title: 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 Comparison of sublingual captopril and nifedipine in immediate treatment of hypertensive emergencies. A randomized, single-blind clinical trial. Placebo-controlled, randomized, double-blind study of intravenous enalaprilat efficacy and safety in acute cardiogenic pulmonary edema. Should hypertension be treated after acute stroke? A randomized controlled trial using single photon emission computed tomography. Nicardipine versus Nitroprusside Infusion as Antihypertensive Therapy in Hypertensive Emergencies Treatment of hypertensive emergency Intravenous Fenoldopam Versus Sodium Nitroprusside in Patients With Severe Hypertension Sublingual nifedipine and captopril in hypertensive urgencies and emergencies. Severe hypertension with cerebral symptoms treated with furosemide, fractionated diazoxide or dihydralazine. Danish Multicenter Study. [Sublingually administered captopril versus nifedipine in hypertension emergencies]. The Use of Lacidipine in the Management of Hypertensive Crises: A Comparative Study with Nifedipine Short- and long-term cerebrovascular effects of nitrendipine in hypertensive patients. Nifedipine in hypertensive emergencies. Comparison between isosorbide dinitrate aerosol and nifedipine in the treatment of hypertensive emergencies Comparison of nitroglycerin with nifedipine in patients with hypertensive crisis or severe hypertension Safety and efficacy of urapidil and sodium nitroprusside in the treatment of hypertensive emergencies Rapid improvement of acute pulmonary edema with sublingual captopril. [Sublingual nitroglycerin or intravenous enalaprilat in preclinical treatment of hypertensive patients with pulmonary edema]. Treatment of hypertensive urgencies and emergencies with nitrendipine, nifedipine, and clonidine: effect on blood pressure and heart rate. HAEMODYNAMIC ADVANTAGES OF ISOSORBIDE DINITRATE OVER FRUSEMIDE IN ACUTE HEART-FAILURE FOLLOWING MYOCARDIAL INFARCTION Nitrate therapy is an alternative to furosemide/morphine therapy in the management of acute cardiogenic pulmonary edema. First‐Line Treatment of Left Ventricular Failure Complicating Acute Myocardial Infarction: A Randomised Evaluation of Immediate Effects of Diuretic, Venodilator, Arteriodilator, and Positive Inotropic Drugs on Left Ventricular Function Fenoldopam mesylate versus sodium nitroprusside in the acute management of severe systemic hypertension. Emergency treatment of severe hypertension evaluated in a randomized study. Effect of rest and furosemide and a randomized evaluation of chlorpromazine, dihydralazine and diazoxide. Danish Multicenter Study. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Hypertensive emergencies in old age: effects of angiotensin converting enzyme inhibition. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema [Comparative study of the use of nifedipine and captopril in hypertensive emergencies]. A randomized comparison of nifedipine and sodium nitroprusside in severe hypertension. Reversibility of cerebral symptoms in severe hypertension in relation to acute antihypertensive therapy. Danish Multicenter Study. Randomized, prospective trial of fenoldopam vs sodium nitroprusside in the treatment of acute severe hypertension. Fenoldopam Study Group. Effects of the administration of an angiotensin-converting enzyme inhibitor during the acute phase of myocardial infarction in patients with arterial hypertension. SMILE Study Investigators. Survival of Myocardial Infarction Long-term Evaluation. Comparison of sublingual captopril, nifedipine and prazosin in hypertensive emergencies during hemodialysis. A comparison of intravenous nicardipine and sodium nitroprusside in the immediate treatment of severe hypertension.
abstract: 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 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 BACKGROUND Converting enzyme inhibitors meet most of the criteria required to be used in acute pulmonary edema . However , they could also induce deleterious effects on renal function and electrolytes . The purpose of this study was to evaluate the efficacy and safety of a single intravenous 2-hour infusion of enalaprilat ( 1 mg ) after an acute pulmonary edema . METHODS AND RESULTS This was a placebo-controlled , r and omized , double-blind study performed in 20 congestive heart failure patients ( New York Heart Association class III or IV ) .  Systemic and regional hemodynamic parameters , biological parameters , and blood gases were measured before and repeatedly after the onset of infusion . Compared with placebo , enalaprilat decreased pulmonary capillary wedge pressure ( -37 % versus -10 % , P = .001 ) , diastolic and mean systemic blood pressures ( -21 % versus 0 % , P = .009 , and -18 % versus -1 % , P = .026 , respectively ) , diastolic and mean pulmonary blood pressures ( -21 % versus -8 % , P = .040 ; -18 % versus -9 % , P = .046 ) , and brachial and renal resistances ( -44 % versus -14 % , P = .017 , and -22 % versus -2 % , P = .014 , respectively ) ; increased brachial and renal blood flows ( + 77 % versus + 8 % , P = .036 , and + 12 % versus 0 % , P = .043 , respectively ) , arterial oxygen tension ( + 2 % versus -16 % , P = .041 ) , and arterial oxygen saturation ( + 1 % versus -2 % , P = .045 ) ; and tended to decrease rate-pressure product ( -19 % versus -7 % , P = .076 ) , increase brachial artery diameter ( + 13 % versus 0 % , P = .081 ) , and improve intrapulmonary shunt ( -18 % versus + 16 % , P = .080 ) . Enalaprilat did not affect cardiac output or carotid or hepatosplanchnic hemodynamics . CONCLUSIONS Early administration of enalaprilat is effective and well tolerated in acute pulmonary edema OBJECTIVE To determine if previously hypertensive patients with acute ischemic stroke should be treated with antihypertensive medication in the immediate poststroke period . DESIGN R and omized double-blind , placebo-controlled trial . SETTING Sixteen consecutive hypertensive patients ( four men and 12 women ; mean age , 66 years [ age range , 46 to 83 years ] ) with middle cerebral artery infa rct ion within 72 hours of onset and blood pressure between 170 and 220 mm Hg(systolic ) and 95 and 120 mm Hg ( diastolic ) . INTERVENTION Placebo ( n = 6 ) , nicardipine hydrochloride ( 20 mg [ n = 5 ] ) , captopril ( 12.5 mg [ n = 3 ] ) , or clonidine hydrochloride ( 0.1 mg [ n = 2 ] ) given every 8 hours for 3 days . MAIN OUTCOME MEASURES Decline in blood pressure , change in cerebral blood flow as measured by single photon emission computed tomography , and clinical change as determined by the National Institutes of Health Stroke Scale . RESULTS Blood pressure fell significantly in both the drug-treated group as a whole and in those patients receiving placebo ( P < .001 ) . There was no difference in blood pressure levels between these two groups throughout the study period . Patients receiving nicardipine had a consistently lower pressure than the other groups . A significant negative relationship was noted between the maximum blood pressure fall and improvement in cerebral blood flow . There were four patients whose blood pressure dropped by more than 16 % of the baseline value on any 24 hours in the first 3 days . All either failed to increase or actually decreased their cerebral blood flow to the affected area . Three of these patients were treated with nicardipine . There was no significant difference in clinical course between the placebo- and drug-treated groups as a whole . CONCLUSIONS Hypertensive ischemic stroke patients with a moderate elevation of blood pressure in the first few days may not require antihypertensive therapy . Nicardipine and possibly other calcium channel blockers may cause an excessive fall in blood pressure and impair cerebral blood flow in these patients and should therefore be used with caution This prospect i ve study compared the efficacy of nicardipine and nitroprusside for treating hypertensive emergencies by measuring haemodynamic indices and serum catecholamine levels . Patients admitted to the emergency department with a hypertensive crisis and acute pulmonary oedema received intravenous infusions of nitroprusside ( starting dose 1 μg/kg per min , n = 20 ) or nicardipine ( starting dose 3 μg/kg per min , n = 20 ) . Both groups experienced significant declines in systolic and diastolic blood pressure after treatment , but there were no significant time-dependent differences between the groups . Heart rate decreased in the nicardipine group and increased in the nitroprusside group , but neither change was significant . Respiration rate decreased and capillary oxygen saturation rate increased after treatment in both groups . Adrenaline and noradrenaline levels decreased significantly after treatment in both groups ; noradrenaline levels were significantly decreased in the nicardipine-treated group compared with the nitroprusside-treated group . Injectable nicardipine is easy to use and as effective as nitroprusside for treating hypertensive crisis with acute pulmonary oedema Objective To present the efficacy and tolerability of a new oral dosage form of the calcium antagonist nitrendipine compared to nifedipine capsules in patients with hypertensive emergency . Design Multicenter r and omized double blind clinical study . Setting 23 study centres ( hospitals ) in Germany . Patients 161 patients between 20 and 70 years with acutely elevated blood pressure ( systolic 200–250 mmHg , diastolic between 110–140 mmHg ) with and without concomitant clinical symptoms . Interventions Double blind treatment with 10 mg nifedipine or 5 mg nitrendipine . Nifedipine was administered as capsules , nitrendipine was given from a small plastic tube ( vial ) , containing 1 ml alcoholic solution . Every patient received in addition to the test medication a placebo corresponding to the other product . Patients with insufficient treatment after 45 min were given either an additional capsule of 10 mg nifedipine or a further vial containing 5 mg nitrendipine according to their group and maintaining the double dummy procedure . Measurements and results Blood pressure and heart rate were measured repeatedly during 4 h , before and 90 min after beginning of the treatment a 12 channel resting ECG was recorded . At 45 min after administration the blood pressure had fallen significantly from 216.0/117.4 mmHg to 170.0/93.3 mmHg under nifedipine and from 216.9/117.3 mmHg to 177.4/94.4 mmHg under nitrendipine . 61.6 % of the nifedipine patients and 58.8 % of the nitrendipine patients had already reached blood pressure values < 180/100 mmHg after 45 min and in both groups 83 % of these patients were still in this limit at the end of the observation period after 4 h. Tolerability was very good in both groups . Conclusion The new dosage form of nitrendipine ( vial with 1 ml of alcoholic solution ) represents an alternative in the treatment of hypertensive emergency In an open-label study , we compared the efficacy and safety of intravenous infusion of fenoldopam mesylate with that of sodium nitroprusside in patients with severe hypertension or in hypertensive crisis . Both antihypertensive medications were infused at a maximal dose increment of 0.2 /ig/kg/min ( fenoldopam ) and 1 jtg/kg/min ( nitroprusside ) , with a maximal infusion rate of 1.5 /ig/kg/min fenoldopam mesylate or 8 //.g/kg/min sodium nitroprusside . Once the desired reduction in diastolic blood pressure was achieved ( less than 110 mm Hg if initial diastolic blood pressure was 120–149 mm Hg , or by at least 40 mm Hg if initial diastolic blood pressure was 150–190 mm Hg ) , the maximal infusion rate used was maintained for at least 1 hour , and then , the infusion was slowed gradually over 2 hours . After the infusion treatment , patients remained in the hospital for 2 days of follow-up . Both antihypertensive agents successfully controlled the blood pressure in all the patients by the end of the maintenance periods . Between the baseline and the end of the maintenance period , analysis of variance showed that the changes in the variables induced by fenoldopam mesylate did not differ significantly from those induced by sodium nitroprusside .  The incidence of side effects listed were similar in both groups of patients . The detection of toxic levels of thiocyanate in two patients treated with nitroprusside , however , shows that fenoldopam might be preferable for the control of a hypertensive crisis or severe hypertension in patients with decreased renal function Fifty two patients of severe hypertension , diastolic blood pressure > or = 115 mmHg , with or without acute complications , were treated with sublingual nifedipine 10 mg or sublingual captopril 25 mg in a r and omized prospect i ve in patient study with careful clinical monitoring . Both the drugs were safe and effective in rapidly lowering blood pressure .  Nifedipine appeared to be superior to captopril with earlier onset of action , greater magnitude of response and longer duration of action . No significant side effects were observed in either of the two groups Emergency treatment of acute , severe hypertension defined as diastolic blood pressure ( DBP ) greater than or equal to 135 mmHg combined with cerebral symptoms was prospect ively monitored in a r and omized multicenter study including 64 patients . Treatment was divided into two periods . In the first hour the patients were observed in the supine position after being given 40 mg furosemide intravenously . If DBP remained greater than 125 mmHg ( n = 52 ) , the patients were put on fractionated diazoxide administered intravenously ( n = 28 ) or dihydralazine administered intramuscularly ( n = 24 ) . Blood pressure ( BP ) decreased with diazoxide from an average of 241/149 mmHg to 180/111 mmHg after 5 hours and with dihydralazine from 237/149 to 161/101 mmHg . The inter-individual BP response varied considerably . A clear and identical regression in neurological symptoms was observed on both drug regimens . No new neurological symptoms were seen to develop . It is concluded that a gradual fall in BP can be obtained after fractionated dosage of diazoxide ( i.v . ) as well as after dihydralazine ( i.m . ) . The indication of acute parenteral therapy compared to less aggressive oral treatment is discussed Aim of the study was to assess the effectiveness and tolerability of sublingual captopril ( SLC ) versus sublingual nifedipine ( SLN ) in treating  hypertensive emergencies . During hypertensive crises ( systolic blood pressure exceeding 200 mmHg and diastolic blood pressure exceeding 115 mmHg ) forty hypertensive patients received either 25 mg of SLC or 10 mg of SLN in a r and omized single blind fashion . Blood pressure and heart rate were then controlled after 5 , 10 , 15 , 20 , 30 , 45 , 60 , 120 min . and , in 18 cases , up to the 8th hour from the administration . Our results showed : 1 ) a satisfactory control of the hypertensive crises in 80 % of patients treated with SLC with a significant blood pressure reduction after 10 min . ( 13/8 mmHg , p less than 0.02 ) , while the maximum hypotensive effect was achieved after 30 min . ( 52/36 mmHg , p less than 0.001 ) ; SLN was able to reduce blood pressure in 90 % of all the cases , with a significant reduction after 5 min . ( 15/11 mmHg , p less than 0.02 ) and hypotensive peak after 20 min ( 57/38 mmHg , p greater than 0.001 ) ; 2 ) no significant differences for hypotensive effectiveness between the two groups , but with SLC having a mildly delayed onset of action when compared to SLN ; 3 ) antihypertensive effect lasting for about 6 hours in patients treated with SLC and blood pressure progressively raising after 4 hours in patients who received SLN ; 4 ) a significant correlation between blood pressure reduction and blood pressure before drug administration in both groups ; a significant correlation between pretreatment PRA and antihypertensive effect in the SLC group . We conclude that both drugs are effective and useful in treating  hypertensive emergencies .  Anyway we think that in severe forms SLN should be preferred for the shorter time preceding onset of action & NA ; This study estimated the efficacy of sublingual nifedipine 10 mg vs. sublingual lacidipine 4 mg in the management of hypertensive crises . We studied 40 patients with diastolic blood pressure ≥120 mm Hg , who were divided into two groups of 20 . Blood pressure and heart rate were assessed in the recumbent position before treatment and after 30 , 120 , and 240 min . Comparison of the effectiveness of these drugs was analyzed by Student 's t test . Both drugs tested revealed a statistically significant hypotensive effect on diastolic and systolic blood pressure , and few side effects . Compared with lacidipine , nifedipine had a greater hypotensive effect on diastolic and systolic blood pressure in the first 30 min and on the diastolic blood pressure after the first 120 min . However , the hypotensive effect of lacidipine is statistically significant . After 4 h , both drugs showed a similar efficacy without significant statistical variations . We concluded that in the management of hypertensive crises the use of each of these drugs can have a particular range : nifedipine can be used when a pronounced and rapid blood pressure decrement is necessary , whereas lacidipine can be used when a more gradual effect is preferable The aim of our studies was to evaluate the effect of acute treatment in hypertensive emergencies and of chronic and acute treatment in uncomplicated hypertensives with calcium antagonists on blood pressure ( BP ) and cerebral blood flow ( CBF ) .  Ten patients with high blood pressure requiring emergency reduction were r and omized to treatment with oral nifedipine or intravenous clonidine . The effect on CBF was investigated using xenon-133 .  Twenty-one patients with mild to moderate hypertension were r and omly assigned to nitrendipine ( n = 10 ) and to verapamil treatment for 4 weeks . After 14 days of washout , all patients received chlorthalidone for 4 weeks . CBF was measured before calcium antagonists , after 4 weeks , after washout , and after 4 weeks of chlorthalidone . Until now , five patients with mild to moderate hypertension entered in an ongoing study . After 14 days of placebo , CBF and BP reduction were measured 2 h and 6 weeks after nitrendipine . In hypertensive emergencies , nifedipine and clonidine lowered BP significantly , whereas CBF increased after nifedipine and decreased after clonidine . After chronic treatment with nitrendipine and verapamil and after chlorthalidone , the BP-lowering effect was significant whereas CBF remained unchanged . Two hours after nitrendipine , BP decreased and CBF remained unchanged . The reason for increasing CBF in hypertensive emergencies after nifedipine is due to its spasmolytic effect on cerebral vessels . The unchanged CBF after short- and long-term treatment with nitrendipine is due to the fact that in these patients the autoregulatory mechanism is intact The effects and safety of using oral nifedipine 10 - 20 mg as acute antihypertensive treatment were studied in a single-blind placebo-controlled study of 25 consecutive patients with very high blood pressure requiring emergency reduction . In addition the effect of this treatment on cerebral blood flow was investigated using xenon-133 in 10 patients r and omly allocated to receive oral nifedipine or intravenous clonidine . Whereas placebo did not alter the blood pressure , oral nifedipine significantly reduced the systolic and diastolic blood pressures in all 25 patients ( from 221 + /- 22/126 + /- 14 mm Hg to 152 + /- 20/89 + /- 12 mm Hg after 30 minutes , p less than 0.001 ) . Heart rate increased from 74 + /- 11 to 84 + /- 11 beats/minute ( p less than 0.01 ) ; this effect was inversely related to age ( r = -0.65 , p less than 0.01 ) . The falls in systolic and diastolic blood pressures were closely related to the blood pressures before treatment ) r = 0.67 , p less than 0.001 for systolic , and r = -0.58 , p less than 0.01 for diastolic values ) . No serious unwanted effects were observed . Measurement of cerebral blood flow after nifedipine showed an increase in flow in four out of five patients . Clonidine , by contrast , reduced cerebral blood flow in all patients by up to 28 % . Nifedipine is a simple , effective , and safe alternative drug for managing hypertensive emergencies , especially when continuous monitoring of the patient can not be guaranteed Background : Nitric oxide donors have been used in the management of hypertensive emergencies ( HE ) .  Isosorbide dinitrate aerosol ( ISA ) is a nitric oxide fast-acting donor . The aim of this study is to compare the efficacy of ISA and nifedipine in the treatment of HE . Methods : Sixty adult patients with an HE were r and omised to receive either ISA  ( 2.5 mg ) or nifedipine  ( 10 mg ) . Patients were given an electrocardiogram ( ECG ) immediately prior , and 30 min after administering the medication . Blood pressure ( BP ) was measured every 5 min for the first 30 min , and then every 30 min for a period of 6 h. Results : Blood pressure values for all patients in the ISA group decreased significantly ( 187 ± 13/121 ± 6 to 153 ± 15/92.3 ± 7.6 mm Hg , P < 0.005 ) . two of the patients in this group had angor pectoris with evidence of subepicardial ischaemia as seen in the first ecg , both of which disappeared with the drug . heart rate decreased by 14 % similarly , all patients in the nifedipine group had significant decreases in bp ( 190 ± 23/115 ± 7 to 153 ± 26/86 ± 6 mm hg , P < 0.005 ) . their first ecg was normal . two patients suffered angor pectoris after nifedipine , with subepicardial ischaemia registering in the second ecg . heart rate increased 11.9 % in this group . during the follow-up period , no clinical ly significant side effects or cases of rebound hypertension were observed in the isa group , whereas in the nifedipine group , eight patients reported having headaches and four others rebound hypertension . Conclusion : Our results show a favourable effect of ISA in the treatment of HE Summary To determine whether nitroglycerin is as effective as nifedipine in lowering the blood pressure in severe hypertension and hypertensive crisis , two goups of 20 patients received in r and om sequence either 1.2 mg nitroglycerin sublingually or a 10-mg nifedipine capsule , which was chewed and swallowed . The blood pressure fell after 5 min in the nitroglycerin group from 211/122 mmHg to 171/95 mmHG and after nifedipine from 210/118 to 185/102 mmHg . The greater effect of nitroglycerine may result from faster absorption through the oral mucosa than through the small intestinal mucosa where nifedipine is primarily absorbed . After 15–20 min a satisfactory reduction in blood pressure was reached in both groups : 157/91 and 158/92 mmHg , respectively . After 30 min the heart rate in the nitroglycerin group had decreased from 83 to 80/min , but in the nifedipine group it had increased from 84 to 90/min . The reduction in blood pressure persisted up to 6 h. No significant differences in side effects were determined . Since a hypertensive crisis is usually accompanied by left ventricular failure , pulmonary edema , angina pectoris , or infa rct ion , nitroglycerin has been definitively shown positively to influence these conditions , and preference should be given to nitroglycerin in the treatment of hypertensive crises 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 OBJECTIVE To test the hypothesis that sublingual captopril produces a more rapid improvement of  acute pulmonary edema ( APE )  than does placebo , when added to a st and ard regimen of O2 , nitrates , morphine , and furosemide . METHODS Prospect i ve , r and omized , double-blind , placebo-controlled clinical trial in an urban teaching hospital ED . Adults brought to the ED with APE were given captopril or placebo sublingually . Every 5 minutes a clinical APE distress score ( APEX ) was obtained . RESULTS Over the first 40 minutes of treatment , the mean APEXs were significantly better for the patients given captopril [ p < 0.001 , F = 14.5 , one-way ( repeated- measures ) analysis of variance ( ANOVA ) ] . At 30 minutes , the patients given captopril had a mean APEX improvement of 43 % ( i.e. , to 57 % of initial distress ) ; the group given the current st and ard regimen plus placebo improved only 25 % ( i.e. , to 75 % of initial distress ; p = 0.03 , multiway ANOVA ) . In addition , there was less respiratory failure necessitating mechanical ventilation in the captopril patients ( 9 % ) vs the placebo patients ( 20 % ) , which did not achieve significance ( p = 0.10 , Fisher 's exact test ) . CONCLUSION In APE , the addition of sublingual captopril to the st and ard regimen of O2 , nitrates , morphine , and furosemide produces more rapid clinical improvement than does the st and ard regimen alone In a prospect ively design ed r and omized study , we compared the efficacy of sublingual nitroglycerine and intravenous enalaprilat in the out-of-hospital treatment of 46 hypertensive patients with pulmonary edema ( defined as rales over both lungs and systolic blood pressure > 200 mm Hg and diastolic blood pressure > 100 mg ) . The out-of-hospital treatment consists of oxygen ( 6 Ll/min ) via a face mask , furosemide 80 mg i.v . , opioids 10 mg s.c . , and either sublingual nitroglycerine ( n = 23 ; initial dose : 0.8 mg ; repetitive application of 0.8 mg every 10 min until a cumulative dose of 3.2 mg ) or intravenous enalaprilat ( initial dose : 2.5 mg ; repetitive application of 2.5 mg every 30 min until a cumulative dose of 10 mg ) . The aim of the antihypertensive treatment was a reduction of systolic blood pressure below 160 mm Hg and diastolic blood pressure below 90 mm Hg until admission to the emergency department . In the emergency room , an arterial and venous blood sample was taken to determine the respiratory ( pO2 , pCO2 ) and metabolic status ( pH value ; base-excess ; serum lactate ) of the patient . Successful antihypertensive treatment was observed in 13/23 ( 57 % ) patients of the enalaprilat group and 15/23 ( 65 % ) patients of the nitroglycerine group ( p = 0.54 ) . Systolic and diastolic blood pressure on admission were similar in both treatment groups ( systolic RR : enalaprilat : 179 [ 31 ] mm Hg ; nitroglycerine : 184 [ 38 ] mm Hg ; p = 0.59 ; diastolic RR : enalaprilat : 96 [ 14 ] mm Hg ; nitroglycerine : 101 [ 14 ] mm Hg ; p = 0.12 ) . No significant differences were observed between the enalaprilat and the nitroglycerine groups concerning respiratory and metabolic parameters on admission ( pO2 : 67 [ 15 ] vs. 64 [ 17 ] mm Hg ; p = 0.50 ; pCO2 : 46 [ 9 ] vs. 47 [ 13 ] ; p = 0.75 ; pH value : 7.27 [ 0.12 ] vs. 7.27 [ 0.09 ] ; p = 0.98 ; BE : -4.2 [ 3.7 ] vs. -5.7 [ 4.1 ] ; p = 0.23 ; lactate : 4.2 [ 3.3 ] vs. 4.2 [ 2.7 ] ; p = 0.98 ) . Intravenous enalaprilat did not exhibit any advantage compared to nitroglycerine in terms of blood pressure reduction or respiratory and metabolic parameters on admission to the emergency room . We conclude that enalaprilat is no substitute for nitroglycerine in the out-of-hospital treatment of hypertensive patients with pulmonary edema Nitrendipine is a new calcium antagonist of the 1,4-dihydropyridine group with strong vasodilating properties . In a r and omized trial involving 45 patients , whose mean blood pressure was 236 + /- 24/129 + /- 21 mm Hg , 5 mg nitrendipine ( given sublingually via a phiole ) was compared with 20 mg nifedipine ( given sublingually via two pierced 10-mg capsules ) and 0.15 mg clonidine ( given intravenously ) . Blood pressure and heart rate were assessed for 8 h after intake of the antihypertensive agents . Within 60 min , nitrendipine reduced blood pressure by an average of 78 + /- 17 mm Hg for the systolic and 42 + /- 12 mm Hg for the diastolic . Heart rate fell significantly from 106 + /- 17 to 87 + /- 11 beats/min . Nifedipine produced equivalent falls in systolic ( -72 + /- 15 mm Hg ) and diastolic ( -41 + /- 11 mm Hg ) blood pressure , but increased heart rate from 89 + /- 13 to 103 + /- 14 beats/min within 1 h. Intravenous administration of clonidine lowers systolic ( -84 + /- 13 mm Hg ) and diastolic ( -35 + /- 10 mm Hg ) blood pressure within 60 min . Heart rate decreased from 96 + /- 15 to 84 + /- 9 beats/min . The antihypertensive effect of each drug was maintained until 8 h after medication . Main side effects were observed in the nifedipine group ( flush and reflex tachycardia ) and in the clonidine group ( dry mouth and drowsiness ) . In conclusion , nitrendipine , nifedipine , and clonidine show similar efficacy in the treatment of hypertensive urgencies and emergencies . However , sublingual application of the calcium antagonists is simple and safe ; moreover , nitrendipine is better tolerated than nifedipine and clonidine The immediate haemodynamic effects of intravenous frusemide ( 1 mg/kg ) and intravenous isosorbide dinitrate ( 50 - 200 micrograms/kg/h ) were compared in a prospect i ve , r and omised , between-group study in 28 men with radiographic and haemodynamic evidence of left ventricular failure following acute myocardial infa rct ion . The diuresis induced by frusemide reduced the left heart filling pressure and cardiac output and transiently raised systemic blood-pressure . In contrast , isosorbide dinitrate was accompanied by a reduction in systemic blood-pressure and peripheral resistance with the result that the cardiac output was not decreased despite a large fall in the pulmonary vascular and left heart filling pressures . These results indicate that reduction of excessive preload by venodilatation may be haemodynamically superior to that induced by diuresis in terms of both reducing myocardial oxygen consumption and maintaining peripheral perfusion . The influence of these contrasting treatments on the prognosis of these high-risk patients warrants further study BACKGROUND Nitrates are superior to furosemide in the management of acute pulmonary edema associated with myocardial infa rct ion ; however , their role in the absence of infa rct ion is unclear . METHODS AND RESULTS A r and omized comparison was undertaken of the relative effectiveness of primary therapy with either intravenous morphine/furosemide  ( men/women ; n = 32 ) or nitroglycerin/N-acetylcysteine ( NTG/NAC ; n = 37 ) in consecutive patients with acute pulmonary edema . The primary end point was change in PaO2/FIO2 over the first 60 minutes of therapy . Secondary end points were needed for mechanical respiratory assistance ( ie , continuous positive airway pressure via mask or intubation and ventilation ) and changes in other gas exchange parameters . Both treatment groups showed improvement in oxygenation after 60 minutes of therapy ; however , this reached statistical significance only with NTG/NAC therapy . There was no significant difference between groups in the assessed parameters ( 95 % CI for differences in Pao2/FIO2 :  furosemide/morphine -12 to 23 and NTG/NAC 4 to 44 ) , a finding also confirmed in 32 patients presenting with respiratory failure . Only 11 % of the study group required mechanical ventilatory assistance ( continuous positive airway pressure in 4 patients and intubation and ventilation in 3 patients ) . CONCLUSIONS NTG/NAC therapy is as effective as furosemide/morphine in the initial management of acute pulmonary edema , regardless of the presence or absence of respiratory failure . The necessity for mechanical ventilatory assistance is infrequent in these patients , regardless of the initial medical treatment regimen A prospect i ve r and omised trial compared the immediate haemodynamic effects of intravenous diuretic ( frusemide ) , venodilator ( isosorbide dinitrate ) . arteriolar dilator ( hydralazine ) , and positive inotropie stimulation ( prenalterol ) as first-line therapy for acute left ventricular ( LV ) failure following myocardial infa rct ion . Forty-eight patients with transmural myocardial infa rct ion and a pulmonary artery occluded pressure ( PAOP ) of > 20 mm Hg were studied within 18 h of admission to a coronary care unit . Both frusemide ( -4 mm Hg : p < 0.01 ) and isosorbide dinitrate ( -6 mm Hg : p < 0.01 ) reduced LV filling pressure without change in cardiac index and heart rate . Although both hydralazine and prenalterol  increased cardiac index ( p < 0.01 ) , the reduction in LV filling pressure ( -2 mm Hg : p < 0.05 ) was less than with frusemide and isosorbide dinitrate . and was associated with an increased heart rate ( + 8 and + 13 beats min−1 : p < 0.01 ) . These data suggest that in acute heart failure following myocardial infa rct ion the four treatment modalities could be ranked in descending order of potential benefit as follows : ( a ) venodilatation ( isosorbide dinitrate )  — decrease of LV pressure/work : ( b ) diuretic therapy (frusemide)—  decrease of LV pressure/work offset by a transient pressor effect : ( c ) arteriolar dilatation ( hydralazine ) —decrease of LV pressure/work and of PAOP . but offset by tachycardia : and ( d ) positive inotropic therapy ( β1-agonist prenalterol )  — tachycardia and augmented LV afterload . Combination of the former and latter agents , because of their differing modes of action , should offer haemodynamic advantages over monotherapy and deserves further evaluation Thirty-three patients with severe systemic hypertension defined as a diastolic blood pressure ( DBP ) > or = 120 mm Hg were r and omized in a single-blind fashion to be treated with either intravenous fenoldopam mesylate ( FNP ) or sodium nitroprusside ( NTP ) . Fenoldopam mesylate and NTP infusion rates began at 0.1 microgram/kg/minute and 0.5 microgram/kg/minute , respectively and were titrated to achieve a goal DBP of between 95 and 110 mm Hg ; or a reduction of at least 40 mm Hg if the baseline DBP was > 150 mm Hg . Fenoldopam mesylate ( n = 15 ) reduced blood pressure from 217/145 + /- 6/5 to 187/112 + /- 6/3 mm Hg ( P < .001 ) at an average infusion rate of 0.5 + /- 0.1 microgram/kg/minute . The average time to achieve goal DBP with FNP was 1.5 + /- 1.4 hours . Nitroprusside ( n = 18 ) reduced blood pressure from 210/136 + /- 5/2 to 172/103 + /- 6/2 mm Hg ( P < .001 ) at an average infusion rate of 1.2 + /- .24 micrograms/kg/minute .  Nitroprusside response time averaged 2 + /- 2.5 hours . There was no significant difference between the magnitude of effect seen with either FNP or NTP ; nor was there any difference observed in the adverse effect rates of the two agents . Fenoldopam mesylate and NTP demonstrate similar overall efficacy in the treatment of severe systemic hypertension . Emergency treatment of  acute , severe hypertension  was monitored prospect ively during a period of nine months in a Danish multicenter trial . A total of 101 patients with supine diastolic blood pressures ( DBP ) , phase V , ≥135 mmHg in three measurements at 5 min intervals entered the study . The emergency treatment was divided into three periods . In period I , lasting for the first hour , the patient was placed in the supine position and no drug treatment was given . If DBP did not fall below 135 mmHg , the patient entered period II , during which furosemide , 80 mg i.v . , was given and observation continued for another hour . Patients with pronounced hypertensive encephalopathy ( n = 15 ) and left venticular heart failure ( n = 2 ) started directly at period II . Provided DBP thereafter was still 135 mmHg or higher , the patients were r and omized in period III ( 2nd-5th hour ) to treatment with either chlorpromazine or dihydralazine in small refractory i.v . doses or diazoxide , 5 mg/kg b.wt . i.v . , as a bolus injection . In period I , DBP fell below our “ emergency limit ” of 135 mmHg in 23 ( 27 % ) of 84 patients whose mean arterial BP fell from 171 to 140 mmHg during the study . In period II , DBP fell below 135 mmHg in 23 ( 30 % ) of 78 patients and their mean arterial BP decreased from 174 to 135 mmHg during the study . In period III , 24 patients were treated with chlorpromazine , 16 with dihydralazine and 15 with diazoxide . In patients treated with chlorpromazine or dihydralazine  , BP decreased gradually during the first hour , on average from 211/146 to 155/103 and from 219/147 to 162/89 mmHg , respectively . After diazoxide BP decreased abruptly in the first two minutes , on average from 211/144 to 166/100 mmHg . The complication rate was generally low and only a few patients were resistant to any of the treatments given . The study was not able to demonstrate that diazoxide is preferable to the other two drugs in emergency treatment BACKGROUND Corticosteroids have been used to treat head injuries for more than 30 years . In 1997 , findings of a systematic review suggested that these drugs reduce risk of death by 1 - 2 % . The CRASH trial -- a multicentre international collaboration-- aim ed to confirm or refute such an effect by recruiting 20000 patients . In May , 2004 , the data monitoring committee disclosed the unmasked results to the steering committee , which stopped recruitment . METHODS 10008 adults with head injury and a Glasgow coma score ( GCS ) of 14 or less within 8 h of injury were r and omly allocated 48 h infusion of corticosteroids ( methylprednisolone ) or placebo . Primary outcomes were death within 2 weeks of injury and death or disability at 6 months . Prespecified subgroup analyses were based on injury severity ( GCS ) at r and omisation and on time from injury to r and omisation . Analysis was by intention to treat . Effects on outcomes within 2 weeks of r and omisation are presented in this report . This study is registered as an International St and ard R and omised Controlled Trial , number IS RCT N74459797 . FINDINGS Compared with placebo , the risk of death from all causes within 2 weeks was higher in the group allocated corticosteroids ( 1052 [ 21.1 % ] vs 893 [ 17.9 % ] deaths ; relative risk 1.18 [ 95 % CI 1.09 - 1.27 ] ; p=0.0001 ) . The relative increase in deaths due to corticosteroids did not differ by injury severity ( p=0.22 ) or time since injury ( p=0.05 ) . INTERPRETATION Our results show there is no reduction in mortality with methylprednisolone in the 2 weeks after head injury . The cause of the rise in risk of death within 2 weeks is unclear 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 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 Forty patients with hypertensive crises , whose pressure levels had not satisfactorily decreased after intravenous furosemide 20 mg , were selected in the Emergency Ward . These patients were divided in two groups . The ones in group A received sublingual nifedipine 10 mg and the others in group B received oral captopril 50 mg . These drugs were repeated after 30 minutes to the maximum of three doses or until obtaining diastolic blood pressure less than 115 mmHg . Most patients ( 77.5 % ) had their blood pressure reduced to the proposed values after the first dose , and the remaining ones ( 22.5 % ) reacted to the therapy only after the administration of the subsequent doses . No side effects were observed . All patients were discharged from the emergency unit and were sent for follow-up in the outpatient service . The use of nifedipine and captopril has proved to be an effective treatment for hypertensive crises We r and omized patients with severe hypertension in the Medical Intensive Care Unit to a treatment regimen of oral nifedipine or intravenous nitroprusside . Patients treated with nifedipine achieved a sustained reduction in diastolic blood pressure to less than or equal to 120 mm Hg in an average of less than five hours . Patients treated with nitroprusside achieved a similar reduction in 14 hours ( p less than 0.05 ) . Treatment with nifedipine was less expensive and required less time in the ICU than treatment with nitroprusside and was accompanied by no associated increase in morbidity or mortality . Oral nifedipine can be used as an alternative to intravenous nitroprusside in severe uncomplicated hypertension Cerebral symptoms were registered in a multicenter study including 64 patients with severe hypertension , diastolic blood pressure ( DBP ) greater than or equal to 135 mmHg , and more or less pronounced hypertensive encephalopathy . The symptoms were : headache ( 70 % ) , dizziness ( 35 % ) , consciousness disturbances ( 28 % ) , nausea ( 27 % ) , paresis ( 23 % ) , blurred vision ( 22 % ) , paraesthesia ( 21 % ) and vomiting ( 14 % ) . None had convulsions or coma . Initial treatment was furosemide i.v . , and if DBP was greater than or equal to 125 mmHg after one hour , patients were r and omized to treatment with either i.v . diazoxide ( bolus injections of 75 - 150 mg ) or i.m . dihydralazine ( bolus injections of 6 - 12.5 mg ) . A gradual fall in blood pressure ( BP ) was obtained in all three groups . Along with BP reduction a substantial regression of neurological symptoms was registered . After 5 hours only minor cerebral symptoms were present without significant difference between diazoxide and dihydralazine . None developed cerebral complications . The study failed to show a significant correlation between BP reduction and regression of neurological symptoms grade d semiquantitatively . Reduction of BP by titration using small repeated bolus injections is recommended , but oral treatment should be considered in the patients who are able to ingest peroral medication in spite of neurological symptoms OBJECTIVE To compare the safeties and efficacies of IV fenoldopam ( FNP ) vs sodium nitroprusside ( NTP ) in severe acute hypertension . METHODS A prospect i ve , r and omized , open-label , multicenter international trial , at 24 academic medical centers , was conducted . The participants were adult patients ( 21 - 80 years of age ) who had supine diastolic blood pressures ( DBPs ) > or = 120 mm Hg , were capable of written informed consent , and did not have selected exclusion criteria . The subjects were r and omized to either FNP or NTP therapy ; DBP was titrated to 95 - 110 mm Hg , or a maximum reduction of 40 mm Hg for very high pressures . Infusions were maintained for at least six hours , then the patients were weaned off the IV therapy and oral medication was started . Measurements included BP , heart rate , and duration of study drug infusion and frequency of side effects or complications . RESULTS A total of 183 patients ( 90 FNP , 93 NTP ) were enrolled . Fifteen patients from each arm were excluded from efficacy analysis due to protocol violation . There was no significant difference in baseline characteristics . The two antihypertensive agents were equivalent in controlling and maintaining DBP . Systolic blood pressure ( SBP ) was reduced to a slightly greater degree for the NTP-treated patients during the initial ( 0.5 - 1-hr ) study period , and both SBP and DBP were reduced more for the FNP-treated patients in the subset receiving infusions during the 12 - 24-hour period . The adverse effect profiles of the drugs were similar , as were the times to achieve target pressure , with no clinical ly relevant difference . CONCLUSIONS For patients who had acute severe hypertension , FNP and NTP were equivalent in terms of efficacy and acute adverse events . Because of a unique mechanism of action , FNP may have advantages in selected subsets of patients . Further studies may be indicated in patient population s with pure " hypertensive emergencies . A positive history of arterial hypertension ( HBP ) is present in as many as 30 % of patients with acute myocardial infa rct ion ( AMI ) and their clinical outcome could be greatly improved by drugs enhancing blood pressure control and preserving ventricular function . The aim of the present study was to evaluate the importance of a history of HBP on the clinical efficacy of early treatment with the angiotensin-converting enzyme ( ACE ) inhibitor zofenopril in patients with anterior AMI . We summarize the results of a post-hoc analysis of data from the Survival of Myocardial Infa rct ion Long-term Evaluation ( SMILE ) study , which r and omly evaluated the efficacy of zofenopril given within 24 h of symptom onset to patients with anterior AMI not undergoing thrombolysis . Of 1441 patients who entered the study , 565 ( 39.2 % ) had a history of HBP . The mean follow-up time was 12 months and the main outcome measures were 6-week combined occurrence of death and severe congestive heart failure ( CHF ) and 1-year mortality . After 6-week of treatment with zofenopril the relative risk of death or severe CHF was 0.60 ( 95 % confidence interval [ CI ] : 0.45 - 0.81 ; 2P < .05 ) in the hypertensive group and 0.89 ( 0.74 - 1.08 ; 2P = .62 ) for normotensive patients , whereas the 1-year risk of death was 0.61 ( 95 % CI : 0.23,0.89 ; 2P < .05 ) and 0.77 ( 95 % CI : 0.52 - 1.17 ; 2P = .22 ) , respectively . The 6-week prevalence of mild-to-moderate CHF was also significantly reduced by zofenopril in the hypertensive population ( 14.1 % v 9.4 % ; 2P < .05 ) . The present data suggest that treatment with zofenopril started within 24 h of the onset of anterior AMI could be highly beneficial in patients with a history of HBP Hypertensive emergencies in hemodialysis require immediate therapy , usually by parenteral drug administration ; however , sublingual medications may have potential in this special condition . Sublingual captopril ( 25 mg ) , nifedipine ( 10 mg ) and prazosin ( 2 mg ) were prescribed to determine the effectiveness and safety of each medication in the treatment of hypertensive emergencies during hemodialysis .  Blood pressure and heart rate were measured continuously up to 120 min postdose . The response rates were 83 % for captopril , 90 % for nifedipine and 11 % for prazosin . The significant hypotensive effects of both sublingual captopril and nifedipine occurred at 10 min and continued up to 120 min . The reduction of systolic blood pressure occurred earlier in nifedipine than captopril ( 10 vs. 15 min ) . No significant difference in heart rate between them was noted . There were no side effects in the captopril group but flushing , tachycardia and headache were observed in 4 patients of the nifedipine group . We concluded that sublingual captopril and nifedipine were effective but captopril seemed to have less side effects than nifedipine and may be an excellent alternative to sublingual nifedipine in the urgent treatment of hypertensive emergencies in hemodialysis .  Prazosin was not recommended because of its low response rate The primary objective of this study was to compare the antihypertensive efficacy and safety of intravenously administered nicardipine with that of intravenous nitroprusside ( SNP ) in patients with severe hypertension . The study was conducted in 121 patients with severe hypertension ( diastolic blood pressure [ BP ] > 120 mm Hg , or systolic BP > 200 mm Hg ) . Patients were r and omized to receive intravenous nicardipine or SNP .  Drugs were administered according to a predetermined dosing schedule for a 10 to 12 h period . Sixty-one patients were r and omized to intravenous nicardipine and 60 to SNP . Pretreatment BP values for the nicardipine and SNP groups were 217/128 mm Hg and 219/128 mm Hg , respectively . Therapeutic response ( diastolic BP < 100 mm Hg , or a decrease of > 15 mm Hg ; systolic BP < 180 mm Hg , or a decrease of > 20 mm Hg ) was achieved in 98 % ( 60/61 ) of patients treated with nicardipine and 93 % ( 56/60 ) of patients treated with SNP . The mean decreases in systolic and diastolic BP were 61 mm Hg and 40 mm Hg after 4 h of nicardipine , and 59 mm Hg and 38 mm Hg after 4 h of SNP . The mean increases in heart rate also were similar in both groups ( nicardipine , 12 beats/min ; SNP 10 beats/min ) . The mean numbers of dose adjustments per hour required to maintain the BP reductions were lower ( P < .01 ) in the nicardipine-treated patients ( 0.5 + /- 0.1 times per hour ) than in the SNP-treated patients ( 1.5 + /- 0.2 times per hour ) . ( ABSTRACT TRUNCATED AT 250 WORDS
target: 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 .
background: 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 .