Here we present a case report of a precipitous drop in blood pressure following immediate-release nifedipine in the emergency treatment of hypertension. A 42-year-old woman with a past history of gestational hypertension and chronic essential hypertension presented 6 days following the delivery of her third child. This had been a spontaneous vaginal delivery at 38 weeks gestation without intrapartum problems. She now complained of a severe right-sided headache and her blood pressure measured 220/110 mm Hg. Physical examination, urinalysis, electrocardiogram and biochemistry were unremarkable. She received 20 mg of an instant-release formulation of nifedipine in capsule form. Her blood pressure response is shown in Figure 1. She was discharged from hospital 5 days later in good health with a blood pressure of 145/90 on Adalat LA (long-acting nifedipine) at a once-daily dose of 60 mg.
Most authorities recommend that in the emergency treatment of hypertension, the aim is to produce a gradual but sustained fall in systemic blood pressure over hours to days.1 For example, the European Society of Hypertension recommends that in hypertensive urgencies (defined as severe elevations in BP >180/120 mm Hg without evidence of target organ damage), blood pressure should be lowered over 24–48 h using orally administered drugs.2 Although the dangers of immediate-release nifedipine are well described these preparations remain in widespread clinical use. This review summarises recent reports of such adverse events. Rapid fall in pressure can compromise cerebral and myocardial perfusion with dramatic consequences. There are numerous case reports in the literature of such calamities following administration of sublingual nifedipine capsules, including reports of cerebrovascular ischaemia, severe hypotension, acute myocardial infarction, conduction disturbances, fetal distress and death.3, 4 Given that sublingual absorption of nifedipine is poor and most of the drug is absorbed by the intestinal mucosa,5 it is to be expected that other immediate-release preparations carry similar risks. There are no large randomized clinical trials showing the frequency of adverse events with immediate-release nifedipine. The few small trials that do exist are outlined in Table 1.
It has been recommended that the use of instant-release formulations of nifedipine in the treatment of hypertension should be either totally prohibited or severely restricted.4 The case in point must, therefore, be seen as a lucky escape.
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Burton, T., Wilkinson, I. The dangers of immediate-release nifedipine in the emergency treatment of hypertension. J Hum Hypertens 22, 301–302 (2008) doi:10.1038/sj.jhh.1002324
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