Introduction:

The management of elevated inpatient blood pressure (BP) requires a structured approach to ensure patient safety and effective care. It involves accurate BP measurement, assessing the severity of the elevation, evaluating for target-organ damage, addressing underlying causes, and carefully balancing the risks and benefits of initiating antihypertensive treatment. Using structured acronyms such as A-I-M (Assess, Identify, Modify) for inpatient management and A-I-M (Arrange, Inform, Monitor) for post-discharge care provides a practical framework.

Proper differentiation between hypertensive emergencies and asymptomatic elevated BP is critical, as each scenario demands distinct evaluation and treatment strategies.

General Approach

Management involves:

1. Accurate BP measurement and reassessment.
2. Evaluating for target-organ damage.
3. Identifying and addressing underlying causes.
4. Careful decision-making regarding antihypertensive treatment, considering risks and benefits

The A-I-M framework is suggested:

• In-hospital: Assess, Identify, Modify.
• Post-discharge: Arrange, Inform, Monitor.

Hypertensive Emergency

• Defined by markedly elevated BP with evidence of new or worsening target-organ damage.
• Key areas to evaluate: Brain, Arteries, Retina, Kidneys, Heart (BARKH).
• Steps include:
  • Detailed history (e.g., chronic hypertension, adherence to medications).
  • Comprehensive physical examination.
  • Investigations like metabolic panels, ECG, chest X-ray, and volume assessment.
• Treatment follows the 2017 Hypertension Clinical Practice Guidelines, often involving prompt initiation of antihypertensives.

Asymptomatic Elevated Inpatient BP

• More common than hypertensive emergency, with unclear treatment guidelines.
• PRN orders for intravenous antihypertensives are discouraged due to risks, including:
  • BP fluctuations.
  • Morning hypotension delaying oral medications.
  • Increased BP variability.

Risks of Over-Treating Asymptomatic Elevated BP

• No RCT evidence supports treatment benefits in asymptomatic patients.
• Observational studies show:
  • Increased risks with intravenous medications, including acute kidney injury, myocardial injury, and hypotension.
  • PRN treatments often result in abrupt BP drops, leading to adverse outcomes:
    • 60% higher risk of myocardial injury.
    • 2-fold higher mortality risk.
    • Risk of abrupt BP reductions (>25% drop).

Conclusion

In managing asymptomatic elevated BP, focus on:

• Proper measurement and identifying reversible factors.
• Avoiding unnecessary PRN antihypertensives.
• Individualized care that minimizes risks, especially in acute hospital settings.