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Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature.
J Gen Intern Med. 2002 Dec; 17(12):937-45.JG

Abstract

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Links

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Authors+Show Affiliations

Cherney D
Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada. dchern@hotmail.com
Straus S
No affiliation info available

MeSH

Antihypertensive AgentsBlood Pressure DeterminationClinical Trials as TopicCritical IllnessEmergenciesEmergency Service, HospitalHumansHypertensionNitroprussidePiperazinesRandomized Controlled Trials as Topic

Pub Type(s)

Journal Article
Review
Systematic Review

Language

eng

PubMed ID

12472930

Citation

Cherney, David, and Sharon Straus. "Management of Patients With Hypertensive Urgencies and Emergencies: a Systematic Review of the Literature." Journal of General Internal Medicine, vol. 17, no. 12, 2002, pp. 937-45.
Cherney D, Straus S. Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature. J Gen Intern Med. 2002;17(12):937-45.
Cherney, D., & Straus, S. (2002). Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature. Journal of General Internal Medicine, 17(12), 937-45.
Cherney D, Straus S. Management of Patients With Hypertensive Urgencies and Emergencies: a Systematic Review of the Literature. J Gen Intern Med. 2002;17(12):937-45. PubMed PMID: 12472930.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature. AU - Cherney,David, AU - Straus,Sharon, PY - 2002/12/11/pubmed PY - 2003/6/5/medline PY - 2002/12/11/entrez SP - 937 EP - 45 JF - Journal of general internal medicine JO - J Gen Intern Med VL - 17 IS - 12 N2 - BACKGROUND: Hypertensive urgencies and emergencies are common clinical occurrences in hypertensive patients. Treatment practices vary considerably to because of the lack of evidence supporting the use of one therapeutic agent over another. This paper was designed to review the evidence for various pharmacotherapeutic regimens in the management of hypertensive urgencies and emergencies, in terms of the agents' abilities to reach predetermined "safe" goal blood pressures (BPs), and to prevent adverse events. METHODS: medline was searched from 1966 to 2001, and the reference lists of all the articles were retrieved and searched for relevant references, and experts in the field were contacted to identify other relevant studies. The Cochrane Library was also searched. Studies that were eligible for inclusion in this review were systematic reviews of randomized control trials (RCTs) and individual RCTs, all-or-none studies, systematic reviews of cohort studies and individual cohort studies, and outcomes research. No language restrictions were used. RESULTS: None of the trials included in this review identified an optimal rate of BP lowering in hypertensive emergencies and urgencies. The definitions of hypertensive emergencies and urgencies were not consistent, but emergencies always involved target end-organ damage, and urgencies were without such damage. Measures of outcome were not uniform between studies. The 4 hypertensive emergency and 15 hypertensive urgency studies represented 236 and 1,074 patients, respectively. The evidence indicated a nonsignificant trend toward increased efficacy with urapidil compared to nitroprusside for hypertensive emergencies (number needed to treat [NNT] for urapidil to achieve target BP, 12; 95% confidence interval [95% CI], number of patients needed to harm [NNH], 5 to NNT, 40 compared to nitroprusside). Several medications were efficacious in treating hypertensive urgencies, including: nicardipine (NNT for nicardipine compared to plabebo, 2 in one study [95% CI, 1 to 5] and 1 in another [95% CI, 1 to 1]); lacidipine (NNT, 2; 95% CI, 1 to 8 for lacidipine vs nifedipine) or urapidil (NNT for urapidil compared to enalaprilat and nifedipine, 4; 95% CI, 3 to 6); and nitroprusside and fenoldopam (all patients reached target BP in 2 studies). The studies reported 2 cases of cerebral ischemia secondary to nifedipine. CONCLUSIONS: Many effective agents exist for the treatment of hypertensive crises. Because of the lack of large randomized controlled trials, many questions remain unanswered, such as follow-up times and whether any of the studied agents have mortality benefit. SN - 0884-8734 UR - https://www.unboundmedicine.com/medline/citation/12472930/Management_of_patients_with_hypertensive_urgencies_and_emergencies:_a_systematic_review_of_the_literature_ DB - PRIME DP - Unbound Medicine ER -