Treating elevated BP in the hospital: more harm than good?

In an inpatient setting, elevated blood pressure (BP; > 140/90 mm Hg) is very common; a 2011 systematic review of nine cohort and cross-sectional studies found a prevalence of 51% to 72%. A recent systematic review found that among 14 international clinical practice guidelines on hypertension, none addressed inpatient BP goals or management of moderately elevated BPs (140–179/90–119 mm Hg) in the hospital. Although the long-term benefits of outpatient BP control are well established, it is not clear whether initiating or intensifying antihypertensive therapy in the hospital is necessary or beneficial. In fact, two large cohort studies have suggested that such therapy may cause more harm than good.

The first study evaluated adults hospitalized in 2017 for noncardiac diagnoses at 10 hospitals in the Cleveland Clinic health system; 78% had at least one elevated BP reading prior to discharge. About 1 in 3 of these patients received acute hypertension treatment, defined as “administration of an intravenous antihypertensive medication or a new class of an oral antihypertensive treatment.” After controlling for potential confounding factors, treated patients had statistically higher rates of acute kidney injury (10.3% vs. 7.9%) and myocardial injury (1.2% vs. 0.6%) than untreated patients. In patients whose antihypertensive medications were increased at discharge, BP control did not improve in the following year.

The second study focused on patients 65 years or older in a Veterans Health Administration hospital for noncardiac diagnoses between October 1, 2015, and December 31, 2017, who had elevated BPs within 48 hours of admission. Using a propensity score overlap weighting analysis to control for confounders, patients who received intensive BP treatment (defined the same as “acute hypertension treatment” in the first study) during this time period were more likely (8.7% vs. 6.9%) to experience a composite outcome of inpatient mortality, intensive care unit transfer, stroke, acute kidney injury, B-type natriuretic peptide elevation, and troponin elevation.

In an article in the February 2024 issue of American Family Physician, Dr. Robert Gauer and colleagues advised taking a conservative approach to elevated BP in the hospital. Clinicians should address causes of transient BP elevations (e.g., pain, agitation, anxiety, fluid overload) rather than reflexively treating the numbers. Noting that “hospitalized patients with elevated BP often see a decrease of 20 mm Hg with subsequent measurements,” the authors suggested that 30 minutes of rest, rather than medications, should be first-line therapy. Patients with severe asymptomatic hypertension (BP > 180/110 mm Hg) should be treated with oral therapy only if they are at high risk for inpatient complications and if secondary causes have been excluded or addressed. Intravenous therapy should generally be avoided.

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This post first appeared on the AFP Community Blog.