Nearly Half of Hospital Doctors Say Don’t Treat Silent High Blood Pressure

When a hospitalized patient’s blood pressure climbs above 140/90 mmHg, many nurses reach for the phone and many physicians reach for the prescription pad. Yet a striking new survey suggests that this reflex may be out of step with what hospital doctors actually believe. In a cross-sectional study published in the Journal of General Internal Medicine, researchers found that nearly half of surveyed hospitalists do not think asymptomatic elevated blood pressure should be routinely treated in the hospital at all, exposing a deep and largely unrecognized divide in everyday inpatient practice.

The scale of the question is enormous. Between 50 and 72 percent of hospitalized patients carry a hypertension diagnosis, and roughly three-quarters experience at least one elevated blood pressure reading during their stay. Acute, symptomatic spikes that cause end-organ damage, known as hypertensive emergencies, demand rapid, high-intensity treatment. But for readings that fall well short of emergency territory and produce no symptoms, the evidence for intervening is remarkably thin, and what observational data exist point in a troubling direction: intensifying antihypertensive medications in the hospital may actually harm patients.

Those signals of harm are not subtle. In a propensity-matched cohort study, hospitalized patients who received antihypertensive medication on an as-needed basis had 24 percent higher odds of acute kidney injury, more than eight times the odds of ischemic stroke, and more than triple the odds of inpatient mortality. Intravenous antihypertensives, in particular, have been linked to prolonged hospital stays, while even oral intensification has been associated with kidney and myocardial injury. Worse, treating elevated blood pressure in the hospital does not appear to improve long-term blood pressure control and may raise the risk of adverse outcomes in the 30 days after discharge.

Recognizing this uncertainty, the American Heart Association issued a Scientific Statement in May 2024 concluding that the risk-benefit ratio of prescribing antihypertensives for asymptomatic elevated inpatient readings is unclear. Blood pressure can rise transiently because of pain, nausea, temperature, or stress, and in those cases the underlying cause, not the number on the monitor, is the appropriate target. But at some threshold, presumably, treatment becomes worthwhile. Where that threshold lies has never been established, which is precisely why a team led by Elizabeth R. Pfoh of the Cleveland Clinic set out to map what physicians actually think.

Between February and October 2024, the researchers emailed anonymous surveys to hospitalists at five academic medical centers: the Cleveland Clinic, Johns Hopkins School of Medicine, the University of Utah School of Medicine, the University of Nebraska Medical Center, and the University of Wisconsin-Madison. They defined elevated blood pressure as readings between 140/90 and 210/120 mmHg without symptoms of hypertensive emergency, deliberately excluding crises from the picture. Of 397 potential respondents, 166 physicians replied, an overall response rate of 42 percent that ranged from 24 to 64 percent across sites. Because the survey straddled the release of the AHA statement, the team also ran a sensitivity analysis comparing sites surveyed before and after May 2024.

The headline finding was a near-even split of professional opinion. When asked whether it is important to treat patients with an elevated blood pressure, 27 percent of hospitalists agreed while 47 percent disagreed, and the remaining quarter were neutral. On average, respondents leaned neutral overall, with a mean score of 3.3 on a five-point scale, but that average concealed a polarized profession: 8 percent strongly agreed treatment was warranted, 19 percent agreed, 30 percent disagreed, and 17 percent strongly disagreed. These attitudes were remarkably consistent across all five institutions, suggesting the divide is not a local quirk but a national pattern.

When it came to numbers, physicians converged loosely around a threshold but disagreed on the details. The median systolic trigger for intensifying medication was 170 to 179 mmHg, yet 38 percent of physicians said they would intensify below 169 mmHg, while 24 percent would hold off until readings reached at least 180 to 189 mmHg. Patience, however, was nearly universal: 79 percent of physicians would wait at least 12 hours before acting on an elevated reading. Patient characteristics mattered even more than the raw numbers. Physicians reported being more likely to treat patients with a history of heart failure (73 percent), stroke (73 percent), myocardial infarction (64 percent), or coronary disease (57 percent), and markedly less likely to treat patients whose elevated readings plausibly stemmed from withdrawal symptoms (81 percent less likely), pain (79 percent), fall risk (77 percent), substance use (61 percent), or nausea (53 percent).

Perhaps the most provocative finding concerned who, in practice, drives treatment. Sixty percent of physicians agreed that treatment is driven by nurses calling physicians, and an overwhelming 89 percent agreed they would prefer not to be contacted by a nurse about an asymptomatic systolic reading below 170 mmHg. Physicians who were least inclined to treat agreed most strongly that nursing calls were pushing them to prescribe, and they expressed the strongest preference for silence below both 170 and even 200 mmHg. The free-text responses laid bare the mechanism: repeated nursing calls create pressure to do something, and for many physicians, the perceived risk of prescribing feels smaller than the discomfort of ignoring an alarm. The AHA’s own framework, which urges hospitals to modify the culture of unnecessary treatment cascades, including default nurse-notification orders, appears aimed squarely at this dynamic.

Qualitative analysis of 133 open-ended responses revealed three broad rationales. Some physicians rejected routine treatment outright, with comments such as increasing medications without symptoms or clear indications puts the patient at higher risk for damage than benefit. Others would treat only when readings remained persistently elevated, for example beyond 24 hours, without another explanation. A third group would act only at very high values, though what counted as very high ranged from above 170 to over 200 mmHg. Underlying it all were two cross-cutting concerns: patient-specific conditions such as heart failure, and process worries such as poor outpatient follow-up after discharge. Meanwhile, only about a quarter of physicians felt there was clear guidance on when to prescribe, and 79 percent strongly disagreed that intravenous medication should ever be used for asymptomatic elevations, a view that hardened further among sites surveyed after the AHA statement.

The survey’s limitations are worth noting. It captured only academic medical centers in five states, response rates were moderate, and anonymity precluded comparisons between responders and non-responders, raising the possibility that physicians with strong opinions were more likely to reply. It is also possible that respondents imagined intensification as a permanent regimen change rather than a single dose, which could have shaped their answers. Still, the picture that emerges is of a profession practicing without a map. A 2024 systematic review found no guidelines at all for asymptomatic elevated inpatient blood pressure, only ten for hypertensive urgencies and eleven for emergencies. Compared with a 2010 survey in which 80 percent of residents called inpatient blood pressure control a high priority, the finding that just 27 percent of today’s hospitalists agree treatment is important suggests opinion has shifted as evidence of harm has accumulated. The authors conclude that randomized trial evidence is urgently needed to inform evidence-based guidelines, which in turn could reduce the wide practice variation that currently governs one of the most common decisions in hospital medicine. Until then, the most defensible approach, the researchers suggest, is the one the evidence already supports: treat the pain, the nausea, the stress, and the underlying illness, and let a truly asymptomatic number wait.

Subject of Research: Hospitalist attitudes toward treating asymptomatic elevated blood pressure readings in hospitalized patients

Article Title: Physicians’ Beliefs About Treating Asymptomatic Elevated Blood Pressure Readings Among Hospitalized Patients

Article References: Pfoh, E. R., Harris, C. M., Singh, M., Pappas, M. A., Ellenbogen, M. I., Shiffermiller, J., Kaiksow, F. A. A., Vaughn, V. M., & Rothberg, M. B. (2026). Physicians’ Beliefs About Treating Asymptomatic Elevated Blood Pressure Readings Among Hospitalized Patients. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10708-9

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10708-9

Keywords: hypertension, hospitalized patients, hospital medicine, antihypertensive medication, blood pressure, American Heart Association, inpatient care, physician survey, overtreatment, clinical guidelines, nursing calls, patient safety