Inpatient Hypertension Management: Emergencies Need Iv Therapy, Use Single-Pill Combinations when Transitioning to Outpatient

Hypertensive emergencies require intravenous (IV) therapy, with the goal of reducing systolic blood pressure (BP) to <140 mm Hg, or to <120 mm Hg in a patient with aortic dissection, said George Bakris, MD. If left untreated, the median survival of a patient with a hypertensive emergency is 10.4 months.1

Hypertensive emergencies are defined as a BP >180/120 mm Hg and associated with evidence of impending or progressive target organ damage.

For adults without a compelling condition, BP should be reduced by no more than 25% within the first hour and if then stable, to 160/100 mm Hg within the next 2 to 6 hours and cautiously to normal during the following 24 to 48 hours.2 “You’ll find that in many cases, you don’t need to give a lot of medications to do this,” he said. “Allaying fear and anxiety can work just as effectively without problems with hypotension.”

The actual BP level may not be as important as the rate of BP rise; patients with chronic hypertension can often tolerate higher BP levels than previously normotensive individuals, said Dr. Bakris, professor of medicine, director, American Heart Association Comprehensive Hypertension Canter, University of Chicago.

In considering the IV medications to treat hypertensive emergency, in a patient in pheochromocytoma crisis, “do not give beta blockers; you will elevate pressures,” he said. “Phentolamine is your drug.”

Patients should be seen by a dietitian in the hospital for help in instituting a low-sodium/moderate potassium diet.

Hypertension urgency is hypertensive emergency without the emergency (target organ damage). It can be managed in the ambulatory setting. In house, major factors in hypertensive urgency are acute anxiety, poor control of pain, or volume overload in patients with end-stage kidney disease.

The approach to the evaluation and management of hypertensive urgency is different—after confirming persistent elevation despite 20 to 30 minutes of quiet rest, give rapid-acting oral agent, adjust long-acting medications, and follow up in 1 to 7 days after discharge.

Transitioning to outpatient setting

In the transition to outpatient therapies, several factors need to be considered.3 One such factor is the patient’s BP prior to the BP elevation that brought the patient to the hospital. If the BP was reasonable on the patient’s home regimen, there would not be a compelling reason to change it. Remember to use agents with synergistic or additive BP-lowering effects, such as a calcium channel blocker plus a renin-angiotensin blocker and a thiazide-like diuretic.4 Avoid an ACE inhibitor/beta blocker combination or clonidine with a beta blocker.

In the patient with memory loss, strive for simplicity (eg, once-daily single pill combinations). If anxiety was the cause of the hypertensive emergency, “an antihypertensive drug isn’t going to fix this,” said Dr. Bakris. For those with anxiety, refer to a psychologist and/or prescribe clonazepam or other benzodiazepine for use on occasion, in addition to recommending slow breathing exercises.

Chlorthalidone is clearly the superior thiazide-type diuretic to hydrochlorothiazide to lower BP.5 “Indapamide is just as good as chlorthalidone and it’s as cheap as hydrochlorothiazide,” he said. Thiazide-type diuretics have a vasodilatory effect as long as the patient is volume replete and not hypokalemic, he said.

Azilsartan medoxomil is more potent than the other angiotensin receptor blockers in its BP-lowering effect, as it binds to the AT1 receptor more tightly than the others in this class.6,7

Before prescribing any medications, ensure that the patient has no sulfa allergies; all thiazide diuretics are sulfa based. Also, check for drug interactions. People ≥65 years and African Americans tend to have low renin levels; in these patients; calcium channel blockers and thiazide-like diuretics are preferred initial BP-lowering agents. In the subgroup with high sympathetic drive, most likely younger patients, who can be identified by very high heart rates, consider a nondihydropyridine calcium channel blocker (ie, diltiazem) or a beta blocker (if the glomerular filtration rate is normal) as an initial choice. In patients with elevated renin levels, renin-angiotensin blockers work best.

He emphasized an initial single pill combination as most acceptable to patients, adding that guidelines recommend an initial single pill combination if the patient’s BP is >20/10 mm Hg above the BP goal.2

Disclosures

Consultant: Merck, Bayer, Vascular Dynamics, KBP Biosciences, Ionis, Alnylam, Astra Zeneca, Quantum Genomics, Horizon, Novo Nordisk

Research support: Steering committee of clinical trials for Bayer, Vascular Dynamics, Quantum Genomics, Alnylam, Novo Nordisk

References

  1. Peixoto AJ. Acute severe hypertension. N Engl J Med 2019;381:1843-52.
  2. 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: executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018;71:1269-1324.
  3. Ferdinand KC. A compendium of antihypertensive therapy. J Clin Hypertens (Greenwich) 2011;13:636-8.
  4. Gradman AH, Basile JN, Carter BL, Bakris GL. Combination therapy in hypertension. J Clin Hypertens (Greenwich) 2011;13:146-54.
  5. Ernst ME, Carter BL, Goerdt C, et al. Comparative antihypertensive effects of hydrochlorothiazide and chlorthalidone on ambulatory and office blood pressure. Hypertension 2006;47:352-8.
  6. White WB, Weber MA, Sica D, et al. Effects of the angiotensin receptor blocker azilsartan medoxomil versus olmesartan and valsartan on ambulatory and clinic blood pressure in patients with stages 1 and 2 hypertension. Hypertension 2011;57:413-20.
  7. Neutel J, Smith DHG. Evaluation of angiotensin II receptor blockers for 24-hour blood pressure control: meta-analysis of a clinical database. J Clin Hypertens (Greenwich) 2003;5:58-63.

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