A recent clinical insights article proposed a new framework for managing asymptomatic elevated blood pressure (BP) in hospitalized patients. The findings may challenge current practices and indicate the need for a more cautious approach based on recent observational studies.

An estimated 50% to 70% of adults experience BP elevations (≥ 140/90 mmHg) during hospitalization. Severe asymptomatic hypertension is defined as severely elevated BP (> 180/120 mmHg) in the absence of acute hypertension-mediated organ damage. While evidence-based guidelines exist for the outpatient management of chronic hypertension, a recent systematic review found no clinical practice guidelines for asymptomatic elevated BP in the inpatient setting.

In the article, published in JAMA Internal Medicine, investigators examined observational data suggesting that intensive treatment of elevated BP in the hospital without acute end-organ damage may be associated with complications, including acute kidney injury, myocardial injury, and stroke. Intensification of antihypertensive regimens at discharge among patients admitted for noncardiac issues may be associated with an increased risk of short-term adverse events but not improvements in long-term BP control or cardiovascular outcomes.

The investigators proposed a six-step approach for managing asymptomatic elevated BP in hospitalized patients:

• Step 1: Assess patients for acute end-organ damage, particularly when BP is severely elevated (> 180/120 mmHg). If a hypertensive emergency is suspected, BP should be reduced rapidly, typically in an intensive care unit.
• Step 2: Ensure appropriate measurement technique, including cuff size, cuff position, and patient position. Remeasure after a period of rest.
• Step 3: Identify and treat contributing factors such as pain, nausea, anxiety, sleep disruption, changes in volume status, drug withdrawal, or intoxication.
• Step 4: Review medications that could contribute to elevated BP (e.g., NSAIDs, acetaminophen, and corticosteroids) and consider discontinuing unnecessary agents. Reinitiate home antihypertensives if appropriate.
• Step 5: Consider patient-specific factors when deciding whether to intensify antihypertensive therapy. Factors arguing against medication intensification include good baseline BP control, frailty, limited life expectancy, or hospital-related functional or cognitive impairment.
• Step 6: Develop a transitional care plan, including timely outpatient follow-up, provision of an ambulatory BP monitor, counseling on BP goals and monitoring techniques, and discussion of medication adherence.

Most hospitalized patients with asymptomatic elevated BP may not warrant modifications to their antihypertensive regimen in the hospital or upon discharge.

The addition or intensification of a long-acting, guideline-concordant oral antihypertensive may be considered in select high-risk patients with chronic cardiovascular-kidney-metabolic or neurovascular diseases, poorly controlled hypertension at baseline, and willingness to make medication changes.

The investigators emphasized that elevated BP in the hospital is common and most often asymptomatic. Recent observational studies suggested that intensive pharmacologic treatment of elevated BP without end-organ damage may be harmful. Modifications to antihypertensive regimens should be avoided for most asymptomatic hospitalized patients, with exceptions for a minority of high-risk patients with persistent BP elevations, underlying comorbidities, poor baseline control, and readiness to enact medication changes.

The investigators proposed a stepwise approach in patients hospitalized for noncardiac, nonneurovascular issues with asymptomatic elevated BP. This approach aims to avoid preventable harm and adverse drug events in the short term while improving long-term outcomes and BP control.

Conflict of interest disclosures can be found in the clinical insights.