Management of Admitted Patients with Hypertension, Tachycardia, and Chronic Kidney Disease

Initial Assessment and Blood Pressure Target

The American College of Cardiology recommends targeting a blood pressure <130/80 mmHg in all patients with chronic kidney disease (CKD), regardless of age, as this goal reduces cardiovascular mortality and slows kidney disease progression 1, 2
The 2017 ACC/AHA guidelines supersede older JNC-8 recommendations that suggested <140/90 mmHg, as more recent evidence demonstrates cardiovascular benefit with the lower target 1
Expect a modest decline in eGFR (5-10 mL/min/1.73m²) with intensive BP control; continue therapy if tolerated as cardiovascular benefits outweigh this decline 2

The American College of Cardiology recommends initiating an ACE inhibitor as first-line therapy in patients with CKD stage 3 or higher, or stage 1-2 with albuminuria ≥300 mg/d 1, 3
If ACE inhibitor is not tolerated, switch to an ARB 1, 3
ACE inhibitors and ARBs provide renoprotection beyond BP lowering, particularly with proteinuria present 4, 5, 6

Add a beta-blocker to control ventricular rate to <90 bpm at rest if tachycardia persists after addressing reversible causes 7
Avoid beta-blockers with intrinsic sympathomimetic activity; do not use atenolol as it is less effective than other agents 1
Titrate beta-blocker dose to achieve heart rate control while monitoring for bradycardia 7

Measure BP at least twice daily during admission to assess response to therapy 2
Monitor serum creatinine and potassium within 1-2 weeks of initiating or titrating ACE inhibitor/ARB 1, 2
Accept creatinine increases up to 30% from baseline if stable thereafter, as this reflects hemodynamic changes rather than kidney injury 2

Do not discontinue ACE inhibitor/ARB for modest creatinine elevation (<30% increase) as cardiovascular benefits outweigh this expected hemodynamic effect 2
Do not target BP <120/70 mmHg as excessive lowering increases risk of acute kidney injury and hypotension-related complications 1

Refer to nephrology if eGFR <30 mL/min/1.73m², rapidly progressive kidney disease, or uncertainty about CKD etiology 2