Hypertension
Terri D’Arrigo
In August 2024, the American Heart Association (AHA) published a scientific statement that identifies evidence-based gaps in managing elevated inpatient BP, including asymptomatic hypertension and hypertensive emergency.
“Most of the information presented and recommendations made [in the statement] are things that many inpatient pharmacists are already doing, such as confirming appropriate blood pressure assessment technique and examining all of the possible causes of elevated blood pressure before starting an antihypertensive,” said Rachel Khan, PharmD, an associate professor of internal medicine at Virginia Commonwealth University School of Pharmacy. “This document provides strong support for many of our current practices and is a concise review to educate other health care professionals we work with.”
Khan noted that the statement, published in the August 2024 issue of Hypertension, incorporates new terminology related to describing elevated BP in hospitalized patients.
“First, it acknowledges the definition of elevated inpatient blood pressure and aligns it with that of uncontrolled hypertension in the 2017 AHA hypertension guidelines,” she said. “It kept the same criteria as the 2017 AHA guidelines on hypertension when defining ‘hypertensive emergency’ and ‘markedly elevated blood pressure,’ which was formerly hypertensive urgency.”
The statement includes a new classification, asymptomatic elevated BP, for patients who meet the criteria for elevated BP but do not meet the criteria for markedly elevated inpatient BP.
“Most patients with elevated blood pressure in the hospital fall into this category, for which we previously had no formal guidance on how to assess and treat,” Khan said.
Antihypertensives
According to the statement, PRN (“as needed”) orders for antihypertensive medications to treat asymptomatic elevated inpatient BP generally should be avoided, especially if the orders are for intravenous antihypertensive medications.
“Parenteral antihypertensive medications can lower [blood pressure] abruptly, particularly in people with acute illness and impaired autoregulation,” the authors wrote. They cited research that suggested a link between parenteral antihypertensive medications and twofold higher risk of death as well as a 24% higher risk of acute kidney injury.
“When pharmacists are verifying orders like this, they can be mindful of these risks and educate prescribers to make a new plan that minimizes patient harm,” Khan said. “Also, when antihypertensives are restarted or newly initiated, pharmacists can set expectations of time to intended effect and how resolution of inpatient factors affecting blood pressure may require timely follow up and monitoring in the outpatient setting.”
However, the authors wrote that there may be times when treating asymptomatic hypertension is beneficial, such as when a patient has a history of persistently high or uncontrolled BP or has a history of or high risk for cardiovascular disease.
Pharmacists at touchpoints in care
The authors noted that NSAIDs, stimulants, corticosteroids, illicit substances such as cocaine or methamphetamine, and excessive intravenous fluids may all raise BP. To that end, they recommended a thorough review of all of the patient’s home and inpatient medications.
“As an inpatient pharmacist, reviewing the patient’s outpatient medications and understanding intentional or accidental discontinuation of those medications in the inpatient setting can prove key to assessing why inpatient blood pressure is high and what to do about it,” Khan said. “I also try to review outpatient records that are available to me to understand the status of a patient’s blood pressure control before admission, as it can help set expectations while inpatient. Being the medication expert on the team allows the pharmacist to identify causes of acutely elevated blood pressure from new medications started or chronic medications held.”
The authors offered recommendations for discharge and post-discharge care for patients with hypertension, including patient education, promotion of self-management and lifestyle modifications, potential use of antihypertensive medications, and home BP monitoring—all of which are areas where pharmacists’ expertise is valuable.
“Pharmacists reviewing and being incorporated into medication reconciliation is key to preventing medication errors that may otherwise persist on hospital discharge,” Khan said. She added that data support maintaining a patient’s prehospital medication regimen rather than intensifying it at discharge.
“This is usually because the many inpatient factors that contribute to elevated inpatient blood pressure resolve soon after discharge,” she said. “If a patient’s prehospital antihypertensive regimen is intentionally adjusted, then close follow up with outpatient providers to assess these medication changes should be done.” ■