Treating Acute Hypertension in the Hospital
A Lacuna in the Guidelines
Physicians treat chronic hypertension almost exclusively in ambulatory care settings according to evidence-based guidelines1 based on blood pressure (BP) measurements obtained under prescribed conditions.2 Other recommendations cover how to deal with hypertension in dialysis units2 and emergency departments,3 but none address a very commonly encountered problem: what to do about acutely elevated BP (which I refer to below in the common parlance of “acute hypertension”) in patients hospitalized for reasons other than hypertension. Indeed, excluding articles on patients with hypertensive emergencies and urgencies, there is little published about treatment of acutely elevated BP in hospitalized patients, although the practice seems to be common and based on firmly held, but poorly justified, beliefs.4 In this commentary, I argue for developing a rational approach to treating acute hypertension that de-emphasizes “treating the numbers” and focuses on patient safety.
How Common Is Acute Hypertension in Hospitalized Patients?
Most patients hospitalized for reasons other than hypertensive emergency or urgency who subsequently sporadically manifest acute hypertension deemed worthy of clinical concern probably also have chronic hypertension. In recent national data of hospitalizations, hypertension was listed as a primary diagnosis (International Classification of Diseases [ICD]–9 CM code 401) for 301 000 admissions but as a secondary diagnosis for 9 003 000 hospitalizations.5 These figures are probably an underestimate of the actual prevalence of hypertension in inpatients because 29% of the US adult population is now affected.6 One estimate of the rate of hypertension in patients in our center (the University of Michigan Health System[UMHS]) can be derived from patients attending our anesthesiology preoperative evaluation clinic, who have an incidence of 26.7% of stage 1 and 10.9% of stage 2 hypertension (unpublished data, 2010). Using these prevalence figures, during a 1-year period (October 1, 2007, to September 30, 2008) in which there were 29 545 adult admissions to …