This article is more than 5 years old. Information may no longer be current.

Inpatient setting ideal for improving hypertension regimen

ORLANDO, Fla. — Because BP levels can be more closely monitored in hospitals, they present an ideal setting for changing hypertension regimens when improvement is needed, according to a presentation at Hospital Medicine 2018.

“Hypertension is the number one cardiac risk factor in the world,” Michael Tanner, MD, clinical associate professor at New York University School of Medicine, said during his presentation. “The leading causes of death on our planet are heart attacks at 8 million and strokes at 6 million. Over 1 billion people have high BP. Globally speaking, hypertension is becoming increasingly important.”

New hypertension guidelines

Results from the SPRINT trial in 2010 have informed the new guidelines, he said.

In the SPRINT trial, the group with a target of 120 mm Hg had a 27% reduction in all-cause mortality at 3.26 years compared with the group with a target of 140 mm Hg, according to Tanner.

“However, there are differences in opinion,” he said.

The American Diabetes Association’s (ADA) BP target for most patients with diabetes remains 140/90 mm Hg, he said. The ADA’s target is largely based on results from the ACCORD-BP trial in 2010 which found no benefit with a target of 120 mm Hg, he said.

“The American Academy of Family Physicians likewise does not endorse the new ACC/AHA guidelines,” he said.

The AAFP released a statement suggesting that the harms of treating to a lower BP were not assessed in the trial, substantial weight was given to the SPRINT trial while results from other trials were minimized, and intellectual conflicts of interest were not addressed, he said.

“But, there’s good news: The tighter BP target of under 130/80 is an opportunity for us to treat hypertension and comorbid illnesses simultaneously,” Tanner said.

In the new guideline, there are five things that are labeled as harmful or inefficacious, Tanner said.

First, combining an ACE inhibitor with an angiotensin receptor blocker does more harm than good, he said. Being too aggressive in lowering the systolic BP (less than 140 mm Hg within 6 hours of the acute event) for cerebral hemorrhage can be harmful, he said. Pregnant patients should not use ACE inhibitors or angiotensin receptor blockers, he added.

Additionally, there is no benefit from verapamil in patients with pure diastolic dysfunction, he said. Within the first 2 to 3 days after an acute ischemic stroke, initiating or reinitiating treatment of hypertension is not effective to prevent death or dependency, he said.

Managing BP in the hospital setting

A patient with a BP level higher than 160/100 mm Hg should not be discharged from the hospital, he said. However, he noted that this decision may depend on the post-discharge follow-up system in the hospital. If a patient can be scheduled for a clinic appointment within 5 days for a BP check, they can be discharged at a slightly higher level, he said.

Tanner advocated for using a once-daily dose of antihypertensive medication rather than multiple daily doses and using combination pills rather than single pills in adults with hypertension to improve adherence.

“Don’t back-burner hypertension in inpatients,” he said. “It tends to get ignored. If the admission medications are suboptimal, improve them and use as few medicines as possible.”

Tanner advised for hospitalists to communicate directly with primary care providers. In cases when you do change the regimen, tell the primary care provider what you changed and why you changed it, he said.

“The inpatient setting is ideal for making changes to the patient’s hypertension regimen because BP levels and electrolyte changes can be monitored closely,” he said.

“We have 68 BP medications to work with. Use them to treat other comorbidities. Be creative and have fun with it,” he said. – by Alaina Tedesco

Reference:

Tanner M. Hypertension from the PCP side of things. Presented at: Hospital Medicine 2018; April 9-11; Orlando, Fla.

Disclosure: Healio Internal Medicine was unable to confirm relevant financial disclosures at the time of publication.