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 South African hypertension guideline 2011. Diclofenac sodium versus pethidine in acute renal colic. Hypertensive emergencies in old age: effects of angiotensin converting enzyme inhibition. The effect of treatment on mortality in "mild" hypertension: results of the hypertension detection and follow-up program. The Dutch Renal Artery Stenosis Intervention Cooperative (DRASTIC) Study: rationale, design and inclusion data. Prognostic value of ambulatory blood pressure monitoring in refractory hypertension: a prospective study. The 2001 Canadian recommendations for the management of hypertension: Part two--Therapy. Self-measurement of blood pressure at home reduces the need for antihypertensive drugs: a randomized, controlled trial. The ABCD (Appropriate Blood Pressure Control in Diabetes) trial. Rationale and design of a trial of hypertension control (moderate or intensive) in type II diabetes. Association of angiotensin II type 1 receptor polymorphism with resistant essential hypertension. Central blood pressure measurements and antihypertensive therapy: a consensus document. Medical treatment of hypertension in Switzerland. The 2009 Swiss Hypertension Survey (SWISSHYPE). Sodium Intake Does Not Influence the Effect of Verapamil in Hypertensive Patients with Mild Renal Insufficiency Olmesartan vs ramipril in the treatment of hypertension and associated clinical conditions in the elderly: a reanalysis of two large double-blind, randomized studies at the light of the most recent blood pressure targets recommended by guidelines Safety and efficacy of urapidil and sodium nitroprusside in the treatment of hypertensive emergencies 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. Antihypertensive effect of diet compared with drug treatment in obese men with mild hypertension. The effect of sour tea (Hibiscus sabdariffa) on essential hypertension. Comparison of sublingual captopril and nifedipine in immediate treatment of hypertensive emergencies. A randomized, single-blind clinical trial. Severe hypertension in pregnancy: hydralazine or labetalol. A randomized clinical trial. Effect of various antihypertensive drugs on plasma fibrinogen levels in patients with essential hypertension. Are Observational Studies More Informative Than Randomized Controlled Trials in Hypertension?: Con Side of the Argument
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 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 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 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 In the Hypertension Detection and Follow-up Program , 7825 ( 71.5 per cent ) of the 10,940 participants had diastolic blood pressures averaging between 90 and 104 mm Hg on entry into the study and were design ated Stratum 1 . Half were referred to their usual source of care in the community ( the referred-care group ) , and half were treated intensively in special clinics ( the stepped-care group ) . Five-year mortality in the Stratum 1 patients given stepped care was 20.3 per cent lower than in those given referred care ( P less than 0.01 ) . Particularly noteworthy was the beneficial effect of stepped-care treatment on persons with diastolic pressures of 90 to 104 mm Hg who had no evidence of end-organ damage and were not receiving antihypertensive medication when they entered the study . This subgroup had 28.6 per cent fewer deaths at five years among those treated with stepped care than among those treated with referred care ( P less than 0.01 ) . These findings support a recommendation that in patients with mild hypertension , treatment should be considered early , before damage to end organs occurs 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 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 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 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 The primary objective of the ABCD ( Appropriate Blood Pressure Control in Diabetes ) Trial is to determine the efficacy of intensive versus moderate antihypertensive control on the outcome of type II diabetic end-organ complications in normotensive and hypertensive population s. The secondary objective is to determine whether any differential effect on end-organ complications exists between an angiotensin converting enzyme inhibitor ( enalapril ) and a calcium channel blocker ( nisoldipine ) . DESIGN The ABCD Trial is a prospect i ve , controlled , r and omized , double-blind trial , with a planned follow-up of 5 years . SETTING All patients are seen at the Colorado Prevention Center , site of the ABCD Trial , for follow-up visits . PATIENTS Patients are type II diabetic males and females between the ages of 40 and 74 years with entry diastolic blood pressures > or = 80 mmHg . Patients were recruited from University of Colorado-affiliated hospitals , several health maintenance organizations , and mailing lists from the Colorado affiliate of the American Diabetes Association . INTERVENTIONS Patients were r and omized to intensive antihypertensive drug therapy or moderate antihypertensive drug therapy . Patients were also r and omized to nisoldipine or enalapril , with open-label medications added if further blood pressure control was necessary . MAIN OUTCOME MEASURES The primary outcome measure is glomerular filtration rate as assessed by 24-hour creatinine clearance . Secondary outcome measures are microalbumin urinary excretion , left ventricular hypertrophy , retinopathy , and neuropathy . Cardiovascular morbidity and mortality will also be evaluated . CONCLUSION Given the data showing the impact of hypertension on diabetic complications , the ABCD Trial was design ed to determine if intensive antihypertensive therapy will be more efficacious than moderate antihypertensive therapy on the outcome of these complications . Results from the ABCD Trial are expected to lend interpretable and clinical ly relevant findings with regards to the treatment of hypertension in type II diabetes Angiotensin II type 1 receptor ( AT1 ) mediates the vasoconstrictive and growth-promoting effect of angiotensin II in humans . It has been reported that a polymorphism of the AT1 gene ( an A/C transversion at position 1166 : A-C1166 ) occurs more frequently in resistant hypertensives taking two or more antihypertensive drugs . On the contrary , a recent study of the influence of the A-C1166 polymorphism on aortic stiffness demonstrated that the distribution of the genotypes did not differ between normotensive and hypertensive subjects . In addition , a recent population -based survey of Caucasian hypertensives reported lower blood pressure values in CC homozygotes than in heterozygotes and AA homozygotes . Because of these controversial results and the lack of a sufficient amount of data the present study was design ed to assess the contribution of the AT , gene A-C1166 polymorphism to resistant essential hypertension . Forty-eight subjects with resistant essential hypertension ( HT ) and 48 normotensive ( NT ) , age and sex-adjusted controls ( from a population of 300 healthy blood donors ) were selected . All subjects were genotyped for the A-C1166 polymorphism in the 3'-UTR of the AT1 gene using PCR-based techniques . The influence of genotype on blood pressure ( BP ) was investigated using ANOVA R and omized Complete Block ( ANOVA RCB ) design according to sex , age and BMI . There were no significant differences in allele or genotype frequencies between HT and NT subjects ( X2 = 0.61 ; P = NS ) . In HT subjects higher values of systolic blood pressure were associated with the C allele of the AT1 gene only in older and overweight patients ( P < 0.001 and P < 0.001 , respectively ) . Also in HT patients an association between the presence of the C allele of the AT1 gene and higher values of diastolic blood pressure was present in overweight patients ( P = 0.001 ) . These results suggest that in resistant hypertensive subjects the AT1 A-C1166 polymorphism is potentially involved in the regulation of blood pressure . As the effects of genotypes on blood pressure are pronounced in older and overweight subjects this polymorphism may amplify the effects of age and BMI on resistant essential hypertension 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 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 Summary Information is limited regarding the efficacy of antihypertensive drugs in patients with hypertension associated with renal insufficiency . To address this question , a group of 14 out patients with essential hypertension and mild renal insufficiency received slow release verapamil 240 mg/day for 14 days after a 4-week washout period . Patients were r and omly assigned to a low ( 4 g/ day ) or high ( 11 g/day ) salt diet , and crossed over to the alternative diet after 7 days .  24-Hour blood pressure monitoring was performed at the end of the washout period and after 7 and 14 days during verapamil treatment . Verapamil induced a significant fall in mean 24-hour blood pressure that was similar for patients on both diets ( p < 0.01 ) . As expected , natriuresis increased significantly during high sodium intake ( p < 0.01 ) , and bodyweight fell significantly when sodium intake was reduced ( p < 0.05 ) . Meanwhile , serum creatinine and creatinine clearance remained stable . These results indicate that the antihypertensive effect of verapamil is independent of sodium intake even in the presence of mild renal insufficiency In this paper , we present the results of a re analysis of the data of two large r and omized , double-blind , parallel group studies with a similar design , comparing the efficacy of an angiotensin-receptor blocker ( olmesartan medoxomil ) with that of an angiotensin-converting enzyme inhibitor ( ramipril ) , by applying two different blood pressure targets recently recommended by hypertension guidelines for all patients , irrespective of the presence of diabetes ( < 140/90 mmHg ) , and for elderly hypertensive patients ( < 150/90 mmHg ) . The efficacy of olmesartan was not negatively affected by age , sex , hypertension type , diabetes status or other concomitant clinical conditions , or cardiovascular risk factors . In most cases , olmesartan provided better blood pressure control than ramipril . Olmesartan was significantly more effective than ramipril in male patients , in younger patients ( aged 65–69 years ) , in those with metabolic syndrome , obesity , dyslipidemia , preserved renal function , diastolic ± systolic hypertension , and , in general , in patients with a high or very high cardiovascular risk . Interestingly , patients previously untreated or treated with two or more antihypertensive drugs showed a significantly larger response with olmesartan than with ramipril . Thus , our results confirm the good efficacy of olmesartan in elderly hypertensives even when new blood pressure targets for antihypertensive treatment are considered . Such results may be relevant for the clinical practice , providing some hint on the possible different response of elderly hypertensive patients to two different drugs acting on the renin – angiotensin system , when patients are targeted according to the blood pressure levels recommended by recent hypertension guidelines Objective : To assess the safety and efficacy of urapidil compared to sodium nitroprusside in the treatment of hypertensive emergencies . Design : r and omized , prospect i ve clinical study . Setting : Emergency department in a 2000-bed inner city hospital . Patients : Eighty-one patients with hypertensive emergencies defined as elevation of systolic blood pressure above 200 mmHg and /or diastolic blood pressure above 110 mmHg plus evidence of end-organ damage were included in the study protocol . The efficacy of therapy was defined as 1 ) blood pressure reduction below 180/95 mmHg within 90 min and 2 ) no re-elevation of blood pressure during a 4-h follow-up period in primary responders . The safety of both drugs was defined as the number of minor and major side effects during treatment . Interventions : Patients received either sodium nitroprusside ( n = 35 ; continuous intravenous administration with a starting dose of 0.5 μg/kg per min ; increase in increments of 0.5 μg/kg per min every 15 min until response to treatment or a maximum of 3 μg/kg per min ) or urapidil ( n = 46 ; intravenous bolus ; starting dose : 12.5 mg ; repetitive administration of 12.5 mg every 15 min until response or a maximum dose of 75 mg ) . Measurements and results : Blood pressure was measured every 2.5 min by using a non-invasive oscillometric blood pressure measurement unit . Response to treatment within 90 min was observed in 75 ( 93 % ) patients ( urapidil : n = 41 [ 89 % ] ; nitroprusside : n = 34 [ 97 % ] ; p = 0.18 ) . During the follow-up period 8/34 ( 24 % ) patients in the nitroprusside group and 1/41 ( 2 % ) patients in the urapidil  group exhibited blood pressure re-elevation . Major side effects were observed in seven patients receiving nitroprusside and two patients in the urapidil group ( p = 0.04 ) . Conclusion : Urapidil is equally effective , compared to sodium nitroprusside , in the treatment of hypertensive emergencies . Due to a smaller number of adverse events , urapidil is a reasonable alternative to nitroprusside in the treatment of hypertensive emergencies 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 OBJECTIVE --To determine whether dietary treatment has a similar antihypertensive effect to conventional drug treatment while being superior to drugs in improving serum lipid concentrations in obese men with mild hypertension . DESIGN --Six week run in period followed by r and omisation to either diet or drug treatment groups for one year . SETTING --Outpatient clinic in city hospital . PATIENTS --61 Men aged 40 - 69 years , body mass index greater than or equal to 26 , diastolic blood pressure 90 - 104 mm Hg when untreated . Exclusion criteria were signs of organ damage secondary to hypertension and diseases that might have interfered with compliance or with interpretation of results . INTERVENTIONS --Dietary treatment was based on weight reduction , restriction of sodium , and decrease of excess alcohol intake ( defined as greater than or equal to 250 g alcohol per week ) . Drug treatment used a stepped care approach with atenolol as drug of first choice . MAIN OUTCOME MEASURES --Diastolic blood pressure less than 90 mm Hg ; absolute reductions in blood pressure and serum lipid concentrations . RESULTS --Mean body weight decreased 7.6 kg in the diet group and increased 0.9 kg in the drug treatment group ( p less than 0.0001 ) , and mean sodium excretion decreased 42 and 10 mmol/24 h respectively ( p = 0.019 ) . There was no difference in reported alcohol intake . Mean systolic blood pressure decreased 4 mm Hg in the diet group and 16 mm Hg in the drug group ( p = 0.003 ) and diastolic blood pressure 3 and 11 mm Hg respectively ( p = 0.002 ) . Diastolic blood pressure of 90 mm Hg was attained by 29 % of the diet group ( nine men ) and 73 % ( 22 ) of those receiving drug treatment ( mean difference 44 % , 95 % confidence interval 21 to 67 % , p = 0.001 ) . Dietary treatment produced decreases in mean serum concentrations of total and low density lipoprotein cholesterol as well as triglycerides and an increase in high density lipoprotein cholesterol concentration . In the drug treatment group the changes were in the opposite direction , and the groups differed significantly in all but total cholesterol . CONCLUSIONS --Dietary treatment was inferior to conventional drug treatment in controlling mild hypertension but superior in lowering serum concentrations of lipids Considering the high prevalence of hypertension , its debilitating end organ damage , and the side effects of chemical drugs used for its treatment , we conducted this experimental study to evaluate the effect of sour tea ( Hibiscus sabdariffa ) on essential hypertension . For this purpose , 31 and 23 patients with moderate essential hypertension were r and omly assigned to an experimental and control group , respectively . Patients with secondary hypertension or those consuming more than two drugs were excluded from the study .  Systolic and diastolic blood pressures were measured before and 15 days after the intervention . In the experimental group , 45 % of the patients were male and 55 % were female , and the mean age was 52.6 + /- 7.9 years . In the control group , 30 % of the patients were male , 70 % were female , and the mean age of the patients was 51.5 + /- 10.1 years . Statistical findings showed an 11.2 % lowering of the systolic blood pressure and a 10.7 % decrease of diastolic pressure in the experimental group 12 days after beginning the treatment , as compared with the first day . The difference between the systolic blood pressures of the two groups was significant , as was the difference of the diastolic pressures of the two groups . Three days after stopping the treatment , systolic blood pressure was elevated by 7.9 % , and diastolic pressure was elevated by 5.6 % in the experimental and control groups . This difference between the two groups was also significant . This study proves the public belief and the results of in vitro studies concerning the effects of sour tea on lowering high blood pressure . More extensive studies on this subject are needed Sublingual captopril ( 25 mg ) was compared with sublingual nifedipine ( 10 mg ) to determine their effectiveness and safety in the treatment of hypertensive emergencies . In nine of 10 patients who received sublingual captopril , mean ( + /- SD ) systolic blood pressure and diastolic blood pressure dropped from 245 + /- 39 to 190 + /- 25 mm Hg ( P less than .0025 ) and from 144 + /- 8 to 115 + /- 8 mm Hg ( P less than .001 ) at 50 minutes , respectively . The hypotensive effect of the drug was maintained for a mean of 4 hours . In six of nine responders to sublingual captopril , blood pressure-lowering effect was associated with a clear improvement of end-organ failure within 60 minutes . There were no side effects , including a dangerous fall in blood pressure or reflex tachycardia . Sublingual nifedipine lowered diastolic blood pressure and systolic blood pressure in eight of 10 patients . The hypotensive effect of nifedipine was more rapid than that of captopril ( 10 vs 20 minutes for diastolic blood pressure and 20 vs 30 minutes for systolic blood pressure , respectively ) , but no difference was observed in the time or in the magnitude of peak hypotensive effect between the two treatments , nor was a difference observed in the duration of hypotensive effect . In six of eight responders to nifedipine therapy , a clear improvement of symptoms and signs of end-organ failure was observed within 60 minutes . In three patients , minor side effects were observed . We conclude that sublingual captopril effectively and safely lowers arterial blood pressure in patients with hypertensive emergencies OBJECTIVE The objective was to compare the safety and efficacy of intravenous labetalol and intravenous hydralazine for acutely lowering blood pressure in pregnancy . STUDY DESIGN Two hundred women with severe hypertension in pregnancy were r and omized to receive hydralazine ( 5 mg as a slow bolus dose given intravenously , and repeated every 20 min up to a maximum of five doses ) or labetalol ( 20-mg intravenous bolus dose followed by 40 mg if not effective within 20 min , followed by 80 mg every 20 min up to a maximum dose of 300 mg ) . The primary end point was successful lowering of blood pressure and maternal hypotension . RESULTS Women were similar with respect to characteristics at r and omization . No significant differences were observed for maternal hypotension or persistent severe hypertension ; only two patients in the hydralazine group presented with hypotension . Palpitations ( p=0.01 ) and maternal tachycardia ( p=0.05 ) occurred significantly more often in patients treated with hydralazine . The main neonatal outcomes were very similar per group ; however , hypotension and bradycardia were significantly more frequent in the labetalol group . There were two neonatal deaths per antihypertensive drug group . CONCLUSIONS This r and omized clinical trial shows that labetalol and hydralazine fulfill the criteria required for an antihypertensive drug to treat severe hypertension in pregnancy In recent years , substantial evidence has accumulated to unambiguously implicate high plasma fibrinogen levels as a major cardiovascular risk factor . An open prospect i ve and r and omised pilot study was therefore undertaken in mild to moderate hypertensives to evaluate the effect of various antihypertensive drugs viz enalapril , felodipine and prazosin on the blood pressure and plasma fibrinogen levels . The systolic and diastolic blood pressures were determined at 0 , 4 and 8 weeks whereas plasma fibrinogen assays were done at baseline and at the end of the 8th week of treatment in all the drug-treated groups . It was observed that although all the three drugs effectively controlled blood pressure , only enalapril significantly reduced plasma fibrinogen levels . Due to this additional effect , enalapril has potential to control two major cardiovascular risk factors -- hypertension and high plasma fibrinogen levels -- simultaneously The very first rigorously design ed , r and omized controlled trial ( RCT ) in the history of modern medicine was published in 1948 . The study , design ed and carried out by the Streptomycin in Tuberculosis Trials Committee of the Medical Research Council , demonstrated the efficacy of streptomycin in treating pulmonary tuberculosis on top of bed rest , which was the best available treatment at that time.1 In the field of hypertension treatment and cardiovascular prevention , the history of event-based RCTs began in 1967 , when the cardiovascular benefits and risks of antihypertensive drug treatment were evaluated in the setting of the Veterans Administration Cooperative Study in Hypertension.2 In that trial , 143 patients with severe hypertension were r and omized to receive blood pressure (BP)–lowering drug treatment or matched placebo for 11 months . A major morbid or fatal event was observed in 26 of 70 patients who received placebo ( 37 % ) and in only 1 of 73 patients under active treatment ( 1 % ) . The amazing results of this l and mark trial established beyond any doubt the striking cardiovascular benefits of antihypertensive drug treatment of hypertension at a time when controversy still persisted regarding the supposedly deleterious effects of BP reduction on organ perfusion.3 Ever since , RCTs have represented a formidable tool for evaluating risks and benefits of hypertension treatment . Over the past 50 years , the remarkable progress in treatment and control of high BP , one of the most outst and ing achievements of modern medicine , has been driven by the results of many large , event-based RCTs . The influential position of RCTs in clinical and therapeutic research as opposed to real-world observational studies ( surveys , registries , and retrospective analyses of existing data bases ) originates from their high internal validity ( ie , the power to address clinical questions with a low level of internal bias ) . A list of strengths and weaknesses of RCTs and observational studies is
There is no RCT evidence demonstrating that antihypertensive drugs reduce mortality or morbidity in patients with hypertensive emergencies .
Furthermore , there is insufficient RCT evidence to determine which drug or drug class is most effective in reducing mortality and morbidity .
There were some minor differences in the degree of blood pressure lowering when one class of antihypertensive drug is compared to another .
However , the clinical significance is unknown .
Hypertensive emergencies occur when high blood pressure is associated with the presence of acute end-organ damage , such as hypertensive encephalopathy .
There is controversy as to when and which antihypertensive drugs to use in these situations .