Blood Pressure

Inpatient Hypertension

William Lavercombe

Background

  • Hypertensive urgency: SBP > 180mmHg/DBP > 120mmHg
  • Hypertensive emergency: SBP > 180 mmHg/DBP > 120 mmHg + new or worsening target-organ damage

Evaluation

  • Are there signs/symptoms of end organ damage?
    • Neurologic symptoms: agitation, delirium, stupor, seizures, visual disturbances
    • Focal neurologic deficits
    • Chest pain
    • Back pain (consider aortic dissection)
    • Dyspnea (consider pulmonary edema)
    • MIcrovasculature manifestations: high grade-retinopathy, AKI, or microangiopathic hemolytic anemia and thrombocytopenia

Management

  • Hypertensive Urgency: Goal to gradually lower BP over 24-48 hrs, initial goal 160/110
  • Hypertensive Emergency
    Initial lowering should depend on the end organ damage observed:
    • Stroke Initial: 130
    • Hypertensive Encephalopathy: Immediate MAP decline of 20-25%  in first hour
    • Cerebral Hemorrhage: Decrease SBP to 140-150 within 1 hr if SBP >150-220
    • Preeclampsia, HELLP, Eclampsia: Immediate SBP <160 mm Hg and DBP <105 mmHg if severe
    • Hypertensive Retinopathy BP Target: SBP <180 mmHg, MAP decline of 15%
    • Acute Kidney Injury: MAP decline 20-25% over several hours
    • Acute Heart Failure: SBP <140 mmHg
    • Pulmonary Edema: Immediate SBP <140 mmHg
    • Acute Coronary Syndrome: SBP <140 mmHg
    • Exceptions to gradual lowering include:
      • Acute stroke: call code stroke, lower ONLY if BP > 185/110 in pts under consideration for reperfusion therapy; or BP > 220/120 in pts not candidates for reperfusion therapy
      • Aortic dissection: Goal = rapidly lower BP in minutes to target of 100-120 systolic to avoid aortic shearing forces; also want to lower heart rate as best as possible.
  • Pharmacologic therapy
    • Ensure their home medicines have been restarted at appropriate doses, formulation (long acting vs. short), and dosing intervals
    • If pt has a rapid acting anti-HTN med, can consider giving a dose early or an "extra dose" and then up titrating their overall daily dose
    • Rescue therapies:
      • Hydralazine PO (10-20mg initial dosing Q6H)
      • Isosorbide dinitrate PO (5-20mg TID)
      • Nifedipine XL PO (dose at 30mg initially, max 90mg BID; NOT sublingual)
      • Labetalol IV (10-40mg initially; dosed up to every 20-30mins)
      • Hydralazine IV (10-20mg initially; dosed up to every 30 mins).
      • Nitroglycerin Infusion
      • Nitropaste 1” (can add/wipe away for titration; dose Q6H until oral meds can be started for better long-acting control)
  • Dialysis if missed session

Additional Information

  • Refractory HTN: try additional agents listed above vs. escalation of care for drip (nicardipine, nitroglycerin, nitroprusside, esmolol).
  • Most drips that can be done for this indication are done in stepdown and usually require no-titration of the infusion and occasionally the MD to be bedside to initiate the infusion.
  • This includes diltiazem, labetalol, nitroglycerin, and verapamil drips. Nicardipine, esmolol, and nitroprusside infusions (ggt) are not allowed on step down.
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