Attitudes and Practices of Resident Physicians Regarding Hypertension in the Inpatient Setting

Abstract

Hypertension is prevalent in the population at large and among hospitalized patients. Little has been reported regarding the attitudes and patterns of care of physicians managing nonemergent elevated blood pressure (BP) among inpatients. Resident physicians in internal medicine (IM), family medicine (FM), and surgery were surveyed regarding inpatient BP management. One hundred eighty-one questionnaires were completed across 3 sites. Respondents generally considered inpatient BP control a high priority. A majority of IM and FM residents indicated following the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) consensus guidelines for inpatients compared to 20% of surgery residents (P<.001). While trainees did not appear to strictly follow JNC 7 guidelines for goal BP of 140 ⁄ 90 mm Hg, they did report making frequent BP medication changes (51% reported changing regimens for >50% of hypertensive patients). Overall 90% indicated that discharging a hypertensive patient on a drug regimen established during hospitalization is preferable to reverting to the regimen in place at the time of admission. Resident physicians regard elevated BP inpatient management as important, but attitudes and practice vary between specialties. JNC 7 guidelines may not be appropriate for inpatient use. Future research should focus on developing functional diagnostic criteria for hypertension in the inpatient setting and determining best practices inpatient BP management. J Clin Hypertens (Greenwich). 2010;12:698-705. W hile guidelines for hypertension management and studies of control efforts over the past 30 years have fittingly concentrated on the outpatient setting, evidence suggests that the prevalence of hypertension in the inpatient setting is as high as 50%.1 Hospitalization is common in the United States. In 2002, there were more than 38 million inpatient hospitalizations and roughly 33 million additional surgical procedures among adults.2,3 Available studies indicate that recognition and control of hypertension in the inpatient setting are suboptimal, even in patients with high-risk conditions such as ischemic heart disease and stroke.4-10 Thus, the inpatient setting might reasonably be a site to focus efforts to improve hypertension treatment.While experts generally agree on principles for treatment of the range of hypertensive emergency

Severe inpatient hypertension prevalence and blood pressure response to antihypertensive treatment

“…36,37 Even though there is no substantive evidence that antihypertensive medications improve outcomes of hospitalized patients who develop HTN, physicians believe it is important. 6 This could be due to fear that untreated HTN could progress to end organ damage or healthcare providers not being aware of the risks of overtreatment. 38 However, a retrospective analysis of veterans admitted for non-CVD causes found an increased rate of 30-day adverse events and readmissions as well as higher 1-year risk of CVD events among patients who had their antihypertensive treatment intensified during inpatient admissions.…”

“…However, far more common is incident severe HTN in already hospitalized patients occurring during an admission unrelated to HTN 3–5 . Increased blood pressure (BP) in ambulatory patients is associated with increased risk of cardiovascular disease (CVD) related outcomes including stroke, myocardial infarction and coronary artery disease increases, but treatment of severe inpatient HTN in the absence of acute target organ injury is currently not directed by guidelines 6,7 . Additionally, recent studies have found that treatment of severe inpatient HTN resulted in greater BP drops, and higher rates of acute kidney injury and myocardial injury 5,8 .…”

“…[3][4][5] Increased blood pressure (BP) in ambulatory patients is associated with increased risk of cardiovascular disease (CVD) related outcomes including stroke, myocardial infarction and coronary artery disease increases, but treatment of severe inpatient HTN in the absence of acute target organ injury is currently not directed by guidelines. 6,7 Additionally, recent studies have found that treatment of severe inpatient HTN resulted in greater BP drops, and higher rates of acute kidney injury and myocardial injury. 5,8 However, these studies used different study populations (Rastogi and coworkers excluded cardiac admissions), used a wide range of blood pressure (BP) thresholds, and did not account for patient level factors (eg, pain, anxiety).…”

Blood pressure elevations in hospital

“…Many residents (44%) considered drugs should be started or adjusted if the systolic blood pressure was mildly high (140-159 mmHg) and that patients with in-hospital blood pressure elevations should be discharged on the antihypertensive regimen prescribed in hospital (91%). 11 In another survey, about a third of hospital doctors would transfer an asymptomatic patient to an intensive care unit because of high blood pressure even in the absence of target organ damage. The average blood pressure that would prompt the transfer was 210/117 mmHg for house officers and 193/110 mmHg for other hospital doctors.…”

Acute Treatment of Hypertensive Urgency

“…3 Among internal medicine and family medicine trainees in one survey, nearly half reported that they would use IV medications in a scenario where an inpatient had an asymptomatic blood pressure above 180 mm Hg. 4…”