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  1. What are the major causes of hypertension in hospitalized patients?

  2. What are the common hospital-acquired or iatrogenic causes that induce hypertension?

  3. What signs and symptoms should be assessed in the initial evaluation of a patient with reported hypertension?

  4. When should you lower blood pressure acutely?

  5. What are the risks associated with acutely lowering the blood pressure in the hospital?

The lifetime risk for the development of high blood pressure (BP) (systolic BP > 40 mm Hg), is 90%; half of patients age 60–70, and three quarters age 70–80 have hypertension. The prevalence of hypertension in the hospital setting has been reported to range from 50.5% to 72%.

The decision about whether to treat high BP in the hospitalized patient with antihypertensive agents is an important one, but it is not always straightforward. The definition of hypertension, goals for treatment, and benefits of therapy in reduction of cardiovascular morbidity and mortality have been well established in numerous clinical trials and widely disseminated to practicing physicians in evidence-based consensus documents. Unfortunately these goals do not necessarily apply to acutely ill patients. Thus the management of hypertension in the hospitalized patient should be highly individualized. There are few if any prospective trials regarding choice of antihypertensive medications in this setting. Recommendations are generally based on consensus opinion, customary use, extrapolation from animal models, and commonsense application of physiologic principles.

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Case 89-1

A 75-year-old man admitted for renal colic was noted on routine vital signs to have a BP of 180/98 mm Hg and a regular pulse of 98. His BP since admission has been in the range of 160–170/85–95 mm Hg. He passed a kidney stone earlier in the evening and his pain was subsiding. He had received saline IV and morphine sulfate for pain earlier. He reported minimal flank pain. Otherwise he felt fine and denied shortness of breath, chest pain, or headache.

He was told years ago that he had high blood pressure and was given medication. He never took the medication and never returned to see a physician. His admission ECG showed nonspecific ST–T wave changes and evidence of a possible prior inferior myocardial infarction; his chemistry profile was notable for a normal potassium and creatinine. A urinalysis showed microscopic hematuria but no protein. His nonenhanced abdominopelvic CT scan showed symmetric, normal sized kidneys and there was no evidence of hydronephrosis.

The covering urology resident ordered topical nitroglycerin (-Nitropaste), which reduced his BP to 150/95 mm Hg in 15 minutes.

Two hours later, the patient woke up with a headache and stood up to go to the bathroom. He fainted, fell, and could not stand up because of hip pain. Although he was alert, oriented, and had no focal findings on neurologic examination, he had intense left groin pain and a shortened and externally rotated left leg, suggesting a hip fracture. His heart rate was 90 and his BP was 110/70 ...

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