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 .
Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema
BACKGROUND Nitrates and furosemide , commonly administered in the treatment of pulmonary oedema , have not been compared in a prospect i ve clinical trial . We compared the efficacy and safety of these drugs in a r and omised trial of patients with severe pulmonary oedema and oxygen saturation below 90 % . METHODS Patients presenting to mobile emergency units with signs of congestive heart failure were treated with oxygen 10 L/min , intravenous furosemide 40 mg , and morphine 3 mg bolus .  110 patients were r and omly assigned either to group A , who received isosorbide dinitrate ( 3 mg bolus administered intravenously every 5 min ; n=56 ) or to group B , who received furosemide ( 80 mg bolus administered intravenously every 15 min , as well as isosorbide dinitrate 1 mg/h , increased every 10 min by 1 mg/h ; n=54 ) . Six patients were withdrawn on the basis of chest radiography results . Treatment was continued until oxygen saturation was above 96 % or mean arterial blood pressure had decreased by 30 % or to below 90 mm Hg . The main endpoints were death , need for mechanical ventilation , and myocardial infa rct ion . The analyses were by intention to treat . FINDINGS Mechanical ventilation was required in seven ( 13 % ) of 52 group-A patients and 21 ( 40 % ) of 52 group-B patients ( p=0.0041 ) . Myocardial infa rct ion occurred in nine ( 17 % ) and 19 ( 37 % ) patients , respectively ( p=0.047 ) . One patient in group A and three in group B died ( p=0.61 ) . One or more of these endpoints occurred in 13 ( 25 % ) and 24 ( 46 % ) patients , respectively ( p=0.041 ) . INTERPRETATION High-dose isosorbide dinitrate , given as repeated intravenous boluses after low-dose intravenous furosemide , is safe and effective in controlling severe pulmonary oedema . This treatment regimen is more effective than high-dose furosemide with low-dose isosorbide nitrate in terms of need for mechanical ventilation and frequency of myocardial infa rct ion
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 .