Really enjoyed @UnremarkableLab last night where we discussed HTN in the hospital.
You are an intern on night float and get called that a patient's BP is 195/110. You:
For anyone who participated, I found this article a really helpful read. I also would suggest listening to the Annals of Call Podcast(acpjournals.org/doi/10.7326/A1…).
the-hospitalist.org/hospitalist/ar…
Some key points the article made:
1. 72% of pts in hospital have HTN
2. 1 study the article cites- 94 pts given IV hydral (only 4 needed)>17 had adverse effects from hypotension
3. Study of pts given IV treatment for HTN- 56% had BP ⬇️ >25%, 2 hypotensive, 6 had to hold BP med
4. Study of 2,189 pts give IV hydral or labetolol. Only 3% indicated. Use IV meds HTN associated with ⬆️ LOS.
5. Even giving a oral med like nifedipine was associated with rapid BP.
Ask about symptoms: chest pain, SOB, AMS, severe headache (not mild to moderate), visual changes, or acute end organ damage> if acutely symptomatic, HTN emergency and should be treatment aggressively (but still be careful to avoid overly rapid fall in BP).
Review if any reason why BP should be be more aggressively controlled in the hospital:
1. Stroke given TPA
2. Unstable bleed that HTN could ⬆️bleeding risk
3. Aortic dissection
4. Recent neurosurgical procedure
ect.
If not, you have some time to figure it out.
When I call back, I ask about pain/agitation/anxiety. Is the HTN a manifestation of pain that is not being adequately controlled? Then I look look back at the med list and see if there are HTN meds that are being held/missed. I will usually restart home meds 1st.
There are also oral agents which have a fast onset like nifedipine (probably best to avoid), carvedilol, clonidine and catopril. It is important to remember that a pt is the hospital is under stress and BP in hospital may not reflect their normal BP.
Most of HTN's adverse effects occur over years and most cases in hospital are asymptomatic. In the case of asympmatic BP elevation, we can do significant harm by lowering BP too quickly. Pretty # do not always = better pt outcomes.
I have replaced the term HTN urgency w/ permissive HTN (even in non-stroke pts). Like treating diabetes in the hospital, over aggressive treatment can lead to harm. Sometimes, you need to tolerate a little HTN in the hospital with good PCP f/u outpt.
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