Commentary based on Bress AP, Anderson TS, Flack JM, et al.; American Heart Association Council on Hypertension, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology. The management of elevated blood pressure in the acute care setting: a scientific statement from the American Heart Association. Hypertension 2024;81:e94-e106.¹

There is an absence of definitive randomized controlled trial data to guide inpatient blood pressure (BP) treatment.¹ Consequently, this paucity of data has resulted in clinical equipoise, in which the benefits and risks of various treatment approaches are unclear.

A new scientific statement from the American Heart Association (AHA) reports a prevalence of high BP affecting up to three-quarters of inpatients.² There has been an absence of national guidelines for treating patients admitted for hospital care, resulting in variations in treatment approaches. This AHA scientific statement addresses best practices for the treatment of inpatient high BP, emphasizing the need for individualized plans.¹

New Terminology for Inpatient BP

A hypertensive emergency remains defined as a severe BP elevation (systolic blood pressure/diastolic blood pressure [SBP/DBP] ≥180/110 mm Hg) with accompanying organ damage. However, the AHA scientific statement recommends dropping terminology such as hypertensive urgency and adopting more specific classifications. Two categories of asymptomatic hypertension are defined: 1) markedly elevated BP, defined as any SBP/DBP measurement ≥180/110 mm Hg; and 2) elevated BP, based on SBP/DBP >130/80 mm Hg.^1,3

This latter category of asymptomatic elevated BP is the most commonly encountered and has a prevalence as high as 50-78% among adults admitted for hospital care, highlighting the importance of these new recommendations on how to manage this large patient population.²

Factors That Contribute to Elevated Inpatient BP

Elevated BP readings among admitted patients can be caused by a combination of factors (Table 1). Adherence to medication regimens is an important consideration because patients who have trouble with outpatient medication adherence are more likely to have high BP during hospitalization.^4,5 Importantly, anxiety (including white coat syndrome) and pain can also cause temporary spikes in BP, underscoring the need for standardized protocols for measuring BP in hospitals to ensure reliable data.^6,7

Table 1: Common Causes of Elevated BP for Patients Who Are Hospitalized

Management of Asymptomatic Elevated BP

A fundamental step in the evaluation of patients with markedly elevated BP is to determine the presence/absence of target-organ damage to suggest a hypertensive emergency, which requires prompt BP treatment per the 2017 multisociety Guideline for the Prevention, Detection, Evaluation, and Management of High BP in Adults.³

The acronym AIM (assess, identify, modify) is a new construct for approaching the management of inpatient BP. The A component relates to accurate assessment of BP readings. As such, potential causes of inaccurate readings in the hospital setting should be identified, which may include device type, calibration, cuff placement, cuff size, and the patient's position.¹

The I component refers to improving how BP is measured. Identifying reversible causes such as acute stress, pain, anxiety, or sleep deprivation is vital to avoid overtreatment. As a result, careful attention should be paid to how BP is measured and how its measurement could be improved. For example, optimal positioning (supine) should be considered, as well as ensuring devices are calibrated.

Finally, the M component refers to review and comparison of a patient's outpatient BP regimen. This information is crucial for guiding long-term management strategies after the patient is discharged. For example, one study's data showed that 41% of patients prescribed as needing antihypertensive agents in the inpatient setting were not receiving their recommended regimens at home.⁸ Another study's data showed that one-half of patients discharged on additional BP medications had good BP control before hospital admission.⁹

Potential Risks of Overtreatment of Inpatient Elevated BP

The results of some observational studies suggest that treating elevated inpatient BP may have risks. For example, of 66,140 patients >65 years of age at a Veterans Affairs (VA) hospital between Oct. 1, 2015 and Dec. 31, 2017, approximately 14,084 received intensive BP treatment in the first 48 hours of a hospitalization. The patients who received intensive treatment were administered more antihypertensive doses during their hospitalizations; the investigators reported a mean of 6.1 (95% confidence interval [CI], 5.8-6.4]) doses over the hospitalization for those who received intensive treatment and 1.6 (95% CI, 1.5-1.8) doses for those who did not, and a mean of 0.9 (95% CI, 0.9-1) doses per day versus 0.3 (95% CI, 0.3-0.3) doses per day.¹⁰ The patients also were at higher risk of inpatient death, transfer to the intensive care unit, stroke, acute kidney injury, and elevation in B-type natriuretic peptide or troponin levels (odds ratio, 1.28; 95% CI, 1.18-1.39).¹⁰ However, even with propensity matching, residual confounding is an important consideration because patients requiring intravenous antihypertensive agents are more likely to be acutely ill, which could account for the higher observed mortality.

The AHA scientific statement advises against using as-needed dosing for BP medications, given that as-needed dosing does not allow consistent BP control and could cause labile changes in BP that could lead to end-organ damage.

When to Treat Asymptomatic Elevated BP

The AHA scientific statement suggests considering treatment for patients with persistently high BP (>180/110 mm Hg) and a documented history of high BP readings in the outpatient setting. The document also emphasizes that the short duration of a typical hospital stay may not be long enough to definitively assess how effective medication changes will be in lowering a patient's BP.¹

Special consideration is given in the AHA scientific statement to the importance of outpatient care. The AHA scientific statement repackages the acronym AIM to arrange, inform, and monitor for guiding the transition to outpatient BP management. Arranging adequate follow-up, informing patients about the importance of BP, and monitoring home BP and screening for secondary causes of elevated BP are essential to ensure effective long-term management.

Populations at Increased Risk of BP Elevation

Some populations appear more susceptible to hypertensive emergency and asymptomatic high BP. These groups include older adults and Black individuals.^4,5 Additionally, those with pre-existing conditions such as diabetes mellitus, chronic kidney disease, and cardiovascular disease (CVD) are at higher risk. Socioeconomic factors play a significant role, as individuals who are underinsured, live in low-income areas, or have trouble adhering to their outpatient medication regimen face an increased risk of being hospitalized with high BP. Geography and locale are also associated factors, as areas lacking sufficient health care professionals to monitor and treat BP in an outpatient ambulatory setting are more likely to have patients with acutely elevated inpatient BP.^4,5

Conclusion

The AHA scientific statement is an important step toward improving high BP in patients who are hospitalized. Broad terms such as hypertensive crisis are replaced with specific classifications and acronyms to facilitate improvements in BP evaluation and treatment. For patients with asymptomatic elevated BP, a personalized approach to in-hospital BP management is paramount, especially when an identifiable, acute cause of elevated BP is present. This strategy, along with a focus on the transition to outpatient follow-up, has the potential to improve patient BP control and CVD outcomes.

References

1. Bress AP, Anderson TS, Flack JM, et al.; American Heart Association Council on Hypertension, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology. The management of elevated blood pressure in the acute care setting: a scientific statement from the American Heart Association. Hypertension 2024;81:e94-e106.
2. Axon RN, Cousineau L, Egan BM. Prevalence and management of hypertension in the inpatient setting: a systematic review. J Hosp Med 2011;6:417-22.
3. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-e248.
4. Abrahamowicz AA, Ebinger J, Whelton SP, Commodore-Mensah Y, Yang E. Racial and ethnic disparities in hypertension: barriers and opportunities to improve blood pressure control. Curr Cardiol Rep 2023;25:17-27.
5. Aggarwal R, Chiu N, Wadhera RK, et al. Racial/ethnic disparities in hypertension prevalence, awareness, treatment, and control in the United States, 2013 to 2018. Hypertension 2021;78:1719-26.
6. Muntner P, Shimbo D, Carey RM, et al. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension 2019;73:e35-e66.
7. Holland M, Lewis PS. An audit and suggested guidelines for in-patient blood pressure measurement. J Hypertens 2014;32:2166-70.
8. Gaynor MF, Wright GC, Vondracek S. Retrospective review of the use of as needed hydralazine and labetalol for the treatment of acute hypertension in hospitalized medicine patients. Ther Adv Cardiovasc Dis 2018;12:7-15.
9. Anderson TS, Wray CM, Jing B, et al. Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study. BMJ 2018;362:[ePub ahead of print].
10. Anderson TS, Herzig SJ, Jing B, et al. Clinical outcomes of intensive inpatient blood pressure management in hospitalized older adults. JAMA Intern Med 2023;183:715-23.