#310 No Tension About Inpatient Hypertension with Dr. Noble Maleque

December 13, 2021 | By Monee Amin

Is there an Urgency to the Emergency about High blood pressure in the hospital?

Summary

Don’t sweat inpatient hypertension any longer. Who needs guidelines when Dr. Noble Maleque (@nobility75, Emory University, Division of Hospital Medicine) explains the spectrum of hypertensive disorders in the inpatient setting, and an approach for thinking about treatment. 

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Credits

• Production, Script, Infographic, and Cover Art: Monee Amin, MD, Meredith Trubitt, MD MPH 
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP, Monee Amin, MD, Meredith Trubitt, MD MPH 
• Reviewer: Adam Barelski MD
• Executive Producer: Beth Garbitelli
• Showrunner: Matthew Watto MD, FACP
• Editor: Clair Morgan of nodderly.com
• Guest: Noble Maleque MD

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Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner, Picks of the Week*
• Definitions
• Case from Kashlak
• Elevated blood pressure / hypertensive urgency
• Contributing factors to elevated blood pressure in the hospital
• Hypertensive urgency—to treat or not to treat
• Transitions of care and case against intensification of treatment
• Case from Kashlak
• Hypertensive emergency diagnosis and treatment
• Secondary Hypertension
• Outro

Inpatient Hypertension Pearls

1.  Hypertensive urgency defined as BP > 180/120 WITHOUT end organ damage.

2.  Hypertensive emergency defined as BP > 180/120 WITH end organ damage.

3. End organ damage clinically determined as shortness of breath, chest pain, encephalopathy, neurologic deficits, and decreased urine output.

4.  Hypertensive urgency terminology would suggest that it should be treated, when data suggests otherwise, and in fact can be harmful if treated.

5. Inpatient blood pressure parameters have been a staple in the hospital but promote the need to treat even without signs of end organ damage.

6. Intensification of treatment at discharge has demonstrated harms.

7. In the patient who warrants treatment, first and foremost treatment should focus on non-pharmacologic therapy (diet, exercise, ensuring adequate BP cuff, journals at home), followed by pharmacologic therapy (start slow and low!)

No Tension About Inpatient Hypertension Show Notes

Definitions

Based upon outpatient blood pressure measurement guidelines. Of note, there are no agreed upon inpatient standards. 

Hypertension = elevated blood pressure (>130/80)

Hypertensive Urgency = blood pressure (BP) > 180/120 WITHOUT end organ damage

Hypertensive Emergency = BP > 180/120 WITH end organ damage

[ACC/AHA Guideline – Whelton et al 2017]

Hypertensive Urgency

A few notes on hypertensive urgency

Hypertensive urgency (or hypertensive crisis): Dr. Maleque notes that the semantics (urgency or crisis) make it difficult to ignore, though frequently no treatment is the best treatment. Additionally, it is worth noting that the phrase hypertensive urgency is falling out of favor because it is counterintuitive to treat something that is not urgent. 

According to ACC/AHA Guidelines – Whelton et al 2017,  obtaining an accurate blood pressure is challenging especially in the inpatient setting (expert opinion).

What are contributing factors that may cause elevated blood pressure in the inpatient setting?

1. Not taking home medications
2. Stressors
3. Acute pain
4. Nausea
5. Anxiety
6. Agitation
7. Recreational alcohol/drug use and withdrawal
8. New medications (i.e. NSAIDs, decongestants, steroids, immunosuppressants, epoetin, SNRIs)
9. Urinary obstruction
10. Volume overload (ESRD, CHF, IVF administration)
11. Waiting in the emergency room for extended time

[Axon, 2015]

What to do with those pesky parameters?

High blood pressure is bad and is a risk factor for other disease processes therefore the instinct when called about an elevated blood pressure is to act. While there are guidelines for blood pressure goals based on disease processes in the outpatient setting, such recommendations do not exist in the inpatient setting. Therefore, in the patient without signs of end organ damage (no symptoms, normal labs), Dr. Maleque thinks this is the time to realize that “no action is the appropriate action.”

Examples of increasing parameters to decrease the use of unnecessary treatment have been demonstrated with successful outcomes. [Jacobs, et al., 2019] [Pasik, et al., 2019]

Potential harms and considerations of escalating blood pressure treatment at discharge 

In general, when the decision is made to treat there are potential adverse consequences. These include dizziness, low blood pressures, falls, and other side effects to the medications such as reflex tachycardia. More recently, Rastogi, et al. 2020 looked at patient centered outcomes in non-cardiac admissions such as resultant AKI, MI, and stroke based on decision to treat, and found that those who were treated inpatient suffered from increased AKI and MI. Additionally, those who had their medications intensified at discharge did not have better blood pressure control at 1 year follow up.

Anderson, et al., 2019, noted that patients admitted with non-cardiac conditions who had their antihypertensives intensified did not have reduced cardiac events nor improved BP control at 1 year, but did have increased risk of readmission and serious adverse event within 30 days from discharge.

Lastly, consider non-pharmacologic interventions as well. Park, et al., 2017 performed a randomized control trial comparing rest with medication treatment, and there was no significant difference between the two in hypertensive urgency patients.

Hypertensive Emergency

What are signs and symptoms of end organ damage?

Cardiac—angina, acute coronary syndromes, pulmonary edema

Neurologic—encephalopathy, CNS deficits, visual complaints

Kashlak Pearl: The famous question of does headache count as a  sign of end organ damage? Generally does not count without other specific neurologic deficits (expert opinion).

Where to triage the patient with hypertensive emergency?

Due to their need to have a drip, and close monitoring, typically would require a higher level of care such as intermediate or step-down vs ICU level of care (ACC/AHA Guidelines – Whelton et al 2017).

If hypertensive emergency causes specific end organ damage (i.e. intracranial hemorrhage, aortic dissection, stroke), appropriate consultants should be involved in the patient’s care. Recognize that these diagnoses have different, specific parameters for goal blood pressures.

Treatment

Initial treatment is with an IV titratable, predictable medication. Hydralazine is not an ideal medication due to its unpredictability in patients and can result in hypotension that is harmful to patients [Campbell, et al., 2011].

For the hypertensive emergency patient who was not taking their home medications, it may be as simple as restarting their home regimen. However, for the hypertensive emergency patient who was not on any medications, ensuring non-pharmacologic opportunities have been optimized is first line (i.e. diet, exercise, appropriate monitoring at home), followed by starting outpatient medications and to start slow and low with close primary care follow up (expert opinion).

Secondary Hypertension

Generally speaking, avoid secondary hypertension work-ups in the hospital. Ensure that you have ruled out contributing factors, and have identified lab abnormalities which may point to a secondary cause (i.e. hypokalemia, abdominal bruit).  If such values are found, this should be communicated  directly to the primary care provider so the appropriate work-up is performed post-discharge.

Links*  

1. When Christmas Comes Around –  Kelly Clarkson

2. We Are Supported by (Podcast)

3. The Apollo Murders by Chris Hadfield

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Goal

Listeners will challenge the convention that all elevated blood pressure readings require treatment in the inpatient setting.

Learning objectives

After listening to this episode listeners will…  

1. Define hypertensive emergency, urgency, and essential hypertension
2. List potential contributing factors to elevated blood pressure in the inpatient setting
3. Determine when treatment of acute hypertension is indicated in the inpatient setting
4. Explain harms and risks to treating hypertensive urgency when treatment is not indicated
5. Identify appropriate pharmacologic therapy for hypertensive emergency

Disclosures

Dr. Maleque reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Amin, M, Trubitt, ME, Maleque, N, Williams PN, Watto MF. “#310 No Tension About Inpatient Hypertension”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list

December 13, 2021