4  Hypertension

4.1 Screening for HTN

The USPSTF recommends HTN screening for those 18+ yo with office BP measurement and confirmation with out-of-clinic measurements (Grade A)

4.2 Flavors of HTN

• Elevated BP

• Stage I HTN

• Stage II HTN

• Resistant HTN

• Refractory HTN

• HTN urgency

• HTN emergency

4.3 Inpatient HTN

4.3.1 Inpatient BP Management

Satya Patel from UCLA has a phenomenal resource he’s put together on this. I first caught wind of it from his tweet. This is part of the much larger UCLA Inpatient Pocket Card Set available at http://bit.ly/pocketcardset.

Source: UCLA IM Pocket Card Set

Go-to list of night float medications by class. Source: Satya Patel’s Inpatient Management of Hypertension Summary.

4.3.2 Hypertensive Crises

Headache does not count as evidence of end-organ injury when evaluating a patient for hypertensive emergency

• Hypertensive Urgency

  • TODO: read the “Things We Do For No Reason” on Acute Treatment of Hypertensive Urgency

• Hypertensive Emergency

  • In patients with acute ischemic stroke, BP >220/120, and did not receive tPA, reasonable to lower BP by 15% in the first 24 hours
  • In patients with acute ischemic stroke, BP <220/120, and did not receive tPA, do not need to initiate hypertension treatment within the first 48-72 hours
  • Initiate or re-start antihypertensives ~72 hours after acute ischemic stroke to maintain a BP <140/90

Source: Satya Patel’s Inpatient Management of Hypertension Summary

4.3.3 Things to know

• Inpatient BP tends to be higher then Outpatient BPs by ~ 7/3 mmHg (Cappelleri et al. 2017)
• Intensifying antihypertensive meds at hospital discharge is associated with an ↑ risk of readmission and serious adverse events within 30 days. Moreover, outpatient BP was comparable to pre-intensification. (Anderson et al. 2019) (Swapnil 🧵: link)
• Polypharmacy among elderly patients often includes anti-HTN meds. OPTIMISE study: non-inferioty study; RCT of 569 patients > 80 yo comparing anti-HTN medication reduction (stop 1 med) to usual care → anti-HTN med reduction was non-inferior to usual care. (Sheppard et al. 2020)
• Does pain cause ↑ BP? (thread)
  • Yes, can cause transient ↑ SBP up to 30 mmHg
  • Mechanism: pain affects the HPA axis and increases sympathetic tone (Saccò et al. 2013)

Anderson, Timothy S., Bocheng Jing, Andrew Auerbach, Charlie M. Wray, Sei Lee, W. John Boscardin, Kathy Fung, Sarah Ngo, Molly Silvestrini, and Michael A. Steinman. 2019. “Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge.” JAMA Internal Medicine 179 (11): 1528–36. https://doi.org/10.1001/jamainternmed.2019.3007.

Cappelleri, Claudia, Alin Janoschka, Reto Berli, Sibylle Kohler, Ruediger C. Braun-Dullaeus, Ludwig T. Heuss, and Mathias Wolfrum. 2017. “Twenty-Four-Hour Ambulatory Blood Pressure Monitoring in Very Elderly Patients: Comparison of in-Hospital Versus Home Follow-up Results.” Medicine 96 (34): e7692. https://doi.org/10.1097/MD.0000000000007692.

Saccò, Marcella, Michele Meschi, Giuseppe Regolisti, Simona Detrenis, Laura Bianchi, Marcello Bertorelli, Sarah Pioli, et al. 2013. “The Relationship Between Blood Pressure and Pain.” The Journal of Clinical Hypertension 15 (8): 600–605. https://doi.org/10.1111/jch.12145.

Sheppard, James P., Jenni Burt, Mark Lown, Eleanor Temple, Rebecca Lowe, Rosalyn Fraser, Julie Allen, et al. 2020. “Effect of Antihypertensive Medication Reduction Vs Usual Care on Short-Term Blood Pressure Control in Patients with Hypertension Aged 80 Years and Older: The OPTIMISE Randomized Clinical Trial.” JAMA 323 (20): 2039–51. https://doi.org/10.1001/jama.2020.4871.