South African hypertension guideline 2011. Treatment of Hypertensive Urgencies with Oral Nifedipine, Nicardipine, and Captopril Intravenous urapidil versus sublingual nifedipine in the treatment of hypertensive urgencies. Central blood pressure measurements and antihypertensive therapy: a consensus document. Self-measurement of blood pressure at home reduces the need for antihypertensive drugs: a randomized, controlled trial. The 2001 Canadian recommendations for the management of hypertension: Part two--Therapy. Sublingual nifedipine and captopril in hypertensive urgencies and emergencies. Treatment of hypertensive urgencies and emergencies with nitrendipine, nifedipine, and clonidine: effect on blood pressure and heart rate. Diclofenac sodium versus pethidine in acute renal colic. The Dutch Renal Artery Stenosis Intervention Cooperative (DRASTIC) Study: rationale, design and inclusion data. A comparison of the antihypertensive efficacy and safety of felodipine IV and nifedipine IV in patients with hypertensive crisis or emergency not responding to oral nifedipine Effects of monotherapy and combination therapy on blood pressure control and target organ damage: a randomized prospective intervention study in a large population of hypertensive patients. Prognostic value of ambulatory blood pressure monitoring in refractory hypertension: a prospective study. Oral labetalol versus oral nifedipine in hypertensive urgencies in the ED. Double-blind, placebo-controlled crossover comparison of five classes of antihypertensive drugs Captopril, nifedipine and their combination for therapy of hypertensive urgencies. Home blood pressure monitoring alone vs. combined clinic and ambulatory measurements in following treatment-induced changes in blood pressure and organ damage. Antihypertensive drug treatment: A comparison of usual care with self blood pressure measurement Hypertensive emergencies in old age: effects of angiotensin converting enzyme inhibition. Rationale and design of the Eplerenone combination Versus conventional Agents to Lower blood pressure on Urinary Antialbuminuric Treatment Effect (EVALUATE) trial: a double-blinded randomized placebo-controlled trial to evaluate the antialbuminuric effects of an aldosterone blocker in hypertensive p [Sublingually administered captopril versus nifedipine in hypertension emergencies]. Medical treatment of hypertension in Switzerland. The 2009 Swiss Hypertension Survey (SWISSHYPE). Long-acting lacidipine versus short-acting nifedipine in the treatment of asymptomatic acute blood pressure increase. Randomized, prospective trial of fenoldopam vs sodium nitroprusside in the treatment of acute severe hypertension. Fenoldopam Study Group. Predictors of Target Organ Damage in Hypertensive Blacks and Whites
OUTCOMES Extensive data from r and omised controlled trials have shown the benefit of treating hypertension . The target blood pressure ( BP ) for antihypertensive management is systolic < 140 mmHg and diastolic < 90 mmHg with minimal or no drug side-effects ; however , stricter BP control is required for patients with end-organ damage , co-existing risk factors and co-morbidity , e.g. diabetes mellitus . The reduction of BP in the elderly and in those with severe hypertension should be achieved gradually over 1 month . Co-existent risk factors should also be controlled . BENEFITS Benefits of management include reduced risks of stroke , cardiac failure , chronic kidney disease and coronary heart disease . RECOMMENDATIONS The correct BP measurement procedure is described , and evaluation of cardiovascular risk factors and recommendations for antihypertensive therapy are stipulated . The total cardiovascular disease risk profile should be determined for all patients to inform management strategies . Lifestyle modification and patient education are cornerstones in the management of every patient . Major indications , pre caution s and contra-indications to each recommended antihypertensive drug are listed . Combination therapy should be considered ab initio if the BP is ≥ 20/10 mmHg . First-line drug therapy for uncomplicated hypertension includes low-dose thiazide-like diuretics , calcium channel blockers ( CCBs ) or angiotensin-converting enzyme inhibitors ( ACE-Is ) ( or ARBs - angiotensin II receptor blockers ) . If the target BP is not obtained , a second antihypertensive should be added from the aforementioned list . If the target BP is still not met , the third remaining antihypertensive agent should be used . In black patients  either thiazide-like diuretics or CCBs can be used initially , because response rates are better than with ACE-Is or β-blockers . In treating resistant hypertension , a central ly acting drug , vasodilator , α-blocker , spironolactone or β-locker should be added . This guideline includes management of specific situations , i.e. hypertensive emergency and urgency , severe hypertension with target organ damage , hypertension in diabetes mellitus , resistant hypertension , fixed drug combinations , new trials in hypertension , and interactions of antihypertensive agents with other drugs . VALIDITY The guideline was developed by the Southern African Hypertension Society Sixty-five patients with unclomplicated hypertenive urgencies were treated in the emergency and cardiology departments with 20 mg nifedipine , 20 mg nicardipine , or 25 mg captopril in a r and omized study . The study population consisted of 65 patients ranging in age from forty-one to seventy-one .  Blood pressure and heart rate were assessed for six hours after intake of the antihyper tensive agents . Within sixty minutes nifedipine reduced blood pressure by an average of 74.7 mmHg for the systolic and 35.4 mmHg for the diastolic . Average heart rate increased significantly by 11.6 beats/min at within thirty minutes . Nicardipine and captopril produced equivalent falls in systolic ( -81.6 and -79.4 mmHg ) and diastolic ( -37.3 and -33 mmHg ) blood pressure respectively , but did not increase heart rate significantly . The antihypertensive effect of each drug was maintained until six hours after medication . In conclusion , nifedipine , nicardipine , and captopril show similar efficacy in the treatment of hypertensive urgencies . The authors believe that these drugs can be used as first-line therapy in the treatment of hypertensive urgencies safely and effectively In a 6-month prospect i ve study , the efficacy and safety of urapidil and nifedipine in an outpatient population with hypertensive urgencies ( systolic blood pressure > 200 mm Hg ; diastolic blood pressure > 110 mm Hg ) was investigated . Response to treatment was defined as a stable reduction of systolic blood pressure below 180 mm Hg and diastolic blood pressure below 100 mm Hg 15 minutes after application of a single dose of either 25 mg urapidil intravenously ( N = 26 ) or 10 mg nifedipine sublingually ( N = 27 ) . If the blood pressure was still elevated , a second dose of 10 mg nifedipine or 12.5 mg urapidil was given , and blood pressure response was evaluated 15 minutes after application of the second dose according to the aforementioned criteria s. After the first application of nifedipine , 19 ( 70 % ) responders have been observed . Eight patients needed an additional 10 mg of nifedipine . In four of these patients , no reduction of blood pressure was observed after a second dose of nifedipine . In contrast , 24 ( 92 % ) patients responded well to the first application of 25 mg of urapidil . Two patients required a second dose of 12.5 mg of urapidil , but no nonresponder to urapidil was observed . No severe side-effects were noted in both groups . Intravenous urapidil is a highly effective drug in the treatment of hypertensive urgencies and is more effective than sublingual nifedipine , because the number of patients treated successfully was significantly higher The 2003 European Society of Hypertension/European Society of Cardiology guidelines for the management of arterial hypertension1 included 2 important novel recommendations : assessment of the total cardiovascular risk should be taken into account in the management of the hypertensive patient , and quantification of risk should include sub clinical target organ damage . These guidelines acknowledged that central ( aortic ) blood pressure ( BP ) , which is the pressure exerted on the heart and brain , may be different from the pressure that is measured at the arm . They also recognized that central pressure may be predictive of outcome in specific population s2 and differently affected by antihypertensive drugs . However , although these guidelines accepted that central augmentation index and pulse wave velocity may be important as measures of sub clinical organ damage , they also stressed the need for prospect i ve trials to establish their predictive values given that such studies were lacking at that time ( 2003 ) . After publication of these guidelines , additional data have strengthened the pathophysiological importance of central BP . Clinical studies have indicated that central BP may have predictive value independent of the corresponding peripheral ( brachial ) BP . More importantly , recent large-scale trials have shown that central hemodynamics may provide a worthwhile treatment target . In addition , central hemodynamics can now be reliably assessed noninvasively with a number of devices . Accordingly , because arterial stiffening and central hemodynamics are markers and manifestations of organ damage , the pertinent key question is whether the balance of evidence on their importance and issues related to clinical practice allows for implementation in patient management . Central ( aortic and carotid ) pressures are pathophysiologically more relevant than peripheral pressures for the pathogenesis of cardiovascular disease.3,4 It is aortic systolic pressure that the left ventricle encounters during systole ( afterload ) , and the aortic pressure during diastole is a determinant of coronary perfusion . Furthermore , the distending pressure in the It is still uncertain whether one can safely base treatment decisions on self-measurement of blood pressure . In the present study , we investigated whether antihypertensive treatment based on self-measurement of blood pressure leads to the use of less medication without the loss of blood pressure control . We r and omly assigned 430 hypertensive patients to receive treatment either on the basis of self-measured pressures ( n=216 ) or office pressures ( OPs ; n=214 ) . During 1-year follow-up , blood pressure was measured by office measurement ( 10 visits ) , ambulatory monitoring ( start and end ) , and self-measurement ( 8 times , self-pressure group only ) . In addition , drug use , associated costs , and degree of target organ damage ( echocardiography and microalbuminuria ) were assessed . The self-pressure group used less medication than the OP group ( 1.47 versus 2.48 drug steps ; P<0.001 ) with lower costs ( $ 3222 versus $ 4420 per 100 patients per month ; P<0.001 ) but without significant differences in systolic and diastolic OP values ( 1.6/1.0 mm Hg ; P=0.25/0.20 ) , in changes in left ventricular mass index ( -6.5 g/m(2 ) versus -5.6 g/m(2 ) ; P=0.72 ) , or in median urinary microalbumin concentration ( -1.7 versus -1.5 mg per 24 hours ; P=0.87 ) . Nevertheless , 24-hour ambulatory blood pressure values at the end of the trial were higher in the self-pressure than in the OP group : 125.9 versus 123.8 mm Hg ( P<0.05 ) for systolic and 77.2 versus 76.1 mm Hg ( P<0.05 ) for diastolic blood pressure . These data show that self-measurement leads to less medication use than office blood pressure measurement without leading to significant differences in OP values or target organ damage . Ambulatory values , however , remain slightly elevated for the self-pressure group OBJECTIVE To provide up date d , evidence -based recommendations for the therapy of hypertension in adults . OPTIONS For patients with hypertension , a number of antihypertensive agents may control blood pressure . R and omized trials evaluating first-line therapy with thiazides , beta-adrenergic antagonists , angiotensin-converting enzyme inhibitors , calcium channel blockers , alpha-blockers , central ly acting agents or angiotensin II receptor antagonists were review ed . OUTCOMES The health outcomes that were considered were changes in blood pressure , cardiovascular morbidity , and cardiovascular and /or all-cause mortality rates . Economic outcomes were not considered due to insufficient evidence . EVIDENCE MEDLINE was search ed for the period March 1999 to October 2001 to identify studies not included in the 2000 revision of the Canadian Recommendations for the Management of Hypertension . Reference lists were scanned , experts were polled , and the personal files of the subgroup members and authors were used to identify other published studies . All relevant articles were review ed and appraised , using prespecified levels of evidence , by content experts and method ological experts . VALUES A high value was placed on the avoidance of cardiovascular morbidity and mortality . BENEFITS , HARMS AND COSTS Various antihypertensive agents reduce the blood pressure of patients with sustained hypertension . In certain setting s , and for specific classes of drugs , blood-pressure lowering has been associated with reduced cardiovascular morbidity and /or mortality . RECOMMENDATIONS The present document contains detailed recommendations pertaining to treatment thresholds , target blood pressures , and choice of agents in various setting s in patients with hypertension . The main changes from the 2000 Recommendations are the addition of a section on the treatment of hypertension in patients with diabetes mellitus , the amalgamation of the previous sections on treatment of hypertension in the young and old into one section , increased emphasis on the role of combination therapies over repeated trials of single agents and expansion of the section on the treatment of hypertension after stroke . Implicit in the recommendations for therapy is the principle that treatment for an individual patient should take into consideration global cardiovascular risk , the presence and /or absence of target organ damage , and comorbidities . VALIDATION All recommendations were grade d according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group . Individuals with potential conflicts of interest relative to any specific recommendation were excluded from voting on that recommendation . Only those recommendations achieving high levels of consensus are reported here . These guidelines will continue to be up date d annually Fifty two patients of severe hypertension , diastolic blood pressure > or = 115 mmHg , with or without acute complications , were treated with sublingual nifedipine 10 mg or sublingual captopril 25 mg in a r and omized prospect i ve in patient study with careful clinical monitoring . Both the drugs were safe and effective in rapidly lowering blood pressure .  Nifedipine appeared to be superior to captopril with earlier onset of action , greater magnitude of response and longer duration of action . No significant side effects were observed in either of the two groups Nitrendipine is a new calcium antagonist of the 1,4-dihydropyridine group with strong vasodilating properties . In a r and omized trial involving 45 patients , whose mean blood pressure was 236 + /- 24/129 + /- 21 mm Hg , 5 mg nitrendipine ( given sublingually via a phiole ) was compared with 20 mg nifedipine ( given sublingually via two pierced 10-mg capsules ) and 0.15 mg clonidine ( given intravenously ) . Blood pressure and heart rate were assessed for 8 h after intake of the antihypertensive agents . Within 60 min , nitrendipine reduced blood pressure by an average of 78 + /- 17 mm Hg for the systolic and 42 + /- 12 mm Hg for the diastolic . Heart rate fell significantly from 106 + /- 17 to 87 + /- 11 beats/min . Nifedipine produced equivalent falls in systolic ( -72 + /- 15 mm Hg ) and diastolic ( -41 + /- 11 mm Hg ) blood pressure , but increased heart rate from 89 + /- 13 to 103 + /- 14 beats/min within 1 h. Intravenous administration of clonidine lowers systolic ( -84 + /- 13 mm Hg ) and diastolic ( -35 + /- 10 mm Hg ) blood pressure within 60 min . Heart rate decreased from 96 + /- 15 to 84 + /- 9 beats/min . The antihypertensive effect of each drug was maintained until 8 h after medication . Main side effects were observed in the nifedipine group ( flush and reflex tachycardia ) and in the clonidine group ( dry mouth and drowsiness ) . In conclusion , nitrendipine , nifedipine , and clonidine show similar efficacy in the treatment of hypertensive urgencies and emergencies . However , sublingual application of the calcium antagonists is simple and safe ; moreover , nitrendipine is better tolerated than nifedipine and clonidine hypertension admitted at the same time because the latter tended to be admitted for other reasons , including vascular complications of hypertension , which might be related to smoking . The lack of association between hypertension and cigarette smoking is well documented,2 ' but inclusion ofcontrol cases with end organ damage might have shown a different trend . The smallireduction in cigarette smoking in the United Kingdom over the past 10 years can not account for the observed excess of smoking in patients with malignant hypertension , which has been confirmed elsewhere.14'6 We were unable to confirm the link of smoking with grade s III and IIa retinopathy , although smoking was slightly more common than in control patients . Other authors usually combined their patients with grade III and IV retinopathy in similar analyses . The prognosis of malignant hypertension , if left untreated , is worse than any form of cancer , with up to 90 % of patients dead in one year."2 Controlling blood pressure prolongs life , " and long term follow up studies have reported a dramatic reduction in mortality.'0 The results oftreatment in our patients were disappointing , but this may be because our cases date d back to 1960 , when effective antihypertensive treatment was not so enthusiastically prescribed . Furthermore , this series includes all patients seen in a district general hospital , some of whom were acutely ill and died within hours or days of admission . The Keith Wagener classification with its gradation of retinopathy from one to four suggests a gradation of risk that is not borne out by our findings . The clinical features ofhypertension in patients with grade s III and IV retinopathy are similar and quite distinct from those seen in patients without retinopathy . Although the severity of hypertension and quality of control of blood pressure with antihypertensive drugs are both potent predictors of risk,23 malignant hypertension seems to carry a particularly bad prognosis , probably related to renal damage due to fibrinoid necrosis of intrarenal arterioles . If control of blood pressure had been better mortality might have been further reduced . The Keith Wagener classification of hypertensive retinopathy , however , seems particularly unhelpful as grade -III and IV do not differ , so we suggest that is should be ab and oned . Malignant and accelerated hypertension are one and the same disease , which should be regarded as a medical emergency requiring accurate long term control of blood pressure . JMW was supported by a grant from ICI Pharmaceuticals and MB by the DHSS computer clinics project . We thank Dr J Mackinnon for providing data from the department of cardiology , Dr A Paton for access to his retinal photography archive , Mr Roy Haynesfor access to the Hospital Activity Analysis Archive , Mrs V L Stewart for secretarial help , and Mrs E Thomas for access to medical records RATIONALE Renal artery stenosis may lead to renovascular hypertension , risking multiple organ damage including damage to the contralateral kidney . Progression of stenosis may impair the function of the affected kidney . It is important to identify individuals with this disease among hypertensive patients . The first aim of the Dutch Renal Artery Stenosis Intervention Cooperative ( DRASTIC ) study is to assess the prevalence of renal artery stenosis in patients with well-defined forms of drug-resistant hypertension , and to determine the predictive value of clinical characteristics and diagnostic tests in these pre-selected patients . With regard to treatment , the effect of renal angioplasty on hypertension is disappointing in atherosclerotic stenosis and technical failure frequently occurs . Therefore , the second aim is to compare the effects of balloon angioplasty and antihypertensive medication on blood pressure in patients with atherosclerotic renal artery stenosis . DESIGN HYPERTENSIVE patients receiving st and ard antihypertensive medication in whom diastolic blood pressure remained > or = 95 mmHg during three consecutive visits to the outpatient clinic underwent full diagnostic work-up , including renal arteriography . The prevalence of renal artery stenosis in this well-defined patient group was then established , and the predictive value of the various diagnostic tests was assessed . Patients with an atherosclerotic renal artery stenosis of > or = 50 % were then r and omly assigned to balloon angioplasty or to treatment with antihypertensive drugs . After 1 year of intensive follow-up of blood pressure and renal function , re-arteriography was performed . CONCLUSION In total , 1205 patients have been included in the study , about 500 have received diagnostic work-up , and it is expected that 100 patients will be r and omly assigned for renal angioplasty or medical treatment Abstract Objective : A clinical definition of a hypertensive emergency is excessively high blood pressure in the presence of symptoms indicating end organ damage . Equally high blood pressure without symptoms is called a hypertensive crisis . Patients with hypertensive crisis or emergency need prompt , effective , and specific therapy and a controlled reduction of blood pressure . Methods : We performed a r and omized , double-blind multi-centre study , to compare the safety , efficacy and tolerability of an intravenous ( IV ) infusion of two dihydropyridine calcium channel blockers ( either nifedipine or felodipine ) in 122 patients , of whom 63 were diagnosed as hypertensive emergencies and 59 as hypertensive crisis , who had not reacted adequately ( diastolic blood pressure < 115 mmHg ) to 5 mg of nifedipine PO . Results : Both drugs lowered blood pressure adequately in more than 90 % of the patients and were well tolerated . Only one patient had to be withdrawn , because of an excessive decrease in blood pressure . Conclusion : Patients with excessively high blood pressure who do not react to oral nifedipine can be treated equally effectively with felodipine and nifedipine IV . Felodipine is easier to h and le because of its lack of light sensitivity This prospect i ve , r and omized trial evaluated the effect of monotherapy and different combination therapies on cardiovascular target organ damage and metabolic profile in 520 hypertensive patients . Patients were allocated to a single agent : carvedilol 25 mg , amlodipine 10 mg , enalapril 20 mg , or losartan 50 mg ( groups C , A , E , and L , respectively ) . After 2 months ( level 2 ) , nonresponders received a low-dose thiazide diuretic , and after 4 months ( level 3 ) , amlodipine ( groups E , C , and L ) and carvedilol ( group A ) . Twenty-four-hour blood pressure was significantly lowered in all treatment groups . Blood pressure control was more pronounced in patients receiving two or three drugs . At the end of the study , the carotid intima-media thickness decreased in group L ( P<.01 ) , left ventricular mass index in groups E and L ( P<.05 and P<.001 , respectively ) , with a concomitant reduction in cholesterol in group L ( P<.03 ) . Diastolic function improved significantly in group L ( P<.05 ) . This study describes the need to control blood pressure with two or more drugs in most hypertensive patients and illustrates good clinical outcomes , independent of blood pressure lowering , using combination therapy with losartan , low-dose thiazide , and amlodipine The objective of this study was to establish whether ambulatory blood pressure offers a better estimate of cardiovascular risk than does its clinical blood pressure counterpart in refractory hypertension . This prospect i ve study assessed the incidence of cardiovascular events over time during an average follow-up of 49 months ( range , 6 to 96 ) . Patients were referred to specialized hypertension clinics ( 86 essential hypertension patients who had diastolic blood pressure > 100 mm Hg during antihypertensive treatment that included three or more antihypertensive drugs , one being a diuretic ) . Twenty-four-hour ambulatory blood pressure monitoring ( ABPM ) was performed at the time of entrance . End-organ damage was monitored yearly , and the incidence of cardiovascular events was recorded . Patients were divided into tertiles of average diastolic blood pressure during activity according to the ABPM , with the lowest tertile < 88 mm Hg ( LT , n=29 ) , the middle tertile 88 to 97 mm Hg ( MT , n=29 ) , and the highest tertile > 97 mm Hg ( HT , n=28 ) . While significant differences in systolic and diastolic ambulatory blood pressures were observed among groups , no differences were observed at either the beginning or at the time of the last evaluation for office blood pressure . During the last evaluation , a progression in the end-organ damage score was observed for the HT group but not for the two other groups . Twenty-one of the patients had a new cardiovascular event ; the incidence of events was significantly lower for the LT group ( 2.2 per 100 patient-years ) than it was for the MT group ( 9.5 per 100 patient-years ) or for the HT group ( 13.6 per 100 patient-years ) . The probability of event-free survival was also significantly different when comparing the LT group with the other two groups ( LT versus MT log-rank , P<.04 ; LT versus HT log-rank , P<.006 ) . The HT group was an independent risk factor for the incidence of cardiovascular events ( relative risk , 6.20 ; 95 % confidence interval , 1.38 to 28.1 , P<.02 ) . Higher values of ambulatory blood pressure result in a worse prognosis in patients with refractory hypertension , supporting the recommendation that ABPM is useful in stratifying the cardiovascular risk in patients with refractory hypertension Therapy in hypertensive urgencies is debated and complicated by the side effects of available agents . In a prospect i ve , r and omized , open labeled study , the use of oral labetalol , an alpha- and beta-adrenergic blocker , with oral nifedipine in hypertensive urgencies in the emergency department was compared . Patients with diastolic blood pressures ( DBP ) of more than 120 mm Hg without criteria for a hypertensive emergency were eligible . The drugs were given in a loading manner with doses and timing based on their respective pharmacokinetics until a DBP of 110 mm Hg or lower was obtained or 4 hours had passed . Either an initial labetalol dose of 200 mg and a repeat dose of 100 to 200 mg at 2 hours , depending on the DBP or nifedipine , 10-mg bite and swallow every hour up to a total dose of 20 mg were given . Ten patients were enrolled into each study group . A 100 % response rate was defined as a DBP of 110 mm Hg or less was observed for nifedipine and an 80 % response rate for labetalol ( P > .2 ) was observed . The mean time to control was 67.5 minutes for labetalol and 60.0 minutes for nifedipine ( P > .2 ) . The pretreatment pressure for labetalol was 195/127 mm Hg and for nifedipine was 198/128 mm Hg ( P > .2 ) , which decreased to a posttreatment pressure for labetalol of 154/100 mm Hg and for nifedipine of 163/100 mm Hg ( P > .2 ) . The mean decrease in systolic (SBP)/DBP was 42.6/26.5 mm Hg with labetalol and 34.9/28.4 mm Hg for nifedipine ( P > .2 ) . No significant side effects occurred with either drug . ( ABSTRACT TRUNCATED AT 250 WORDS Objective Hypertension guidelines recommend initial treatment with a β-blocker or diuretic and adding the other drug where blood pressure is not controlled . We hypothesized that systematic rotation through the major classes of antihypertensive drugs would demonstrate substantial differences in the pattern of an individual patient 's response , and suggest a more rational approach to choosing best treatment . Design Thirty-four young hypertensives ( age 28–55 , median 47 ) rotated in a double-blind , Latin-square , crossover fashion through 6 weeks of treatment each with amlodipine , doxazosin , lisinopril , bisoprolol , bendrofluazide and placebo . Blood pressure was measured at each visit . ‘ Best ’ drug , defined by efficacy and tolerability , was repeated at the end . Results Rotation doubled the number of patients reaching target blood pressure ( systolic < 140 mmHg ) on one drug ( P = 0.03 ) . All five drugs were represented among the ‘ best ’ drugs . In six patients , the blood pressure on ‘ best ’ drug was at least 10 mmHg lower than on any other . Response to the ‘ best ’ drug was highly correlated ( r = 0.79 ) with its previous administration . By contrast , there were only weak correlations between responses to pairs of drugs , except for angiotensin-converting enzyme ( ACE ) inhibitor ( A ) with β-blocker ( B ) , and calcium blocker ( C ) with diuretic ( D ) – each r = 0.71 , P < 0.005 ) . In these young patients , the majority of patients ( 23/34 ) responded best to a drug suppressing the renin system ( A and B ) . Conclusions Patients vary reproducibly in their response to initial treatment , and switching among drugs can increase the efficacy of monotherapy . The results support an AB/CD scheme for choosing therapy , in which the first drug is taken from one of these pairs , and uncontrolled patients switch to one of the other pair Twenty patients with acute severe hypertension were r and omised to therapy with either nifedipine capsules ( 10 mg ) or captopril tablets ( 25 mg ) given sublingually and the blood pressure recorded for 240 minutes . Oral monotherapy with either agent followed for 3 weeks , then the agents were combined for a further 2 weeks and in the final 6 weeks of the trial a beta-blocker and diuretic were added , if needed . Thirteen patients completed the trial . The major results were : ( i ) nifedipine decreased blood pressure more rapidly than captopril 60 minutes after first ingestion but at 240 minutes equal degrees of fall in blood pressure had been obtained ; ( ii ) neither agent given as sustained monotherapy was able to reduce blood pressure adequately , although nifedipine was better than captopril ; and ( iii ) combination therapy with both agents was conspicuously successful in achieving reduction in blood pressure . It is suggested that combination nifedipine-captopril therapy be subject to a formal trial for early therapy in acute severe hypertension BACKGROUND Out-of-office blood pressure ( BP ) measurement using home BP ( HBP ) or ambulatory BP ( ABP ) monitoring is often necessary for the accurate evaluation of hypertension . These methods have several similarities but also have major differences . Therefore , they are regarded as complementary , and there is uncertainty on how they should be applied in clinical practice . This study compared hypertension management based on clinic and ABP measurements or on HBP measurements alone . METHODS Untreated subjects with elevated BP were r and omized to treatment initiation and titration based on clinic and ABP measurements or on HBP measurements alone . Target organ damage was assessed at baseline and after 1 year of treatment with echocardiographic left ventricular mass index ( primary endpoint ) , pulse wave velocity , and urinary albumin excretion . RESULTS A total of 145 subjects were r and omized , and 116 completed the study ( mean age = 50.7±10.5 years ; 69 men ( 59 % ) ; mean follow-up = 13.4±1.4 months ) . There was no difference between the 2 arms in treatment-induced change in left ventricular mass index ( mean difference = 0.50±1.11 g/m2 ; 95 % confidence interval ( CI ) = -1.70 to 2.70 ) . Moreover , there was no difference between the 2 arms in treatment-induced changes in pulse wave velocity ( mean difference = -0.16±0.42 m/s ; 95 % CI = -0.99 to 0.66 ) , urinary albumin excretion ( mean difference = -0.85±4.28 mg/dl ; 95 % CI = -9.37 to 7.66 ) , HBP and ABP levels , and hypertension control rates . CONCLUSIONS These data suggest that HBP monitoring alone is as reliable as combined clinic and ABP measurements in monitoring the effects of antihypertensive drug treatment on BP and pre clinical target organ damage Blood  pressure self-measurement is increasing in most communities and yet its role in the management of hypertension is poorly understood . This study was devised to evaluate the behaviour of doctors in general practice when treating patients with poorly controlled essential hypertension who use self-measurement . Patients , most of whom were already taking antihypertensive medications were commenced on perindopril or indapamide at their doctor ’s discretion and were r and omly allocated to self-measurement ( SM ) using an OMRON HEM706 oscillometric device or a continuation of their usual care ( UC ) over an 8-week period . This was an observational study without any specific or set treatment goals for the doctor to follow . Sixty of 62 subjects completed the study and the two groups were equally matched for age , body mass index , gender , and blood pressure ( BP ) . While additional perindopril or indapamide produced a significant fall in BP in both groups over the study period , the systolic pressure remained significantly higher in the SM group ( sitting 148 ± 3 compared with 142 ± 3 ; 145 ± 3 compared with 138 ± 3 mm Hg respectively ; P < 0.05 ) . twenty-four hour and daytime ambulatory monitor systolic pressures were also significantly higher in the sm group . differences in diastolic bp were not statistically significant . furthermore , sm patients were less likely to have their medications increased and more likely to have them reduced or ceased . doctors and patients found self-measurement convenient and useful . this study suggests that doctors prescribing decisions are influenced by evidence from self-measurement of bp with consequential increases in office bp related to reduced drug use . while self-bp measurement can offer reassurance about adequacy of control when away from a physicians office , our best evidence of underst and ing target blood pressures comes from large r and omised studies using office blood pressures as an end-point . there is an urgent need for further study to provide arbitration between self-measurement and office blood pressures although each measurement must contribute to the management of hypertension Hypertensive emergencies , and to a certain extent their treatment , contribute to morbidity and mortality in elderly patients . We studied 22 hospitalized patients , aged 70 - 90 years , all of whom had moderate essential hypertensive . During acute hypertension , mean systolic and diastolic blood pressure rose to 230 + /- 24 and 120 + /- 22 mmHg , respectively . Symptoms of reduced tissue perfusion/oxygenation and /or organ failure occurred , forcing us to begin antihypertensive therapy . We administered 50 mg of the angiotensin converting enzyme ( ACE ) inhibitor captopril sublingually , and within 15 min , systolic blood pressure decreased by an average 60 + /- 16 mmHg and diastolic blood pressure by an average 25 + /- 14 mmHg . There was no significant change in the heart rate . In addition , we treated 22 comparable patients with 10 mg nifedipine sublingually and observed , in four cases , a greater fall in blood pressure ( up to 90 mmHg ) together with tachycardia . These results show the beneficial effects of captopril in the treatment of hypertensive emergencies in elderly patients . The absence of dangerous side effects indicates that ACE inhibitors can be used as first-choice drugs for the treatment of acute hypertensive crises , even in old age Although inhibitors of the renin – angiotensin system are effective as first-line antihypertensive drugs in hypertensive patients with chronic kidney disease , they can not completely prevent the progression of renal injury . Many animal studies , including our own , and a few human studies suggest that mineralocorticoid receptor blockade could inhibit the ongoing renal damage in chronic kidney disease . Thus , we design ed this double-blinded , r and omized , placebo-controlled trial to evaluate the antialbuminuric effect of a low dose ( 50 mg day−1 ) of the mineralocorticoid receptor antagonist eplerenone . The study subjects will include 340 hypertensive patients ( blood pressure : 130–180/80–100 mm Hg ) with albuminuria ( urinary albumin/creatinine ratio : 30–600 mg g−1 in the first morning void urine ) , who are treated with an inhibitor of the renin – angiotensin system . Other classes of antihypertensive drugs may be added as needed to achieve the target blood pressure ( < 130/80 mm Hg ) . The primary study end point is the change in the urinary albumin/creatinine ratio after a 1-year study period . This trial is expected to show whether a low dose of mineralocorticoid receptor antagonists can exert an antialbuminuric effect in patients with chronic kidney disease Aim of the study was to assess the effectiveness and tolerability of sublingual captopril ( SLC ) versus sublingual nifedipine ( SLN ) in treating  hypertensive emergencies . During hypertensive crises ( systolic blood pressure exceeding 200 mmHg and diastolic blood pressure exceeding 115 mmHg ) forty hypertensive patients received either 25 mg of SLC or 10 mg of SLN in a r and omized single blind fashion . Blood pressure and heart rate were then controlled after 5 , 10 , 15 , 20 , 30 , 45 , 60 , 120 min . and , in 18 cases , up to the 8th hour from the administration . Our results showed : 1 ) a satisfactory control of the hypertensive crises in 80 % of patients treated with SLC with a significant blood pressure reduction after 10 min . ( 13/8 mmHg , p less than 0.02 ) , while the maximum hypotensive effect was achieved after 30 min . ( 52/36 mmHg , p less than 0.001 ) ; SLN was able to reduce blood pressure in 90 % of all the cases , with a significant reduction after 5 min . ( 15/11 mmHg , p less than 0.02 ) and hypotensive peak after 20 min ( 57/38 mmHg , p greater than 0.001 ) ; 2 ) no significant differences for hypotensive effectiveness between the two groups , but with SLC having a mildly delayed onset of action when compared to SLN ; 3 ) antihypertensive effect lasting for about 6 hours in patients treated with SLC and blood pressure progressively raising after 4 hours in patients who received SLN ; 4 ) a significant correlation between blood pressure reduction and blood pressure before drug administration in both groups ; a significant correlation between pretreatment PRA and antihypertensive effect in the SLC group . We conclude that both drugs are effective and useful in treating  hypertensive emergencies .  Anyway we think that in severe forms SLN should be preferred for the shorter time preceding onset of action OBJECTIVES Despite a broad and efficient pharmacological antihypertensive armamentarium , blood pressure ( BP ) control is suboptimal and heterogeneous throughout Europe . Recent representative data from Switzerl and are limited . The goal of the present survey was therefore to assess the actual control rate of high BP in Switzerl and in accordance with current guidelines . The influence of risk factors , target organ damage and medication on BP levels and control was also evaluated . METHODS A cross-sectional visit-based survey of ambulatory hypertensive patients was performed in 2009 in Switzerl and . 281 r and omly selected physicians provided data on 5 consecutive hypertensive patients attending their practice s for BP follow-up . Data were anonymously collected on demographics , comorbidities and current medication , and BP was recorded . Subsequent modification of pharmacological antihypertensive therapy was assessed . RESULTS Data from 1376 patients were available . Mean age was 65 ± 12 years , 53.9 % were male subjects . 26.4 % had complicated hypertension . Overall , BP control ( < 140/90 mm Hg for uncomplicated and < 130/80 mm Hg for complicated hypertension ) was achieved in 48.9 % . Compared to patients with complicated hypertension , BP control was better in patients with uncomplicated hypertension ( 59.4 % vs. 19.2 % , p < 0.001 ) . As a monotherapy the most prescribed drug class were angiotensin receptor blockers ( ARB , 41 % ) , followed by angiotensin converting enzyme ( ACE ) inhibitors ( 21.5 % ) , betablockers ( 20.8 % ) and calcium channel blockers ( CCB , 10.8 % ) . The most prescribed drug combinations were ARB + diuretic ( 30.1 % ) and ACE inhibitors + diuretic ( 15.3 % ) . 46 % were receiving a fixed drug combination . In only 32.7 % of patients with uncontrolled hypertension was a change in drug therapy made . CONCLUSION This representative survey on treated adult hypertensive patients shows that , compared to earlier reports , the control rate of hypertension has improved in Switzerl and for uncomplicated but not for complicated , particularly diabetes-associated hypertension . ARBs and ACE inhibitors are the most prescribed antihypertensive drugs for monotherapy , whereas diuretics and ARBs were the most used for combination therapy We compared antihypertensive efficacy and safety of a single administration of equipotent doses of lacidipine versus nifedipine in the hypertensive urgencies . Twenty-nine asymptomatic essential hypertensive patients ( nine men , 20 women ) with a mean age of 55.03+/-11.19 years and baseline diastolic blood pressure ( DBP ) of > or = 120 mm Hg after resting 30 min , not taking antihypertensive drugs for the last 24 h , were r and omized in a single-blind fashion to receive lacidipine , 4 mg ( LCD , 15 patients ) or short-acting nifedipine , 20 mg ( NFD , 14 patients ) in a single dose . Blood pressure ( BP ) and heart rate ( HR ) were taken every 30 min during the first 8 h and every 2 h until 24 h of follow-up . Baseline BP values were similar in the two groups ( LCD , 222.5+/-32.8/124.6+/-8.4 mm Hg vs. NFD , 215.9+/-20.6/128+/-7.7 mm Hg ; p = NS ) . Both drugs promoted a significant reduction of systolic blood pressure ( SBP ; 169.6+/-27.8 vs. 170.6+/-25.3 mm Hg ) and diastolic blood pressure ( DBP ; 104.1+/-16 vs. 102.9+/-12.4 mm Hg ) after 8 h. However , either SBP ( 165+/-27.3 vs. 190.6+/-18.2 mm Hg ; p = 0.008 ) and DBP ( 99.9+/-12.3 vs. 117.2+/-11.4 mm Hg ; p = 0.001 ) were significantly higher in the NFD group after 24-h dosing . Eleven patients in the LCD group had a decrease in BP > 25 % of the baseline value both 8 and 24 h after the dose . Although 10 patients showed the same response in the NFD group 8 h after the dose , only four patients maintained these values at 24 h. One patient treated with NFD had a transient cerebrovascular ischemic attack . No adverse effects were observed in the LCD group . We conclude that the long-acting calcium antagonist lacidipine was more effective than the short-acting nifedipine in both controlling BP and maintaining this BP reduction over 8 h in essential hypertensive patients with acute asymptomatic BP increase OBJECTIVE To compare the safeties and efficacies of IV fenoldopam ( FNP ) vs sodium nitroprusside ( NTP ) in severe acute hypertension . METHODS A prospect i ve , r and omized , open-label , multicenter international trial , at 24 academic medical centers , was conducted . The participants were adult patients ( 21 - 80 years of age ) who had supine diastolic blood pressures ( DBPs ) > or = 120 mm Hg , were capable of written informed consent , and did not have selected exclusion criteria . The subjects were r and omized to either FNP or NTP therapy ; DBP was titrated to 95 - 110 mm Hg , or a maximum reduction of 40 mm Hg for very high pressures . Infusions were maintained for at least six hours , then the patients were weaned off the IV therapy and oral medication was started . Measurements included BP , heart rate , and duration of study drug infusion and frequency of side effects or complications . RESULTS A total of 183 patients ( 90 FNP , 93 NTP ) were enrolled . Fifteen patients from each arm were excluded from efficacy analysis due to protocol violation . There was no significant difference in baseline characteristics . The two antihypertensive agents were equivalent in controlling and maintaining DBP . Systolic blood pressure ( SBP ) was reduced to a slightly greater degree for the NTP-treated patients during the initial ( 0.5 - 1-hr ) study period , and both SBP and DBP were reduced more for the FNP-treated patients in the subset receiving infusions during the 12 - 24-hour period . The adverse effect profiles of the drugs were similar , as were the times to achieve target pressure , with no clinical ly relevant difference . CONCLUSIONS For patients who had acute severe hypertension , FNP and NTP were equivalent in terms of efficacy and acute adverse events . Because of a unique mechanism of action , FNP may have advantages in selected subsets of patients . Further studies may be indicated in patient population s with pure " hypertensive emergencies . The purpose of this study was to evaluate the association of the insulin resistance syndrome with both blood pressure and target organ damage in blacks and whites with essential hypertension . Eighty-two black and 63 white French Canadian patients were studied . None had diabetes , and antihypertensive medications had been discontinued for ≥1 week . Measurements included 24-hour blood pressure monitoring , fasting plasma lipids , insulin sensitivity determined with the Bergman minimal model , echocardiogram , microalbumin excretion , and inulin and lithium clearances . Compared with the white French Canadians , black patients had an attenuated nighttime reduction in blood pressure ( P < 0.02 ) , increased cardiac dimensions ( P < 0.001 ) , greater microalbumin excretion ( P < 0.05 ) , increased inulin clearance ( indicative of glomerular hyperfiltration;P < 0.001 ) , and decreased lithium clearance ( indicative of increased sodium reabsorption in the proximal tubule;P < 0.001 ) . Blood pressure levels were not related to insulin resistance ; although in blacks , the nighttime reduction in systolic blood pressure was inversely related to fasting plasma insulin ( r = −0.18 , P < 0.04 ) . In a stepwise multivariate analysis ( including blood pressure levels and components of the insulin resistance syndrome as independent variables ) , race was the strongest predictor of left ventricular mass ( r = 0.53 , P < 0.000 ) , relative wall thickness ( r = 0.49 , P < 0.000 ) , and both inulin ( r = 0.53 , P < 0.000 ) and lithium ( r = 0.41 , P < 0.000 ) clearances . Nighttime systolic blood pressure was also a significant determinant of concentric left ventricular hypertrophy ( r = 0.37 , P < 0.000 ) . In blacks , microalbumin excretion was related to insulin resistance . These observations are consistent with the hypothesis that there is a genetic contribution to cardiac hypertrophy , glomerular hyperfiltration , and sodium retention in blacks with essential hypertension
There is important evidence in favor of the use of angiotensin-converting enzyme inhibitors for treating hypertensive urgencies , compared with calcium channel blockers , considering the better effectiveness and the lower frequency of adverse effects ( like headache and flushing )
CONTEXT AND OBJECTIVE Hypertensive urgencies are defined as severe elevations in blood pressure without evidence of acute or progressive target-organ damage .
The need for treatment is considered urgent but allows for slow control using oral or sublingual drugs .
If the increase in blood pressure is not associated with risk to life or acute target-organ damage , blood pressure control must be implemented slowly over 24 hours .
For hypertensive urgencies , it is not known which class of antihypertensive drug provides the best results and there is controversy regarding when to use antihypertensive drugs and which ones to use in these situations .
The aim of this review was to assess the effectiveness and safety of oral drugs for hypertensive urgencies .