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Management of patients with hypertensive urgencies and emergencies

A systematic review of the literature

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Abstract

BACKGROUND: Hypertensive urgencies and emergencies are common clinical occurrences in hypertensive patients. Treatment practices vary considerably to because of the lack of evidence supporting the use of one therapeutic agent over another. This paper was designed to review the evidence for various pharmacotherapeutic regimens in the management of hypertensive urgencies and emergencies, in terms of the agents’ abilities to reach predetermined “safe” goal blood pressures (BPs), and to prevent adverse events.

METHODS:medline was searched from 1966 to 2001, and the reference lists of all the articles were retrieved and searched for relevant references, and experts in the field were contacted to identify other relevant studies. The Cochrane Library was also searched. Studies that were eligible for inclusion in this review were systematic reviews of randomized control trials (RCTs) and individual RCTs, all-or-none studies, systematic reviews of cohort studies and individual cohort studies, and outcomes research. No language restrictions were used.

RESULTS: None of the trials included in this review identified an optimal rate of BP lowering in hypertensive emergencies and urgencies. The defintions of hypertensive emergencies and urgencies were not consistent, but emergencies always involved target end-organ damage, and urgencies were without such damage. Measures of outcome were not uniform between studies. The 4 hypertensive emergency and 15 hypertensive urgency studies represented 236 and 1,074 patients, respectively. The evidence indicated a nonsignificant trend toward increased efficacy with urapidil compared to nitroprusside for hypertensive emergencies (number needed to treat [NNT] for urapidil to achieve target BP, 12; 95% confidence interval [95% CI], number of patients needed to harm [NNH], 5 to NNT, 40 compared to nitroprusside). Several medications were efficacious in treating hypertensive urgencies, including: nicardipine (NNT for nicardipine compared to plabebo, 2 in one study [95% CI, 1 to 5] and 1 in another [95% CI, 1 to 1]); lacidipine (NNT, 2; 95% CI, 1 to 8 for lacidipine vs nifedipine) or urapidil (NNT for urapidil compared to enalaprilat and nifedipine, 4; 95% CI, 3 to 6); and nitroprusside and fenoldopam (all patients reached target BP in 2 studies). The studies reported 2 cases of cerebral ischemia secondary to nifedipine.

CONCLUSIONS: May effective agents exist for the treatment of hypertensive crises. Because of the lack of large randomized controlled trials, many questions remain unanswered, such as follow-up times and whether any of the studied agents have mortality benefit.

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References

  1. Kitiyakara C, Guzman N. Malignant hypertension and hypertensive emergencies. J Am Soc Nephrol. 1998;9:133–42.

    PubMed  CAS  Google Scholar 

  2. Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P. Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension. 1996;27:144–7.

    PubMed  CAS  Google Scholar 

  3. Kincaid-Smith P, McMichael J, Murphy EA. The clinical course and pathology of hypertension with papilloedema (malignant hypertension). QJM. 1958;37:117–53.

    Google Scholar 

  4. Bechgaard P, Kopp H, Neilson J. One thousand hypertensive patients followed from 16–22 years. Acta Med Scand. 1956;312(suppl):175–83.

    CAS  Google Scholar 

  5. Haynes RB, Wilczynski C, McKibbon A, Walker C, Sinclair J. Developing optimal search strategies for detecting clinically sound studies in MEDLINE. J Am Med Inform Assoc. 1994;1:447–58.

    PubMed  CAS  Google Scholar 

  6. Sackett DL, Straus S, Richardson WS, Rosenberg W, Hagro RB. Evidence-Based Medicine. How to Practice and Teach Evidence-Based Medicine. 2nd ed. London: Churchill Livingston; 2000.

    Google Scholar 

  7. Mount Sinai Hospital-University Health Network. 2000. Centre for Evidence Based Medicine: NNT Tables. Available at: http://www.mtsinai.on.ca/masterframe.htm. Accessed April 12, 2001.

  8. Hirschl MM, Binder M, Bur A, et al. Safety and efficacy of urapidil and sodium nitroprusside in the treatment of hypertensive emergencies. Intensive Care Med. 1997;23:885–8.

    Article  PubMed  CAS  Google Scholar 

  9. Hirschl MM, Seidler D, Zeiner A, et al. Intravenous urapidil versus sublingual nifedipine in the treatment of hypertensive urgencies. Am J Emerg Med. 1993;11:653–6.

    Article  PubMed  CAS  Google Scholar 

  10. Franklin C, Nightengale S, Mambani B. A randomized comparison of nifedipine and sodium nitroprusside in severe hypertension. Chest. 1993;90:500–3.

    Google Scholar 

  11. Komsuoglu B, Sengun B, Bayram A, Komsuoglu SS. Treatment of hypertensive urgencies with oral nifedipine, nicardipine, and captopril. Angiology. 1991;42:447–54.

    PubMed  CAS  Google Scholar 

  12. Jaker M, Atkin S, Soto M, Schmid G, Brosch F. Oral nifedipine vs. oral clonidine in the treatment of urgent hypertension. Arch Intern Med. 1989;149:260–5.

    Article  PubMed  CAS  Google Scholar 

  13. Zeller KR, Kuhnert LV, Matthews C. Rapid reduction of severe asymptomatic hypertension: a prospective, controlled trial. Arch Intern Med. 1989;149:2186–9.

    Article  PubMed  CAS  Google Scholar 

  14. Rutledge J, Ayers C, Davidson R, et al. Effect of intravenous enalaprilat in moderate and severe hypertension. Am J Cardiol. 1988;62:1062–67.

    Article  PubMed  CAS  Google Scholar 

  15. Rohr G, Reimnitz P, Blanke P. Treatment of hypertensive emergency. Comparison of a new dosage form of the calcium antagonist nitrendipine with nifedipine capsules. Intensive Care Med. 1994;20:268–71.

    Article  PubMed  CAS  Google Scholar 

  16. McDonald AJ, Yealy DM, Jacobson S. Oral labetalol vs. oral nifedipine in hypertensive emergencies in the emergency department. Am J Emerg Med. 1993;11:460–3.

    Article  PubMed  CAS  Google Scholar 

  17. Panacek EA, Bednarczyk EM, Dunbar LM, Foulke GE, Holcslaw TL. Randomized, prospective trial of fenoldopam vs. sodium nitroprusside in the treatment of acute severe hypertension. Acad Emerg Med. 1995;2:959–65.

    Article  PubMed  CAS  Google Scholar 

  18. Pilmer BL, Green JA, Panacek EA, et al. Fenoldopam mesylate versus sodium nitroprusside in the acute management of severe systemic hypertension. J Clin Pharmacol. 1993;33:549–53.

    PubMed  CAS  Google Scholar 

  19. Reisin E, Huth M. Intravenous fenoldopam versus sodium nitroprusside in patients with severe hypertension. Hypertension. 1990;15(suppl I):159–162.

    Google Scholar 

  20. Gonzalez ER, Peterson MA, Racht EM, Ornato JP, Due DL. Dose-response evaluation of oral labetalol in patients presenting to the emergency department with accelerated hypertension. Ann Emerg Med. 1991;20:333–8.

    Article  PubMed  CAS  Google Scholar 

  21. Angeli P, Chiesa M, Caregaro L, et al. Comparison of sublingual captopril and nifedipine in immediate treatment of hypertensive emergencies. A randomized, single-blind clinical trial. Arch Intern Med. 1991;151:678–82.

    Article  PubMed  CAS  Google Scholar 

  22. Wallin JD, Fletcher E, Ram CV, et al. Intravenous nicardipine for the treatment of severe hypertension: a double-blind, placebocontrolled multicenter trial. Arch Intern Med. 1989; 149:2662–9.

    Article  PubMed  CAS  Google Scholar 

  23. Pascale C, Zampaglione B, Marchisio M. Management of hypertensive crisis: nifedipine in comparison with captopril, clonidine and furosemide. Curr Ther Res. 1992;51:9–18.

    Google Scholar 

  24. Hirschl MM, Seidler D, Mullner M, et al. Efficacy of different antihypertensive drugs in the emergency department. J Human Hypertension. 1996;24:1684–9.

    CAS  Google Scholar 

  25. Sanchez M, Sobrino J, Ribera L, Adrian AJ, Torres M, Coca A. Long-acting lacidipine versus short-acting nifedipine in the treatment of acute asymptomatic acute blood pressure increase. J Cardiovasc Pharmacol. 1999;33:479–84.

    Article  PubMed  CAS  Google Scholar 

  26. Habib GB, Dunbar LM, Rodrigues R, Neale AC, Friday KJ. Evaluation of the efficacy and safety of oral nicardipine in the treatment of urgent hypertension: a multicenter, randomized, double-blind, parallel, placebo-controlled trial. Am Heart J. 1995;129:917–23.

    Article  PubMed  CAS  Google Scholar 

  27. Psaty BM, Guralnik JM, Corti MC, et al. The risk of myocardial infarction associated with antihypertensive drug therapies. JAMA. 1995;274:620–5.

    Article  PubMed  CAS  Google Scholar 

  28. Epstein M. Calcium antagonists should continue to be first-line treatment of hypertension. Arch Intern Med. 1995;155:2150–6.

    Article  PubMed  CAS  Google Scholar 

  29. Messerli FH. Case-control study, meta-analysis and bouillabaisse: putting the calcium antagonist scare into context. Ann Intern Med. 1995;123:888–9.

    PubMed  CAS  Google Scholar 

  30. Ramsay LE, Williams B, Johnston GD, et al. for the British Hypertension Society. Guidelines for the management of hypertension: report of the Third Working Party of the British Hypertension Society. J Hum Hypertens. 1999;13:569–92.

    Article  PubMed  CAS  Google Scholar 

  31. Feldman RD, Campbell N, Larochelle P, et al. for the Task Force for the Development of the 1999 Canadian Recommendations for the Management of Hypertension. 1999 Canadian recommendations for the management of hypertension. CMAJ. 1999;161(suppl 12):1–17.

    Google Scholar 

  32. The Sixth Report of the Joint National Committee on Prevention. Detection, Evaluation and Treatment of Hypertension. Arch Intern Med. 1997;157:2413–46.

    Article  Google Scholar 

  33. De Sanctis RW, Doroghazi RM, Austen WG. Aortic dissection. N Engl J Med. 1987;317:1060–7.

    Article  Google Scholar 

  34. Crawford ES. The diagnosis and management of aortic dissection. JAMA. 1990;264:2537–41.

    Article  PubMed  CAS  Google Scholar 

  35. Erbel R, Alfonso F, Boileau C, et al. Diagnosis and management of aortic dissection. Eur Heart J. 2001;22:1642–81.

    Article  PubMed  CAS  Google Scholar 

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Correspondence to David Cherney MD.

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Received from the Department of Medicine, Toronto Genral Hospital, University of Toronto, Toronto, Ontario, Canada.

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Cherney, D., Straus, S. Management of patients with hypertensive urgencies and emergencies. J GEN INTERN MED 17, 937–945 (2002). https://doi.org/10.1046/j.1525-1497.2002.20389.x

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