#144 NephMadness: Inpatient Hypertension

March 18, 2019 | By Justin Berk

“As needed” Hypertension Treatment and Peri-operative ACE-inhibitors

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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Credits

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

Sponsor

Get your ACP membership today and use the code CURB100 to save $100 when you join by March 31, 2019.

Time Stamps

• 00:00 Kidney Pun Contest with Hannah Abrams
• 01:16 Disclaimer
• 01:45 Sponsor – Become an ACP Member today!
• 02:14 Intro and guest bios
• 03:50 Picks of the weeks
• 06:00 Sponsor – Become an ACP Member today!
• 07:20 Case of acute severe hypertension; Does hypertensive urgency exist? Should we treat it?
• 26:40 Case of perioperative medicine. Should we hold the ace inhibitor? Is there evidence to guide us?
• 35:02 Take home points
• 36:54 Everyone picks their NephMadness winners for the hospital medicine region
• 43:13 Outro

Inpatient Hypertension Pearls

PRN Hydralazine and Perioperative ACE inhibitors

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.

Inpatient Hypertension Show Notes

Definitions

Hypertension Urgency: An elevated blood pressure of SBP > 180 or DBP > 120.

Hypertension Emergency: An elevated blood pressure with associated signs of end-organ damage (including altered mental status, blurred vision, chest discomfort, acute coronary syndrome, shortness of breath, kidney damage)

Hypertensive Crisis – PRN Medications

Hypertensive Crisis (Urgency vs. Emergency)

• Curbsiders debate over whether hypertensive urgency is a true pathological condition. (See previous episode for further discussion)
• General consensus: High blood pressure without end-organ damage does not need acute intervention but chronically elevated BP should not be ignored.

Evaluating inpatient hypertension

• Greater than 40% of providers prescribe PRN medications to inpatients with elevated BP.
• Only 7.5% of patients that received IV PRN medications were actually seen by physician!
• About 40% of patients receiving PRN medications had not been continued on home antihypertensive regimen!

Step 1: Rule out hypertension emergency (i.e. end-organ damage).

Signs of end-organ damage

Signs of end-organ damage from elevated blood pressure include: altered mental status, blurred vision, chest discomfort, myocardial infarction, shortness of breath, renal damage

Inpatient Hypertension Workup

Work-up includes: ophthalmoscope for fundoscopic exam, urinalysis for proteinuria, and seeing the patient.

Causes of Inpatient Hypertension

Causes of inpatient hypertension: pain, anxiety, gratuitous fluid resuscitation, discontinuation or non-adherence to home antihypertensive medications, gratuitous fluid resuscitation, poor measurement.

Should you treat Hypertensive Urgency?

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

Systems Issues for Inpatient Hypertension

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.

Evaluating hypertensive crisis (urgency vs emergency) in the outpatient / ED

Is an outpatient workup safe?

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.

What about the guidelines?

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.

IV Hydralazine is rarely indicated

• Up to 8% of doses of IV hydralazine are associated with adverse events. These are not just limited to hypotension.
• Hydralazine is somewhat unpredictable with a wide range of effect on BP. In one study, following hydralazine, BP was reduced by 24/9 ± 29/15 mmHg

Peri-Operative ACE-inhibitors and ARBs

Risks and Benefits of Continuing ACE-inhibitors and ARBs

• Withholding medication can cause hypertensive emergency that postpones surgery

• Continuing medication may Increase likelihood of intraoperative hypotension. But, it is unclear if this has clinical significance.
• No randomized control trials exist to provide guidance. Most studies have been limited to outpatient surgeries (and exclude emergency surgeries).

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)

Guidelines / Evidence

• The 2014 ACC/AHA Guidelines state that continuation of ACEi/ARB is reasonable
• The 2017 Canadian Cardiovascular Society Guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery recommend withholding ACEi/ARB 24-hours before noncardiac surgery
• In a secondary analysis of patients on chronic ACEi or ARB, when the drug was held for 24 hours preoperatively there was a relative risk of 0.82 for 30-day all-cause mortality, stroke, or myocardial injury.
• A 2016 Cochrane analysis attempting to answer the question of continuing vs. holding preoperative ACEi/ARB before either cardiac or non-cardiac surgery could not give definitive conclusions since the included studies had poor methodology, high risk of bias, and lack of power to answer the question.

Goals and Learning Objectives

Goal

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.

Learning objectives

After listening to this episode listeners will…

1. Define hypertensive urgency and hypertensive emergency
2. Treat hypertensive urgency and determine if ED referral / inpatient admission is necessary
3. Recognize the harms of prescribing IV antihypertensives when they are not needed
4. Evaluate and manage an inpatient with elevated BP
5. Identify the concerns of continuing ACEi/ARB therapy during surgery
6. Identify the concerns of withholding ACEi/ARB therapy during surgery
7. Recognize the recommendations of varying society guidelines in regards to perioperative ACEi/ARB therapy

Disclosures

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.

Links from the show

1. NephMadness
2. Twitter
3. AJKD Editorial Internship
4. Book recommendation: Ending Medical Reversal
5. TV Series: Corporate
6. TV Series: The Expanse
7. The Curbsiders Episode #20: Hypertensive Urgency
8. Attitudes of Resident Physicians regarding HTN in the Inpatient Setting
9. Unjustified use of inpatient hydralazine (adverse events and wide range of effect)
10. An Update on Inpatient Hypertension Management (discussion of causes)
11. Drug non-adherence is a common cause of HTN Urgency (J Hypertension 2019)
12. Inpatient blood pressure measurement is often inaccurate (Circulation 2005)
13. 40% of patients receiving PRN medications had not been continued on home antihypertensive regimen
14. Things We Do For No Reason: Acute Treatment of Hypertensive Emergency (Journal of Hospital Medicine 2018)
15. Characteristics of Patients with HTN Urgency in Outpatient Setting (JAMA IM 2016)
16. ACC 2017 Guidelines on HTN
17. The American College of Emergency Physicians (ACEP) Guidelines on HTN
18. Hypertensive Urgency mortality prediction of 9%
19. Evidence for treatment of chronic HTN: VA Trial (JAMA 1967), SPRINT Trial (NEJM 2015)
20. 2014 ACC/AHA Guidelines state that perioperative continuation of ACEi/ARB is reasonable
21. Canadian Cardiovascular Society Guidelines recommend withholding ACEi/ARB 24-hours before noncardiac surgery
22. A Prospective Cohort Study suggesting withholding ACE-inhibitor was associated with a 20% decrease in risk of mortality and postoperative events. (Roshanov et al. Anesthesiology 2017)
23. 2016 Cochrane analysis on withholding ACEi/ARB perioperative could not give definitive conclusion.