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Treatment of hypertensive emergencies: blood pressure cosmetics or outcome evidence?

Journal of Human Hypertension volume 22, pages 585–586 (2008)Cite this article

For almost half a century, the standard approach to the treatment of hypertensive emergencies has been based on the evidence from a case series by Gifford. In this study, the blood pressure was promptly reduced with either reserpine, the drug of first choice at the time, or sodium nitroprusside.1 In 1991, the Lancet stated, ‘Clearly the immediate goal of treatment should be a reduction in pressure that begins quickly and continues gradually.’2 At that time, some of the preferred drugs to be used for achieving blood pressure control were sublingual captopril or nifedipine. Interestingly, the Lancet editorial also stated emphatically, ‘In case of doubt, nifedipine will be the safer option.’2 We, since then, have learned that this dictum was not necessarily true.

Although nifedipine is a powerful vasodilator and lowers blood pressure rapidly,3, 4, 5, 6, 7, 8 such a precipitous pressure reduction can, in susceptible patients, lead to significant morbidity and mortality. Indeed, numerous instances of acute myocardial infarction, devastating strokes and even death have been reported with the sublingual use of nifedipine. Although blood pressure studies with nifedipine are legion, its safety and efficacy has never been established. Not surprisingly, sublingual nifedipine was pulled from the antihypertensive arsenal for hypertensive emergencies after its dismal risk/benefit ratio was publicized and its widespread use came to a screeching halt.5 More recently, common practice has been to rapidly lower blood pressure by no more than 25% within the first 2 h and to achieve a blood pressure level of about 160/100 mm Hg after 6 h.9

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  1. Department of Cardiology, St Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY, USA

    F H Messerli & D J Eslava

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  1. F H Messerli
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  2. D J Eslava
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Correspondence to F H Messerli.

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Messerli, F., Eslava, D. Treatment of hypertensive emergencies: blood pressure cosmetics or outcome evidence?. J Hum Hypertens 22, 585–586 (2008). https://doi.org/10.1038/jhh.2008.28

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