Elevated blood pressure is a common dilemma encountered by emergency department and inpatient physicians, but there are no guidelines or recommendations to direct medical providers for the care of patients who are hospitalized with elevated blood pressure.
According to survey data from 2011 to 2012, chronic hypertension occurred in 29% of the US adult population.1 Elevated blood pressure in patients who are hospitalized is even more common. A 2010 review in the Journal of Hospital Medicine reports that 51% to 72% of patients have elevated blood pressure during their hospitalization.2 Although there is little evidence that treating inpatient blood pressure improves outcomes, physicians strongly believe that blood pressure control in patients who are hospitalized is important.3
This review will describe medical terminology related to elevated blood pressure, survey the available literature related to its management, and make recommendations to guide providers’ approach to elevated blood pressure in the inpatient setting.
Hypertension is the syndrome that results from persistently elevated blood pressures. In 2005, the Hypertension Writing Group defined hypertension as “a progressive cardiovascular syndrome arising from complex and interrelated etiologies.4 Early markers of [these] co-existing medical problems are often present before BP elevation is sustained. Therefore, hypertension cannot be classified solely by discrete pressure thresholds. Progression of the syndrome leads to functional and structural cardiovascular abnormalities that damage the heart, kidneys, brain, vasculature, and other organs that lead to premaster morbidity and death.”
Practically, hypertension is the application of current blood pressure guidelines.5 For most patients, this is a systolic blood pressure of less than 130 mm Hg and diastolic blood pressure of less than 80 mm Hg.6 Blood pressure guidelines assume a standard measurement of blood pressure. Hypertension is diagnosed with 3 measurements that are above a standard for age and comorbidities and performed on at least 2 separate ambulatory visits. Blood pressure may be taken on either arm by a sphygmomanometer after a period of sufficient rest in the seated position with the back and feet supported. The arm should be supported at the level of the heart and the sphygmomanometer bladder should encircle at least 80% of the arm and not more than 100%. A greater emphasis has been placed on confirming elevated blood pressure in the office with ambulatory and home blood pressure monitoring in the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines.
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-Bryan Stanistreet, MDa, Joseph A. Nicholas, MD, MPHa, John D. Bisognano, MD, PhDb
