Things We Do For No Reason: Acute Treatment of Hypertensive Emergency by Tony Breu. There is no real data to support the use of acute antihypertensive agents. Plus, there are adverse outcomes when bringing down hypertension acutely e.g. lightheadedness, syncope, falls
Systemic challenges still exist (e.g. BP thresholds for disposition, triage/level of care, transfer of patients, and rapid response threshold). These issues require education of all stakeholders including our nursing colleagues.
In reality, PCPs see many of these patients in the outpatient setting. A large study following patients that were sent home versus sent to the ED found No change in 30 day (or 6 month) outcomes (except hospital admission). Another study found that the one-year mortality for those experiencing an episode of hypertensive urgency is approximately 9% versus 39% in hypertensive emergency.
Treating chronic hypertension has been shown to be beneficial. BUT, it does not require referral to an ED. The guidelines agree.
ACC 2017 Guidelines on HTN: Do not refer hypertensive urgency to the ED. Do not admit HTN Urgency to hospital.
The American College of Emergency Physicians (ACEP) recommends against giving IV meds to treat asymptomatic uncontrolled hypertension.
Caption: Adapted from van Diepen et al JAHA 2018, Figure 2 Incidence of postoperative inopressor requirement, intravenous vasodilatory use, and vasoplegic shock by randomized treatment assignment. ACE indicates angiotensin‐converting enzyme inhibitor; ARB, angiotensin receptor blocker (https://doi.org/10.1161/JAHA.118.009917)
Listeners will challenge the convention of prescribing as-needed medications for acute control of elevated blood pressure (acute severe hypertension) and recognize the limited guidance on balancing risks and benefits of perioperative ACEi therapy.
After listening to this episode listeners will…
Dr Khairallah reports no relevant financial disclosures. Dr Topf lists the following disclosures on his website “I have an ownership stake in a few Davita run dialysis clinics and a vascular access center. Takeda Oncology made a donation to MM4MM the program that is taking me to Mount Everest in 2018”. Dr Wray is an editor for the Journal of Hospital Medicine and mentioned their fellowship program. The Curbsiders report no relevant financial disclosures for this episode.
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