CEimpact Podcast

Hypertensive Urgency

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Hypertensive urgency - asymptomatic patients with elevated blood pressure - is frequently treated in the hospital and outpatient setting. Join host, Geoff Wall, as he critically examines the evidence to assess risk over benefit.
 
The GameChanger
Treatment of asymptomatic hypertension has not been shown to improve clinical outcomes. Recent data highlights the risk with increased mortality through aggressive management.
 
Host
Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health
 
Reference
Anderson TS, Herzig SJ, Jing B, et al. Clinical Outcomes of Intensive Inpatient Blood Pressure Management in Hospitalized Older Adults. JAMA Intern Med. 2023;183(7):715–723. doi:10.1001/jamainternmed.2023.1667

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2805021
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CPE Information
 
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Explain the difference between hypertensive urgency and emergency
2. Discuss recent data about the possible harms of treating asymptomatic hypertension in the hospital setting

0.05 CEU/0.5 Hr
UAN: 0107-0000-23-330-H01-P
Initial release date: 10/23/2023
Expiration date: 10/23/2024
Additional CPE details can be found here.

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Speaker 1:

Welcome to the Game Changers podcast, where we have clinical conversations that impact your pharmacy practice. Let's listen in as our team discusses this week's clinical practice game changer.

Speaker 2:

Welcome to Game Changers clinical conversations. I am Jeff Wall, your host. I'm a professor of pharmacy practice at Drake University. Welcome to our podcast. Today we're going to talk about something that has been floating around for a while.

Speaker 2:

It's something that I've certainly seen in 30 years of being a hospital pharmacist is the whole notion of hypertensive urgencies and emergencies. Certainly as long back as I can remember, somebody comes in with an unbelievably high blood pressure where the top of their head is about ready to pop off from how high their blood pressure is. We race around to make sure that we get their blood pressure down, whether or not they absolutely have symptoms associated with it. I was always taught and I think the guidelines even say, that the differentiation between hypertensive urgencies and emergencies isn't so much the blood pressure. The blood pressure is that hypertensive emergencies have some sort of target organ damage going on right at the time the blood pressure is high. That can be things like an acute myocardial infarction or an intracranial hemorrhage or flash pulmonary edema or dissecting aneurysm, something along those lines that it's like okay, the blood pressure is definitely causing this and we absolutely need to get the blood pressure down as quickly as we possibly can, and not necessarily to 120 over 80, but definitely knock down 25 to 50% of the blood pressure within that first couple of hours. Then we have the notion of hypertensive urgencies, which again is just a sky high blood pressure without any particular target organ damage. They're fine and they're sitting there, but they have super high blood pressure. That doesn't necessarily mean they're not having symptoms or consequences of high blood pressure.

Speaker 2:

I had a patient on my medicine service just a couple of weeks ago who was feeling weak and dizzy and came in and his blood pressure was about 230 over 150. He was just a patient who just never sought healthcare. He just wanted to have a regular doctor or anything and was in his late 50s at this point and they did an MRI of his brain and found extensive damage and atrophy due to this high level of blood pressure or a long period of time. There's no doubt that the blood pressure caused that. But the $64 question is do we have to get his blood pressure down to 120 over 80 or 130 over 80 right away during that hospital stay? That's the difference between hyperegns of urgencies and emergencies.

Speaker 2:

From a logistics perspective, the thoughts always been that hyperegns of emergencies are usually treated with intravenous anti-hypertensives in the ICU, whereas urgencies could be treated on the floor, even as an outpatient. That's the history surrounding this, what I was taught and certainly what I've seen in practice in my institutions that I've been at for many, many years. But in the last two years or so there's been some reevaluation of that. Authors have taken a look at things and said we've been doing this for over 50 years, 60 years, 70 years, but there's really no studies that show that actual acute decreasing of blood pressure actually improves outcomes in a hospital stay. You could argue and I think it's a good argument that you're not going to be able to do a randomized control study and somebody who has a dissecting neurotic aneurysm and trying to randomize them into regular control and high blood pressure control. Not only would it take a significant number of patients to have the power to show a difference there, but I think you're going to have incredibly difficult recruitment problems because I think that many treating physicians are not going to be jumping up and down to not put these people's blood pressure down. The bottom line is that we don't have a good randomized trial data that suggests that acutely lowering people's blood pressure actually improves outcomes.

Speaker 2:

Researchers in various reports and various review articles have argued that even the notion of hypertensive emergencies is due to this reverse causation. They come in with this problem and they happen to have high blood pressure. Therefore, the high blood pressure must be causing this problem. There's certainly some cases where that's undoubtedly true, but the question is, does fixing their blood pressure fix the problem or at least minimize the damage associated with that problem? That's, I think, what has been of some controversy in recent years. Looking back, the whole notion of hypertensive urgency has been around us with the guidelines ever since the guidelines came out, the very first JNC report, which came out way back in 1984. We basically had this differentiation of hypertensive emergencies and urgencies. That definition, with some small changes, has pretty much been upgraded and put into every single set of major guidelines for blood pressure control ever since the original JNC report came out.

Speaker 2:

The latest major guideline in the United States, of course, is the 2017 American Heart Association American College of Cardiology Hypertensive Guidelines which basically, if you take a look, have the exact same definitions A high blood pressure which they consider over a blood pressure over 180. Systolic, over when diastolic that's associated with some target organ damage, including hypertensive encephalopathy, intercranial hemorrhage, acute ischemic stroke, acute myocardial infarction, acute lymphaticicular failure, unstable angina, dissecting aortic aneurysm, acute renal failure and eclampsia. And they note that the recommendations in those guidelines is to reduce blood pressure by about 25% in the first several hours and a slow decrease after that. The European guidelines, you know, basically say the same thing and they even have a definition of malignant hypertension which is characterized by fundoscopic changes, you know, apapalodema, or a DIC caused by very high blood pressure, disseminated in vascular coagulation, caused by very high blood pressure. But bottom line is that that's you know, both European and American guidelines have have really kind of transplanted the original definitions of hypertensive, urgency and emergency, you know, to the to their latest set of guidelines.

Speaker 2:

And so you know again, you know that if you read some of the literature on this in the last couple years there have been experts who have argued that maybe it's time to kind of retake a look at this and say, okay, we're not saying ignore high blood pressures in the acute setting, but the bottom line is that patients who come into the hospital often have very high blood pressures for a variety of reasons and it may not necessarily be a longstanding problem. They may not necessarily be due to cardiovascular. You know causes against somebody who's in severe pain, for example, may have a high blood pressure, even in things that we know are vascular origins, such as a AAA right. So, you know, somebody has an aurelchianurism and it's starting to dissect. Those are very painful conditions and that pain in and of itself, as well as anxiety and all this other stuff in and of itself, may cause very, very high blood pressures.

Speaker 2:

So some experts have suggested then that that, you know, we should really discard the diagnosis of hypertensive urgency for a number of reasons. One, that it basically puts a lot of focus on just getting blood pressure under control and some of these things. So somebody comes in with flash pulmonary edema, with acute lepentricular failure, and somebody with a sky blood pressure. Well, you know, we need to get the blood pressure under control by any means necessary rather than saying, okay, they have acute lepentricular failure, let's get an echocardiogram, let's diarheize them. And if we're going to pick an anti-abritance, let's pick one that is in the gold recta therapy column of anti-abritances, including ACE inhibitors, arb stuff like that, which is not what we would normally do. Right, we would just start them on an intravenous high you know, high dose anti-abritensive to try and get the blood pressure immediately under control. So, in other words, you know, not saying kind of there's a one size fit all, they have to go to the ICU, they have to get put on intravenous medication, but really targeting why they're in the hospital and rather than just attributing the high blood pressures the sole cause of what's going on, and that's one part of a complex way to kind of approach treatment in those patients. They know it again that there's an absence of clinical trials with cardiovascular outcomes, with hypertensive urgencies and emergencies, that there's, you know, really no one set of guidelines or protocols on how to treat it. And that's certainly true.

Speaker 2:

You know, I've certainly seen a CET change during my practice career where, when I came out of school, sodium nitropresside was pretty much the standard drug that almost everybody got. The only people who really didn't get it were intracranial hemorrhages, because a nitropresside may actually increase intracranial pressures. But when I came out of school, you know, everybody who had hypernesia, urgencies and emergencies was pretty much put on intravenous nitropresside. As many of the more veteran listeners remember that. The big problem with that, of course, is that a significant part of the molecule of nitride is cyanide. So if you had them on the drug really for over about 72 hours with them at very high risk of cyanide toxicity.

Speaker 2:

And I remember back in the day we would draw cyanide levels and thiocyanate levels. We would add an amp of sodium pyl sulfate to every bag of nitropresside to decrease formation of cyanide. I mean, we did all these tricks that they don't try and decrease that, and I think really you know that fell out of favor, partially because we had other very potent anti-embrace intensive drugs and partially because of the fear of cyanide toxicity. To the point now, in 2023, I think we have an entire generation of clinicians who've never used it or actually kind of afraid to use it, and from a from a practical standpoint, because of the decline in use. Now only one company makes it and it's unbelievably expensive, and so that's another reason that people just really aren't using it.

Speaker 2:

So you know, as the years progressed, I personally seen in my system where we've really kind of settled on two big intravenous drugs, and that's intravenous calcium shadow blockers such as nicardipine and our drug is nicardipine here, though I know other places are using other intravenous calcium shadow blockers and then intravenous labata law, which is an alpha and beta blocker, and they're used for different things, though our neurosurgeons tend to like to use intravenous nicardipine just because, again, calcium shadow blockers tend to decrease intercranial pressure. I've used both for a variety of reasons over the years and have pretty good luck with both of them in getting people's blood pressure down. But the bottom line is we, and I think a lot of health systems, really don't have a standardized protocol of how to approach treatment with these patients, and I think the point is is that there really probably shouldn't be. You know, everyone comes in with a high blood pressure shouldn't automatically get put on IV nicardipine that we should take a look at. You know what's the cause of what's going on and, yes, treating their high blood pressure might be a piece of that treatment, but it should be the primary goal that we, that we look at.

Speaker 2:

So and and then you know the other, the other thing that they note is that this, you know, basically, you know, forces us to kind of take a look at at trying to get their blood pressure down below this kind of arbitrary number, right, you know? Okay, well, we've got to get their blood pressure below 160, or why? Well, because that's what we do. Well, is there any evidence showing that getting their blood pressure below 160 acutely versus getting their blood pressure below 140 acutely improves or or worsens outcomes? No, not really.

Speaker 2:

We just kind of pick that number out of the air and so you know experts have argued well, if, if we don't even know what number to try and reach, you know why are we going, you know, bending over backwards to just get, you know, get their blood pressure acutely below a number when this is really, you know, almost always a chronic condition, that we should, you know, approach from a, from a chronic perspective. So you know the bottom line is, is I think experts have have suggested that you know the whole notion of hypertensive urgencies and emergencies is, is, is something that kind of just again needs reevaluation, not to say we're not going to treat somebody, for example, comes in with an acute stroke and has blood pressure of, you know, 260, 270 that we're not going to try and get their blood pressure under some some level of control, but trying to get them to to a completely normal or even even a high.

Speaker 2:

You know. You know, within the normal range of of what we consider okay, high blood pressures acutely is probably not associated with with with benefit. And there's actually some recent evidence suggesting that in hypertensive urgencies and people who don't necessarily have symptoms associated with with with high blood pressure, that it may actually lead to harms. And so you know, if you take a look at some of the individual disease states, we've known for a long time in strokes that the theory has long been that that someone who's having an acute ischemic stroke, that allowing permissive hypertension is the way to go and that if you rapidly get their blood pressure to normal and someone who's been hypertensive for a long period of time, that can extend the stroke.

Speaker 2:

And and that's like I think, why you know both the American cardiology guidelines and the American- stroke guidelines from American Neurology Association all suggest that permissive hypertension is fine and that unless the patient is a candidate for thrombolytics where you'd have to get a lower blood pressure are kind of right off the gate, there's a high level of uncertainty about the benefits and risks of intensive, intensive blood pressure lowering functional outcomes. I think it's the same as true with acute coronary syndromes. According to the ACA guidelines, the unstable angina and acute malacrylifaration, you know, again fall under this hypertensive emergency and we should you know, you know try to get their blood pressures under, under major control before they go on to the cath lab and things like that again, despite the fact that there are no clinical trials that have really assumed that that's going to help and have certainly not targeted a specific blood pressure to look at. Now I think certainly many of these patients with chest pain may often get put on intravenous nitric glycerin which in fact may decrease their blood pressure some, but I think that's not. You know, the goal of that is not necessarily. Well, I'm putting them on nitric glycerin that's going to get their blood pressure better, it's. I'm putting them on nitric glycerin because they have chest pain and I want to. I want to relieve their chest pain. So you know, again not looking at at the blood pressure as the as the primary issue that we're dealing with, though we may use anti-avortenses that that have another purpose. So again, like we were talking about with with acute heart failure that just happened, to lower blood pressure.

Speaker 2:

On top of it with preeclampsia and eclampsia, which is is one of the more scary things that occurs with with pregnancy, again there are many randomized control trials that have looked at different drugs and you know, and as far as maternal fetal outcomes, but there are no studies saying okay, we need to get somebody with preeclampsia to this blood pressure level or that blood pressure level. So again, it's kind of a recurring theme. If you look at the literature that you know, we know that that in some cases lowering blood pressure may be beneficial, but we really don't know what the target should be and we really don't know what drug we should use to get there. Now, as if you talk to to internists and hospitalists I think they're their contention, at least the ones that I work with would suggest that you know they feel like they get a lot of pressure from other clinicians to get blood pressure or control. Certainly, I think you know, nurses are taught in their training hey, high blood pressure is bad and we need to do something. And so they are going to call the provider or contact the provider when the blood pressure is above X level. And again, it's no slight on nurses, that's just kind of how they were taught, you know. You know if the patient's blood pressure is above X, you need to call the provider to do something about it. And so I think inpatient clinicians are often felt like like they're under pressure because they're getting a lot of calls from nursing. They're getting a lot of calls from other clinicians saying, hey, what are you going to do about this person's blood pressure? And you know, many of us just follow the path of least resistance and say, okay, let's put them on. You can give them an order for oral quantidine. You can give them an oral or order for intravenous hydrolyzine, both of which can be given on the floor usually. And that's. You know that. You know I don't know if it's going to help their blood pressure, but I'm, you know I'm not going to get the heat from everybody about doing something about their blood pressure.

Speaker 2:

Now, experts have have, I think, really turned on clonidine as a drug in general for high blood pressure, but even for acute blood pressure lowering, just because of its very short half life.

Speaker 2:

And you know, we were always taught, and I'm sure the listeners remember, that you know if someone's on clonidine for a long period of time and you suddenly stop it, you can get rebound hypertension.

Speaker 2:

Well, evidence now suggests that that's true, even in the short term. So you may get their blood pressure low, you know, after an hour of being on clonidine, but because of its short half life, if you don't follow that up with something, they're not only going to have a rebound right back to where they were before, but impact may actually go higher. And so you know there's I think, I think that's another, that's a topic for another another game changer's podcast talking about. You know the interesting changes we think about antihemorrh-tensors, but you know, bottom line is that is that you know this this intention of we need to do something to fix the numbers has very little data to support it and in fact, a recent study has now suggested that it may actually cause more harm than good. And we're going to talk about that study just recently published in Jam and Trill Medicine right after this break from CE Impact.

Speaker 1:

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Speaker 2:

So we are talking about perhaps abandoning the terms or at least giving less importance to the terms hyper tens of emergencies and hyper tens of emergencies. And again, there's some thought that not only is fixing these numbers not beneficial but it may be harmful, and I think experts in the field of hypertension have suggested this now for several years. And finally, a large retrospective database study may actually support that contention. This was a study done and again just recently published in Jameturnal Medicine and we actually will have a link in the show notes, as we always do. But this was done in the VA center. Again, I commend the clinicians at the high level of the VA, the data analytics people and the clinicians who are now doing these kind of you know, retrospective cohort studies with this huge database of information from VA patients, or even pragmatic randomized control studies where you know they basically allow clinicians to make decisions on stuff but then, kind of you know, break them into blocks and take a look at them. And we've learned actually a lot in the treatment of acerocardial vascular diseases just from these kind of pragmatic studies and some of this other stuff. So this was a cohort study and it was a study again looking at veterans in the VA system. It was a kind of a standard, you know large cohort study. They looked at 66,000 patients who were hospitalized for non-cardiac conditions. So again, these were really did not come in with an acute heart failure, acute MI, stuff like that. They use propensity score matching to try and decrease the confounding factors. Again, you know there's no way to completely eliminate confounding factors, but propensity score matching is one of the best ways to try and minimize that. They actually look at the receipt of an intensive inpatient anti-arbitensive treatment and this was usually intravenous anti-arbitances and in fact that was the primary thing they looked at as far as scanning their database for patients who received treatment for acute high blood pressure was the incidence of use of intravenous anti-arbitances, especially the drugs that didn't have an oral analog, that the patients weren't on the outpatient basis. So this cohort study looked again at, between October 2015 and 2017, patients over age 65, hospitalized with non-cardiovascular diagnoses who experienced an elevated blood pressure in the first 48 hours of hospitalization. They defined then intensive blood pressure control, not necessarily at a gold blood pressure, but just the receipt of intravenous anti-arbitances, which were most of the patients in the study or oral classes not used prior to admission. So it wasn't just patients who went to the ICU and got intravenous nicardopine. It's patients who came in and, let's say, their blood pressure was 165 or 170. They weren't on anything for high blood pressure and they added something you know, added a lotapine or an ACE inhibitor or something like that.

Speaker 2:

Again, a propensity score match study where the primary outcome was a composite of inpatient mortality, intravenous or intensive care unit transfer, acute stroke, acute kidney injury, elevation of v-type naturopath and elevation of troponin. Now one of the criticisms I have of the study is those are pretty disparate outcomes. You have all the way from inpatient mortality to just the elevation of troponin. So that's something to keep in mind. Is that with that kind of broad outcome, you're going to need to divide all that in German? If there is a difference, where does that difference lie?

Speaker 2:

They did again this propensity score matching and they used overlap waiting to adjust for numerous confounding factors that you might expect to happen. Again, they looked at about 66,000 charts with a mean age of 75 years. This is the VA, so 98% of patients were male and the vast vast majority of them were white. About. Of that cohort, 21.3% or about 14,000 patients did receive their definition of intensive blood pressure treatment in the first 48 hours of hospitalization.

Speaker 2:

They took a look at the outcome Patients who received early intensive treatment versus those who did not receive entry in treatment, despite, again, a high blood pressure, basically had an increase in the primary outcome. Actually, the primary composite outcome was 8.7% in the patients who received intensive blood pressure control versus 6.9%, which translated into an odds ratio of 1.28, which was statistically significant, the highest risk. When they did it up between the people who received new onset oral agents versus intravenous agents, patients who had only intravenous agents had a much higher elevated risk of the primary outcome with an odds ratio of 1.9. Again, with this kind of disparate kind of the composite outcome, they did divide things up into different groups and they found that each of these components in the primary outcome was statistically significantly more likely in the intensive control arm, except for stroke and mortality, which you could argue were two of the most important ones. But they did find that intensive care unit transfer, acute kidney injury and elevation of BMP and antroponins were statistically more likely in the patients who received intensive blood pressure control versus not.

Speaker 2:

When they took a look at that again, they did took a look at the individual drugs. There didn't seem to be a whole lot of difference between there. Those numbers were really kind of divvy, very small, so I'm not sure they would have found a difference. Even if they did so, they found that during hospitalization that on the whole patients did receive about six more doses of anti-abritances compared to one in, you know, which is just a normal in patients who did not receive intensive therapy. They findings were consistent across subgroups, including age, frailty, pre-admission blood pressure which I think is very interesting early hospitalization and cardiovascular disease activity.

Speaker 2:

So you know, the bottom line of the study was that even though it's a retrospective study, it does not suggest that intensive blood pressure lowering is beneficial and you could argue there's a signal for harm. You know again, you know it would have, I think, had a little more punch to the results if they would have found an increase in mortality or stroke. You know those were probably the two most important or most serious outcomes in their composite outcome. But just the fact that there was an increase risk of acute kidney injury and intensive care transfer, you know, may make it enough to say you know, maybe we shouldn't be so aggressive about treating blood pressure, but there was certainly no benefit in the study. So I mean, I think you could argue even if it just falls into the things we do for no reason sort of thing that intensive blood pressure control certainly wasn't beneficial and in fact that may have had a signal for harm.

Speaker 2:

So what do I take away from all this? Is someone who you know works, you know, in internal medicine and the ICU and deals with this all the time. I think I'm trying to be a little bit less Panicked about when you know the the people on my team are like all their blood pressures 170, you know, and you know, and and you know, what are we gonna do about that? And I've been trying to make the recommendation on rounds to say, well, you know, really probably nothing, you know, they're here for pneumonia.

Speaker 2:

You know, I get that the blood pressure is high. Maybe the thing we should do is make some recommendations in their discharge summary and let them have close follow-up with with their primary care Clinician, who, let's face it, as the person who's gonna be dealing with this in the long term, right. So I've tried to be less panicky about, you know, you know big blood pressure changes. I've tried to not be the person who immediately say, hey, they need to be on on lamblodipine, let's start amelodipine right away. I've tried to be better about all that stuff. Now I again.

Speaker 2:

This is gonna require, I think, some, some educational pieces across the healthcare spectrum.

Speaker 2:

I think not only prescribers, but I think nurses and other healthcare clinicians need to know this data and need to know that there isn't some magical number we need to reach.

Speaker 2:

No matter how many drugs it takes to get there, to try and get somebody's blood pressure control, especially when we're talking about hypertensive Urgencies, hypertensive emergencies, I doubt that the standard of care is gonna change anytime soon.

Speaker 2:

I think that that you know. So when it comes in with with the with an acute MI, acute stroke or an eric dissection who has an oh my goodness high blood pressure, there's going to be some attempt to try and get that blood pressure under some some control, and I doubt that there's ever gonna be, you know, really good studies that tell us which drug or what the target blood pressure could be, and so I'm not sure how much of this is gonna translate as far as a standard of care thing when we get into the Tiber tens of emergencies. But certainly on the floor when somebody doesn't have target organ damage and all we're looking at is a high number, I'm trying to step away from from jumping up and doing a lot of stuff about it. I'm trying to Again, kind of less as more as, as the very College of Medicine says, is maybe the way to go is is not, you know, make these dramatic changes in their blood pressure regimen?

Speaker 2:

and, I think, many of my internists are have, who have read this data as well, are kind of an agreement with that. So, basically, less is more in many of these cases, don't you know, immediately jump it at starting new medications. Don't immediately give things like clotting just because their blood pressure is 175, especially when it comes to high for tens of urgency. So that's it for this week of game changers. Thanks for listening. As always, we will see you next week, but until then, remember time flies. I don't know where it's going, but most important day is today. Take care.

Speaker 1:

Jen here. Be sure to check out our education at CEM packcom. You'll find it to be your one-stop shop for all the CE resources you need. Become a pharmacist by design member today to access it all for free, including CE for this podcast. Thanks for listening. We'll talk to you next week on game changers clinical conversations.