Blood pressure elevations in hospital

Abstract

Long-term hypertension control in the community significantly reduces cardiovascular risk. However, the benefit of controlling acute elevations of blood pressure in hospitalised patients is unclear.In-hospital elevations of blood pressure are relatively common and might not reflect poorly controlled blood pressure before admission. The measurement of blood pressure in hospital patients significantly differs from the best practice recommended for primary care and outpatients.Recent observational studies suggest that the pharmacological treatment of acute, asymptomatic, in-hospital elevations of blood pressure may have no benefit. However, it may increase the risk of in-hospital and post-discharge complications.A study in a UK hospital highlighted why inpatient blood pressure measurement may be unreliable. Blood pressure was measured once only (96% of measurements), an incorrect cuff size was used (36%), and staff and patients were conversing during the measurement (41%). 9 This study casts doubt on the use of these measurements as a justification for starting or increasing antihypertensive treatment for inpatients who are asymptomatic.

Meeting medical emergency response criteria for hypertension is not associated with an increased likelihood of in-hospital mortality in a tertiary referral center

“…Currently, there are no clear guidelines for treating inpatient hypertension, particularly in the absence of signs or symptoms of acute target organ damage. 11 Situational factors such as pain, nausea, fever, anxiety, stress, erratic intake of existing antihypertensive agents, exposure of new drugs and white coat syndrome can transiently elevate blood pressure during hospitalization. 11 However, it is unknown whether these responses are adaptive or harmful, adding to the complexity in predicting outcomes related to increased blood pressure.…”

“… 11 Situational factors such as pain, nausea, fever, anxiety, stress, erratic intake of existing antihypertensive agents, exposure of new drugs and white coat syndrome can transiently elevate blood pressure during hospitalization. 11 However, it is unknown whether these responses are adaptive or harmful, adding to the complexity in predicting outcomes related to increased blood pressure. 12 The non-significant positive likelihood ratio of systolic blood pressure 200 mmHg and in-hospital mortality suggests that a more conservative approach in managing inpatient hypertension may be reasonable except in high-risk patient groups such as acute ischemic stroke.…”

Systolic blood pressure levels and mortality in Australian medical inpatients

“…The awareness of elevated blood pressure among inpatients has not been addressed in manner comparable to that of hypertension within the community 3 . There is also limited evidence to guide management of such elevations, particularly in the absence of signs and symptoms of target organ damage 4 . Although hypertensive urgencies describe a systolic pressure ≥180 mmHg without end‐organ damage, there are conflicting evidence regarding patient benefits with different treatments and significant variation in practice 5 .…”

“… 3 There is also limited evidence to guide management of such elevations, particularly in the absence of signs and symptoms of target organ damage. 4 Although hypertensive urgencies describe a systolic pressure ≥180 mmHg without end‐organ damage, there are conflicting evidence regarding patient benefits with different treatments and significant variation in practice. 5 In addition, in‐hospital systolic blood pressure elevations are commonly characterized by systolic blood pressure values between 140 and 180 mmHg, where there is even less evidence in terms of clinical significance and the effect of management.…”

Approach and intervention in blood pressure abnormalities

“…While long-term control of hypertension in individuals significantly reduces cardiovascular risk, the benefit of controlling acute BP elevations in hospitalized patients is controversial. 2 In the case of hypertensive emergencies or urgent situations, antihypertensive treatment should be initiated after consideration of the approach to the recommendations. However, current hypertension guidelines do not address in-hospital asymptomatic -BP elevations or recommendations for their diagnosis, management, and follow-up.…”