Blood Pressure


Inpatient Hypertension

Rob Churchill

Background

  • Hypertensive urgency SBP > 180 mmHg/DBP > 120 mmHg.
  • 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, encephalopathy. 
    • Cardiopulmonary: Chest pain, Back pain (aortic dissection), Dyspnea (pulmonary edema). 
    • Microvasculature: high grade-retinopathy, AKI, or microangiopathic hemolytic anemia, thrombocytopenia.

Management

  • Hypertensive Urgency: Goal to gradually lower BP over 24-48 hrs, initial goal 160/110 
    • Reinstitute or intensify pre-existing oral medications. 
  • Hypertensive Emergency 
    • General principles: escalate care for strict BP monitoring and IV antihypertensives, avoid excessive BP reduction (100-120 mmHg), transition to PO medications 6-12 hours after IV to prevent rebound HTN. 

Initial lowering should depend on the end organ damage observed: 

  • Cerebral Hemorrhage: Decrease SBP to 140-150 within 1 hr if SBP >150-220. Avoid SBP < 130 mmHg. 
  • Hypertensive Encephalopathy: Immediate MAP decline of 20-25% in first hour, then 160/100 by 2-6 hours. 
  • Acute Coronary Syndrome: SBP <140 mmHg within 1 hour; maintain DBP > 60 mmHg. 
  • CHF/Pulmonary Edema: SBP < 140 mmHg within 1 hour; avoid B blockers. 
  • Acute Kidney Injury: MAP decline 20-25% over several hours. 
  • 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%. 
  • 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 100-120 systolic to avoid aortic shearing forces; also want to lower heart rate as best as possible.

Pharmacologic therapy

  • General Principles: Ensure 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. 
  • PO/Topical 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). 
    • 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.

IV therapies: reserved for hypertensive emergency and refractory hypertension

  • Labetalol IV (10-40mg initially; dosed up to every 20-30mins). 
  • Hydralazine IV (10-20mg initially; dosed up to every 30 mins). 
  • Nitroglycerin Infusion.

IV therapy considerations

  • Consider secondary workup (urine metanephrines, renal vascular US, renin-aldosterone levels).
  • 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 (gtt) = not allowed on step down.
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