A Lacuna in the Guidelines

Physicians treat chronic hypertension almost exclusively in ambulatory care settings according to evidence-based guidelines1 based on blood pressure (BP) measurements obtained under prescribed conditions.2 Other recommendations cover how to deal with hypertension in dialysis units2 and emergency departments,3 but none address a very commonly encountered problem: what to do about acutely elevated BP (which I refer to below in the common parlance of “acute hypertension”) in patients hospitalized for reasons other than hypertension. Indeed, excluding articles on patients with hypertensive emergencies and urgencies, there is little published about treatment of acutely elevated BP in hospitalized patients, although the practice seems to be common and based on firmly held, but poorly justified, beliefs.4 In this commentary, I argue for developing a rational approach to treating acute hypertension that de-emphasizes “treating the numbers” and focuses on patient safety.