aggressive BP treatment in chronic hypertension inpatient can be harmful

This patient presents with a headache that has characteristics of a tension headache. Although it is tempting to want to attribute his headache to high BP, the best scientific evidence shows that this relationship is weak. The same can be said for epistaxis and hypertension. The more likely explanations in this case are that this patient’s severe tension headache brought him to medical attention and that his headache is aggravating his hypertension.

It is clear from review of his medical history, ECG, and creatinine level that he has had severe, poorly controlled hypertension. He is not, however, experiencing a hypertensive emergency, which is defined as an acute elevation of BP associated with signs of acute organ injury. There is no evidence from results of his physical examination, laboratory and other tests, or head CT scan that he has any acute end-organ injury. His condition is better described as a hypertensive urgency. True hypertensive emergencies, such as myocardial infarction, acute heart failure, eclampsia, aortic dissection, and so on, are treated in the ICU with titratable antihypertensives. In contrast, hypertensive urgencies may be treated in the outpatient arena with oral antihypertensives. Because this patient’s headache may well be aggravating his BP, it would be reasonable to start with an analgesic, like acetaminophen, while slowly restarting previously prescribed oral antihypertensives. The rate of titration of an oral medication should be directed by its onset of action, peak effect, and half-life, remembering that to achieve steady-state pharmacokinetics of a drug will require four to five half-lives. The goal is to achieve BP improvement within a couple of days, although BP control should ideally occur over weeks to allow time for adaptation to lower perfusion pressures.

The harms of aggressive BP lowering are now known. Anderson and colleagues investigated the clinical outcomes of aggressive inpatient BP management in more than 66,000 older adults hospitalized without acute end-organ damage. The OR of the composite end point of death, ICU transfer, stroke, acute kidney injury, or BNP or troponin level elevation was significantly higher among patients treated aggressively and was highest among those treated with parenteral agents. In a similar study, Rastogi and coworkers studied a cohort of more than 22,000 inpatients in the Cleveland Clinic system who had asymptomatic hypertension. They found that more than one-third of these patients received additional inpatient antihypertensives and that the intervention was associated with higher rates of both acute heart and kidney injury.12345

Footnotes

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  2. 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(7):715-723. PubMed ↩

  3. Fagernæs CF, Heuch I, Zwart JA, et al. Blood pressure as a risk factor for headache and migraine: a prospective population-based study. Eur J Neurol. 2015;22(1):156-e11. PubMed ↩

  4. Gus M, Fuchs FD, Pimentel M, et al. Behavior of ambulatory blood pressure surrounding episodes of headache in mildly hypertensive patients. Arch Intern Med. 2001;161(2):252-255. PubMed ↩

  5. Rastogi R, Sheehan MM, Hu B, et al. Treatment and outcomes of inpatient hypertension among adults with noncardiac admissions. JAMA Intern Med. 2021;181(3):345-352. PubMed ↩