Treating Hypertension in the Hospital: A Few Scenarios That Challenge Primary Care

Much of the ground covered at the 2013 ASH meeting addressed “big” issues in hypertension, such as speculation over the content of JNC 2013 and the downgrading of beta-blocker efficacy in patients with hypertension.

On a day-to-day basis, plenty of “smaller” issues can complicate a primary care clinician’s life:  When and how should preoperative hypertension be treated? Should the elderly patient with Parkinson disease, supine hypertension, and orthostatic hypotension be treated at all?

Many of my preceding commentaries from ASH have addressed those “bigger” topics and the ambulatory management of hypertension. However, hospitalists, for example, are frequently asked to evaluate and treat inpatient hypertension in a variety of situations. A non-exhaustive list of those includes perioperative hypertension and blood pressure (BP) elevations in dialysis patients and in patients who have been made NPO and so unable to take their home medications.

Despite a surfeit of data for chronic, ambulatory BP management, there is a paucity of data to guide inpatient decisions. A few case scenarios helped highlight this disparity.

An 84-year-old woman with either Parkinson disease or a Parkinson-plus syndrome has a supine BP of 180/104 mm Hg complicated by severe orthostatic hypotension (80/40 mm Hg). Should she be treated, and if so how? There is little evidence to guide this perplexing management question. Most of the assembled agreed that individualization of treatment is critical. Treating the supine hypertension may lead to falls. Falls can be devastating-either hip fractures or head injuries. Trying to increase upright BPs may make supine BPs worse. At the age of 84, her life expectancy must be factored in as well.

Some in attendance proposed approaches that included no BP treatment at all (the majority), low-dose nighttime clonidine that can “wear off” by morning when the patient arises, or even placing blocks under the bed to mitigate supine BP without significant medication adverse effects. In patients such as the one described here, drinking water can raise BP in 35 minutes. That would be one way to noninvasively raise her upright BP. Another possibility would be to concentrate on the orthostatic hypotension by administering midodrine for daytime activities.

Inpatient and perioperative BP increases are also problematic. Most attendees agreed that treatment should be avoided. Studies from the 1970s by Lee Goldman, the father of perioperative medicine, demonstrated that most BP elevations approximating 160 to 180/95 to 110 mm Hg did NOT adversely affect surgical outcomes. It was also agreed that holding medications with long half-lives (ie, ACEI and ARBS) before surgery was a good idea. Most BP increases during surgery can be controlled by the anesthesiologist. Overtreatment before surgery may lead to hypotension.

Guidelines from ER medicine have also suggested that is less is more. One should hesitate to treat BPs less than 180/110 mm Hg acutely. Obviously, withholding therapy requires careful evaluation of the patient to uncover any target-organ damage. The 180/110 mm Hg value is a boundary for severe hypertension. But most of these individuals do not have end-organ damage and can be treated gently (after exam) to lower BP over 24 to 48 hours.

Some other “no-nos” were also raised. Hydralazine for inpatient rises in BP was called a “nightmare.” It is a vasodilator and can cause myocardial ischemia. It can induce unpredictable hypotension. An anxiolytic or pain medication is all that is required in many instances. Data for aggressive in-hospital lowering of BP is simply not available. Simple things, such as an inability to void, should lead to relief of the bladder distention and NOT an antihypertensive agent. This is an understudied area in need of more evidence, but most agreed in-hospital hypertension is overtreated and the consequences can be dangerous.
 
Another case was discussed: a late night admission of a dialysis patient. He was short of breath and his BP was 180/108 mm Hg; the question was should it be lowered? The patient was 6 liters over dry weight. He was to be dialyzed early in the morning. If aggressive efforts were made to drop his BP, the fluid removal on dialysis would be compromised by dialysis hypotension. Again, either no treatment or mild interventions such as oxygen or nitroglycerine as a patch and assurance that dialysis will be done soon, would be safe and suffice.
 
The message was clear and repeated frequently: The greatest danger of hypertension in the hospital is overtreatment.