Background: There is no consensus on the management of asymptomatic inpatient hypertension. This is alarming as the prevalence of inpatient hypertension may be as high as 72%. Hypertension treatment guidelines focus on chronic hypertension in the outpatient setting and evidence for inpatient management is lacking. Aggressive treatment of asymptomatic inpatient hypertension with intravenous antihypertensives is a common practice, but has no proven benefit, leads to excess costs and has the potential to cause harm from hypotensive events.
Purpose: Develop a standardized approach to the management of inpatient asymptomatic hypertension with the goal of reducing the use and possible complications of intravenous antihypertensives.
Description: We developed an algorithm to manage inpatient asymptomatic hypertension that was vetted and approved by Hospital Medicine (HM), Cardiology, Nephrology and Nursing leadership (Figure 1). The first step is assessing for symptoms or signs of hypertensive emergency, which is managed more aggressively to prohibit ongoing end organ damage. After excluding hypertensive emergency, evaluate for common factors contributing to hypertension, including pain, agitation, withdrawal, volume overload/depletion, or a new medication. The home medication list should be reviewed and home antihypertensives resumed if clinically appropriate. If high-risk and urgent treatment is needed, a short-acting oral antihypertensive can be considered. If not deemed high-risk and hypertension persists, current oral antihypertensive therapy should be titrated or appropriate antihypertensive therapy per JNC 8 guidelines should be initiated.
Educational sessions on the algorithm were conducted with faculty in HM at well-attended division meetings, internal medicine house staff at resident meetings, and at nursing staff meetings on HM wards. Further, the algorithm was posted at workstations located on the HM wards, distributed as a reminder in monthly digital newsletter to HM faculty and reinforced on a routine basis at resident meetings.
Conclusions: We retrospectively evaluated the use of intravenous antihypertensive therapy pre- and post-educational sessions. Our preliminary data showed the use of intravenous labetalol and hydralazine decreased by 33% (323 to 216) with the biggest effect on intravenous hydralazine use which decreased by 48% (306 to 158) comparing pre- to post-educational sessions.
Evidence on the management of asymptomatic inpatient hypertension is lacking. Clinicians often use potentially harmful intravenous antihypertensives to treat asymptomatic inpatient hypertension without any proven benefit. Our standardized algorithm and educational sessions helped reduce the use of intravenous antihypertensives to treat asymptomatic inpatient hypertension.
.jpg)