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