Patients With Hypertensive Crises Who Are Admitted to a Coronary Care Unit: Clinical Characteristics and Outcomes

Patients with hypertensive crises, especially hypertensive emergencies, require immediate admittance to an intensive care unit for rapid blood pressure (BP) control. The authors analyzed the prevalence of hypertensive crisis, the clinical characteristics, and the evolution of patients with hypertensive emergencies and urgencies. Patients were divided into 3 groups according to their BP values: group I, predominant systolic hypertension (≥180/≤119 mm Hg); group II, severe systolic and diastolic hypertension (≥180/≥120 mm Hg); and group III, predominant diastolic hypertension (≤179/≥120 mm Hg). Of all of the patients admitted to a coronary care unit, 538 experienced a hypertensive crisis, which represented 5.08% of all admissions. Hypertensive emergency was predominant in 76.6% of the cases, which corresponded to acute coronary syndrome and acute decompensated heart failure in 59.5% and 25.2% of the cases, respectively. A pattern of predominant systolic hypertension (≥180/≤119 mm Hg) was most commonly observed in the hypertensive crisis group (71.4%) and the hypertensive emergency group (72.1%). The medications that were most commonly used at onset included intravenous vasodilators (nitroglycerin in 63.4% and sodium nitroprusside in 16.4% of the patients). The overall mortality rate was 3.7%. The mortality rate was 4.6% for hypertensive emergency cases and 0.8% for hypertensive urgencies cases.     

The Felodipine Event Reduction (FEVER) Study: a randomized long-term placebo-controlled trial in Chinese hypertensive patients

OBJECTIVE: To compare the incidence of stroke and other cardiovascular events in hypertensive patients receiving a low-dose diuretic and low-dose calcium antagonist combination with those receiving low-dose diuretic monotherapy, and assess the effects of a small blood pressure difference at achieved levels lower than those achieved in previous placebo-controlled trials. METHODS: The Felodipine Event Reduction (FEVER) trial was an investigator-designed, prospective, multicentre, double-blind, randomized, placebo-controlled, parallel group trial. It enrolled 9800 Chinese patients, of either sex, aged 50-79 years, with one or two additional cardiovascular risk factors or disease, whose blood pressure, 6 weeks after switching from previous antihypertensive therapy to low-dose (12.5 mg a day) hydrochlorothiazide, was in the range 140-180 mmHg (systolic) or 90-100 mmHg (diastolic). These patients were randomly assigned either to low-dose felodipine extended release or placebo, and followed at 3-month intervals for an average of 40 months. RESULTS: The intention-to-treat analysis included 9711 randomly selected patients with only 30 (0.3%) lost to follow-up. A total of 31 842 patient-years of follow-up were accumulated, with 85.9% of patients remaining on blinded randomized treatment. Add-on therapy was given to 33.9% of the hydrochlorothiazide-felodipine patients and to 42.3% of the hydrochlorothiazide-placebo patients. In the felodipine group, systolic blood pressure (SBP)/diastolic blood pressure (DBP) decreased (from randomization to study end) from 154.2/91.0 to 137.3/82.5 mmHg, and in the placebo group from 154.4/91.3 to 142.5/85.0 mmHg, with an average difference throughout the trial of 4.2/2.1 mmHg. In the felodipine group, the primary endpoint (fatal and non-fatal stroke) was reduced by 27% (P = 0.001). Among secondary endpoints, all cardiovascular events were reduced by 27% (P < 0.001), all cardiac events by 35% (P = 0.012), death by any cause by 31% (P = 0.006), coronary events by 32% (P = 0.024), heart failure by 30% (P = 0.239), cardiovascular death by 33% (P = 0.019), cancer by 36% (P = 0.017) in the felodipine group. No significant differences were found in new-onset diabetes. Both treatments were very well tolerated. CONCLUSIONS: In moderately complicated hypertensive patients from China even a difference in SBP/DBP as small as 4/2 mmHg, such as that induced by adding low-dose felodipine to low-dose hydrochlorothiazide, is associated with very substantial reductions in the incidence of most types of cardiovascular events. As the SBP achieved in the felodipine group was below the recommended goal of less than 140 mmHg, and SBP in the placebo group was slightly above that level, FEVER provides the required evidence in support of the guidelines recommended goal, even for a hypertensive population not entirely consisting of patients with diabetes or previous cardiovascular events.     

Decreased exercise capacity in mild essential hypertension: non-invasive indicators of limiting factors.

Available data suggest that exercise capacity is limited in hypertension. The mechanism of this reduced maximal exercise capacity has not been fully elucidated. In this study 22 patients with mild essential hypertension (162 +/- 22 mmHg systolic and 95 +/- 8 mmHg diastolic) and 36 normotensive control subjects (128 +/- 13 mmHg systolic and 80 +/- 7 mmHg diastolic) (P less than 0.01) performed an ergometer test till exhaustion. Body mass index in the two groups did not differ. The maximal oxygen consumption VO2 was lower in the hypertensive group (18 +/- 7 versus 23 +/- 8 ml/kg/min; P less than 0.02) as was the maximal workload (141 +/- 52 vs. 185 +/- 70 Watt; P less than 0.01). Rate pressure product rose only 2.7 fold in hypertensive patients versus 3.5 fold in the control group (P less than 0.001). In hypertensive patients maximal workload decreased with increasing resting systolic blood pressure (P less than 0.05) while in the normotensive subjects maximal workload rose with increasing resting systolic blood pressure (P less than 0.05). In conclusion both high and low blood pressure was associated with a decreased maximal voluntary exercise capacity. Even mild hypertension was accompanied by lower maximal exercise capacity. Hypertensive patients also had a lower maximal VO2 and lower maximal rate pressure product than did normotensive subjects.     

The Study on Cognition and Prognosis in the Elderly (SCOPE): principal results of a randomized double-blind intervention trial

BACKGROUND: The prognostic benefits of blood pressure lowering treatment in elderly hypertensive patients were established more than a decade ago, but are less clear in those with mildly to moderately elevated blood pressure. OBJECTIVE: To assess whether candesartan-based antihypertensive treatment in elderly patients with mildly to moderately elevated blood pressure confers a reduction in cardiovascular events, cognitive decline and dementia. DESIGN: Prospective, double-blind, randomized, parallel-group study conducted in 1997-2002. SETTING AND PARTICIPANTS: The study was of 4964 patients aged 70-89 years, with systolic blood pressure 160-179 mmHg, and/or diastolic blood pressure 90-99 mmHg, and a Mini Mental State Examination (MMSE) test score >or= 24. A total of 527 centres in 15 countries participated in the study. INTERVENTION: Patients were assigned randomly to receive the angiotensin receptor blocker candesartan or placebo, with open-label active antihypertensive therapy added as needed. As a consequence, active antihypertensive therapy was extensively used in the control group (84% of patients). Mean follow-up was 3.7 years. MAIN OUTCOME MEASURES: The primary outcome measure was major cardiovascular events, a composite of cardiovascular death, non-fatal stroke and non-fatal myocardial infarction. Secondary outcome measures included cardiovascular death, non-fatal and fatal stroke and myocardial infarction, cognitive function measured by the MMSE and dementia. RESULTS: Blood pressure fell by 21.7/10.8 mmHg in the candesartan group and by 18.5/9.2 mmHg in the control group. A first major cardiovascular event occurred in 242 candesartan patients and in 268 control patients; risk reduction with candesartan was 10.9% [95% confidence interval (CI), -6.0 to 25.1, P = 0.19]. Candesartan-based treatment reduced non-fatal stroke by 27.8% (95% CI, 1.3 to 47.2, P = 0.04), and all stroke by 23.6% (95% CI, -0.7 to 42.1, P = 0.056). There were no significant differences in myocardial infarction and cardiovascular mortality. Mean MMSE score fell from 28.5 to 28.0 in the candesartan group and from 28.5 to 27.9 in the control group (P = 0.20). The proportions of patients who had a significant cognitive decline or developed dementia were not different in the two treatment groups. CONCLUSIONS: In elderly hypertensive patients, a slightly more effective blood pressure reduction during candesartan-based therapy, compared with control therapy, was associated with a modest, statistically non-significant, reduction in major cardiovascular events and with a marked reduction in non-fatal stroke. Cognitive function was well maintained in both treatment groups in the presence of substantial blood pressure reductions. Both treatment regimens were generally well tolerated.     

Treatment of hypertensive urgencies with oral nifedipine, nicardipine, and captopril

Sixty-five patients with uncomplicated hypertensive urgencies were treated in the emergency and cardiology departments with 20 mg nifedipine, 20 mg nicardipine, or 25 mg captopril in a randomized study. The study population consisted of 65 patients ranging in age from forty-one to seventy-one. Blood pressure and heart rate were assessed for six hours after intake of the antihypertensive agents. Within sixty minutes nifedipine reduced blood pressure by an average of 74.7 mmHg for the systolic and 35.4 mmHg for the diastolic. Average heart rate increased significantly by 11.6 beats/min at within thirty minutes. Nicardipine and captopril produced equivalent falls in systolic (-81.6 and -79.4 mmHg) and diastolic (-37.3 and -33 mmHg) blood pressure respectively, but did not increase heart rate significantly. The antihypertensive effect of each drug was maintained until six hours after medication. In conclusion, nifedipine, nicardipine, and captopril show similar efficacy in the treatment of hypertensive urgencies. The authors believe that these drugs can be used as first-line therapy in the treatment of hypertensive urgencies safely and effectively.     

Effectiveness of treatment with beta-blocking agents and diuretics in fixed combination, in aged hypertensive patients

The antihypertensive activity and tolerability of oxprenolol 80 mg plus chlorthalidone 10 mg in fixed combination were evaluated in 15 hypertensive patients aged more than 60 years (group 1) and, comparatively, in 11 hypertensive patients aged below 60 years (group 2), all with a lying B.P. value greater than 160/100 mmHg at the end of a two weeks placebo wash-out. Lying and standing systolic and diastolic B.P. decreased (P less than 0.001) (lying position: group 1, from 181.0/103.0 to 159.6/87.5 mmHg; group 2, from 173.6/105.4 to 143.3/86.1 mmHg); decrements in group 1 were minor than those in group 2. A diastolic blood pressure normalization was achieved in 12/15 patients of group 1 and in 10/11 of group 2. Side-effects were rare and of mild severity. Results obtained show that the fixed combination oxprenolol 80 mg plus chlorthalidone 10 mg can be safely administered also in the elderly hypertensive patients, without risk of cardiovascular complications, allowing satisfactory blood pressure control, with a simple dosage schedule, thus improving patient compliance to the therapy.     

EVAluation of the prognostic value of BARoreflex sensitivity in hypertensive patients: the EVABAR study

AIMS: The prognostic value of baroreflex sensitivity in hypertensive patients has not much been studied. METHOD: A cohort of 451 hypertensive patients without cardiovascular history was studied for an average of 6.2 +/- 2.8 years follow-up. Each patient had a baroreflex sensitivity measurement by the sequence method, which is represented by the slope of up-sequences (systolic blood pressure+/pulse interval+) and down-sequences (systolic blood pressure-/pulse interval-) of spontaneous fluctuations in systolic blood pressure and pulse interval. RESULTS: During the follow-up, there were 20 deaths from any cause and 30 patients presented a major adverse cardiovascular event. Deaths and major adverse cardiovascular events were associated with a reduction in baroreflex sensitivity (systolic blood pressure+/pulse interval+ and systolic blood pressure-/pulse interval-). In multivariate analysis, the reduction in baroreflex sensitivity systolic blood pressure+/pulse interval+ was associated with an increased risk of deaths from any cause (Odds ratio 1.23; 95% confidence interval 1.02-1.67, P = 0.04). A baroreflex sensitivity systolic blood pressure+/pulse interval+ under 4.5 ms/mmHg was associated with a 2.5-increased relative risk of major adverse cardiovascular event (95% confidence interval 1.11-5.93, P = 0.03). However, multivariate analysis showed that baroreflex sensitivity systolic blood pressure-/pulse interval- was not associated either with death or major adverse cardiovascular events. CONCLUSIONS: Reduction in baroreflex sensitivity marked by a reduction in vagal reflexes is an independent marker of the risk of mortality and major adverse cardiovascular events in hypertensive patients.     

Relationship between blood pressure and depression in the elderly. The Three-City Study

OBJECTIVE: To examine the relationship between blood pressure and depression in a large sample of noninstitutionalized elderly people. METHODS: Cross-sectional community-based study in 9294 participants aged 65 years and over, living at home, in three French cities (Bordeaux, Dijon and Montpellier). Participants were categorized as depressive, based on three different markers of depression. Multiple linear regression analyses of the relation between depression and mean systolic and diastolic blood pressure values were conducted, taking into account potential confounders like age, sex, education, smoking, alcohol consumption, body mass index and history of cardiovascular events. RESULTS: Our working sample had a mean age (SD) of 73.7 (5.0) years, and included 60.7% of women. Overall, 31% of participants met the criteria for depression, 77.5% had hypertension, and 49.5% were on antihypertensive drugs. Analyses showed lower systolic and diastolic blood pressure values in depressive individuals compared with nondepressive ones, in both men (systolic blood pressure 148.2 versus 151.8 mmHg, P < 0.002; diastolic blood pressure 83.0 versus 84.7 mmHg, P = 0.003) and women (systolic blood pressure 141.7 versus 144.7 mmHg, P < 0.0001; diastolic blood pressure 80.7 versus 81.4 mmHg, P < 0.02). These associations were independent of age and of use of antihypertensive or psychotropic agents. CONCLUSION: In a large sample of elderly individuals from the general population, depressive individuals had lower blood pressure values than nondepressive ones, independent of medications and of history of cardiovascular events.     

Influence of the presence of doctors-in-training on the blood pressure of patients: a randomised controlled trial in 22 teaching practices

Until now, no information is available about the effect of the presence of a doctor-in-training on a patient's blood pressure. We tested the hypothesis that the presence of a last year medical student might increase the blood pressure of the patient, in addition to the possible pressor response to the doctor-trainer. Normotensive and hypertensive patients with a minimum age of 25 years, visiting for any reason, were recruited at 22 teaching general practices. Patients were randomised into a 'trainee' group (n=133) and a 'no trainee' (n=129) group. The blood pressure was measured at two subsequent contacts. In the 'trainee' group, a student was present at the first visit only. In the 'no trainee' group, both visits were without student. Both groups had similar anthropometric characteristics at entry. At the first visit, systolic pressure was higher in the 'trainee' group than in the control group (139.5 vs 133.1 mmHg, P=0.004), with a similar trend for diastolic pressure (80.2 vs 77.8 mmHg, P=0.07). From the first contact to the follow-up visit, blood pressure decreased in the trainee group by 4.8 mmHg systolic (P<0.001) and 1.7 mmHg diastolic (P=0.03), whereas the corresponding changes in the control group were -0.1 mmHg (P=0.90) and +1.5 mmHg (P=0.03). Thus, the between group differences in these trends averaging 4.7 mmHg (CI 1.5-7.9, P=0.005) systolic and 3.2 mmHg (CI 1.1-5.3, P=0.003) diastolic were statistically significant. We conclude that in teaching-practices, the presence of a doctor-in-training has a significant pressor effect when an experienced general practitioner measures a patient's blood pressure. If confirmed, our findings imply that doctors should be cautious to initiate or adjust antihypertensive treatment when blood pressure readings are obtained in the presence of a student.     

Effects of immediate versus delayed antihypertensive therapy on outcome in the Systolic Hypertension in Europe Trial

BACKGROUND: To assess the impact of immediate versus delayed antihypertensive treatment on the outcome of older patients with isolated systolic hypertension, we extended the double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial by an open-label follow-up study lasting 4 years. METHODS: The Syst-Eur trial included 4695 randomized patients with minimum age of 60 years and an untreated blood pressure of 160-219 mmHg systolic and below 95 mmHg diastolic. The double-blind trial ended after a median follow-up of 2.0 years (range 1-97 months). Of 4409 patients still alive, 3517 received open-label treatment consisting of nitrendipine (10-40 mg daily) with the possible addition of enalapril (5-20 mg daily), hydrochlorothiazide (12.5-25 mg daily), or both add-on drugs. Non-participants (n = 892) were also followed up. RESULTS: Median follow-up increased to 6.1 years. Systolic pressure decreased to below 150 mmHg (target level) in 2628 participants (75.0%). During the 4-year open-label follow-up, stroke and cardiovascular complications occurred at similar frequencies in patients formerly randomized to placebo and those continuing active treatment. These rates were similar to those previously observed in the active-treatment group during the double-blind trial. Considering the total follow-up of 4695 randomized patients, immediate compared with delayed antihypertensive treatment reduced the occurrence of stroke and cardiovascular complications by 28% (P = 0.01) and 15% (P = 0.03), respectively, with a similar tendency for total mortality (13%, P = 0.09). In 492 diabetic patients, the corresponding estimates of long-term benefit (P < 0.02) were 60, 51 and 38%, respectively. CONCLUSIONS: Antihypertensive treatment can achieve blood pressure control in most older patients with isolated systolic hypertension. Immediate compared with delayed treatment prevented 17 strokes or 25 major cardiovascular events per 1000 patients followed up for 6 years. These findings underscore the necessity of early treatment of isolated systolic hypertension.     

Hypertensive emergencies and urgencies: Pathophysiology and clinical aspects

A hypertensive urgency should be distinguished from a hypertensive emergency. Although the distinction may not always be obvious, certain guidelines may help the clinician determine which therapeutic approaches are most appropriate for each patient. Hypertensive emergencies include those conditions in which new or progressive severe end-organ damage is present and a delay in appropriate therapy might result in permanent damage, progression of complications, and a poor prognosis. Hypertensive urgencies include those conditions with minimal to no obvious end-organ damage in which blood pressure should be lowered expeditiously. The risk of immediate complications or organ damage is less likely to occur, and thus the immediate prognosis is better, although the ultimate prognosis, if untreated, is poor. There is a marked individual, racial, sexual, and age difference in the ability to tolerate high intraarterial pressure, as evidenced by patients' symptoms and signs of end-organ damage.Patients may have no symptoms of elevated blood pressure until significant intraarterial levels are reached. If symptoms are present, they may include headache, dizziness, blurred vision, shortness of breath (especially with exertion), chest pain, rapid pulse, palpitations, malaise and fatigue, nocturia, or pedal edema.^7,11–14 Signs of hypertensive disease vary and depend not only on the level of blood pressure but also include funduscopic changes with arteriolar narrowing, atrioventricular nicking, hemorrhages, exudates or papilledema, central nervous system changes and neurologic abnormalities, cardiac changes with gallop rhythm, cardiomegaly, tachycardia, ectopic ventricular beats, left ventricular hypertrophy or signs of congestive heart failure, pulmonary edema, and signs of renal insufficiency.^7,11–14Although there is a definite correlation between the level of blood pressure and end-organ damage, there is no definite systolic or diastolic level of blood pressure that induces end-organ damage. Some patients may tolerate very high blood pressures with few symptoms or signs, whereas others may manifest end-organ damage at lower blood pressures. Thus, the definition of hypertensive emergency and urgency depends on the clinical assessment of the blood pressure level and clinical and laboratory assessments of end-organ damage. The absolute blood pressure in itself does not determine the seriousness of the clinical situation, the expediency of treatment, or the need for in-hospital monitoring in a critical care unit.It is important not to lower the blood pressure precipitously or to a subnormal level particularly in patients with end-organ damage. Such treatment may critically reduce blood flow and perfusion to vital organs and induce a cerebrovascular accident, myocardial ischemia, or renal failure. A smooth, gradual reduction in blood pressure is crucial to patient management with oral or parenteral antihypertensive drugs. However, in hypertensive emergencies blood pressure control should be accomplished within 1 hour, whereas with hypertensive urgencies control should be within 24 hours.Those patients who have hypertensive emergencies with malignant hypertension and end-organ damage should be admitted to a hospital intensive care unit for evaluation and treatment. These patients have a diffuse arteritis, as of a result of their hypertension, that may take 4 to 6 weeks to heal. Many patients who present with diastolic blood pressure 120 mm Hg or greater will be found to have a secondary cause of hypertension (such as renovascular hypertension) after careful evaluation. On the other hand, those patients with hypertensive urgencies as defined previously can be treated in the emergency room or outpatient department and can avoid hospital admission. Careful, immediate, and routine follow-up is important in these patients.     

Hypertensive emergencies

Critical cases of high blood pressure are common clinical occurrences that may account for as many as 25% of all medical emergencies. About 75% of these increases in blood pressure can be judged as hypertensive urgencies, 25% are even hypertensive emergency situations. Nevertheless, only less than 1% of the hypertensive population experiences hypertensive urgency or emergency situations. Hypertensive emergencies are defined as acute cardiac, vascular or cerebral target organ damages. In these cases an acute lowering of blood pressure is inevitable. The rate and intensity of blood pressure depression is dependent on the localization of organ damages. For cardiac and vascular damages it is absolutely necessary to lower the blood pressure rapidly to near normal values. On the contrary, cerebral organ damages are better treated by a moderate lowering of blood pressure peaks to slightly increased blood pressure levels. In hypertensive urgencies no target organ damages occur. For these patients a slow lowering of blood pressure values to normal levels is adequate.     

Hypertensive urgencies in the emergency department: evaluating blood pressure response to rest and to antihypertensive drugs with different profiles

To study the efficacy of a treatment strategy for the management of hypertensive urgencies, the authors evaluated 549 patients admitted to the emergency department. They were first assigned to a 30-minute rest period, then a follow-up blood pressure measurement was carried out. Patients who did not respond to rest were randomly assigned to receive an oral dose of an antihypertensive drug with different mechanisms of action and pharmacodynamic properties (perindopril, amlodipine, or labetalol), and blood pressure was reassessed at 60- and 120-minute intervals. A satisfactory blood pressure response to rest (defined as postintervention systolic blood pressure < 180 mm Hg and diastolic blood pressure < 110 mm Hg, with at least a 20 mm Hg reduction in basal systolic blood pressure and/or a 10-mm Hg reduction in basal diastolic blood pressure) was observed in 31.9% of population. Among nonresponders, 79.1% had a satisfactory blood pressure response to the antihypertensive drug treatment in a 2-hour average follow-up period. No major adverse events were observed. This treatment strategy, based on standardized rest as an initial step and different antihypertensive drugs, can be effective and safe for the management of patients with hypertensive urgencies.     

Treatment of isolated systolic hypertension: the SHELL study results

OBJECTIVE: Our aim was to compare the effect of lacidipine and chlorthalidone on cardiovascular outcome as a primary parameter and blood pressure as a secondary in elderly patients with isolated systolic hypertension in a prospective study with an open design. METHODS: 1882 males and females outpatients > or = 60 years were randomly assigned to the administration of chlorthalidone 12.5 mg o.d. or lacidipine 4 mg o.d. Patients were recruited if sitting systolic blood pressure was > or = 160 mmHg with a diastolic blood pressure equal or lower than 95 mmHg. Primary endpoint was a composite of cardiovascular and cerebrovascular events. RESULTS: At randomization mean systolic blood pressure was 178.1 mmHg in the lacidipine and 178.2 mmHg in the chlorthalidone group, the corresponding mean diastolic values being 86.9 and 86.8 mmHg. In both lacidipine and chlorthalidone groups treatment caused a significant (p < 0.001) and marked systolic blood pressure reduction which was maintained throughout the treatment period with a significant (p < 0.001) and steady although less marked reduction in diastolic blood pressure as well. At the end of treatment period (median 32 months), the reduction was 36.8/8.1 mmHg (systolic/diastolic) in the chlorthalidone and 38.4/7.9 mmHg in the lacidipine group, the final on treatment blood pressures being 142.0/79.2 and 143.2/79.5 mmHg, respectively. Treatments were similarly effective in males and females and in age groups between 60 and 69 years (n = 763), 70 and 79 years (n = 744) and > or = 80 years (n = 375). Similar reductions were obtained in a subgroup of patients (n = 209) followed in double-blind fashion for 1 year. The overall incidence of the primary endpoints was 9.3% with no significant between-group difference. Total mortality was also similar between groups. CONCLUSIONS: In elderly patients with isolated systolic hypertension, administration of lacidipine or chlorthalidone markedly reduced systolic blood pressure with no difference in the incidence of cardiovascular events and total mortality.     

Thromboembolism in nonvalvular atrial fibrillation: the answer may be in the ventricle.

Hypertensive emergencies, including hypertensive encephalopathy represents an acute threat to vital organ functions and call for urgent treatment. The intravenous medications currently available for the management of hypertensive emergencies, have significant potential for serious side effects and acute lowering of blood pressure has often been the cause of considerable morbidity and mortality. Nifedipine is known to be effective as an antihypertensive agent and it is widely used in hypertensive emergencies. We studied the efficacy and effective dose of nifedipine in 22 patients (9 females and 13 males; mean age 51) with hypertensive encephalopathy. Nifedipine (20 mg by oral drop) caused a significant fall in diastolic an systolic blood pressure in all patients from 236/121 to 172/96 mmHg after 30 minutes (P less than 0.005, P less than 0.001). Continuous therapy with nifedipine (2-5 mg every 2-3 hours, mean total dose 52 mg/24 h) gave successful control of blood pressure. These data prove that nifedipine can be used as the first-line drug for the treatment of hypertensive crises in patients with hypertensive encephalopathy.     

Impaired cardiovascular recovery following stress predicts 3-year increases in blood pressure

OBJECTIVE: To assess whether variation in the rate of cardiovascular recovery following exposure to acute psychological stress predicts changes in blood pressure longitudinally, independently of blood pressure at baseline and other covariates. DESIGN: A 3-year longitudinal study. PARTICIPANTS: A total of 209 men and women aged 45-59 years at baseline, with no history of cardiovascular disease including hypertension. METHOD: Measurement of blood pressure, heart rate, heart rate variability, cardiac index and total peripheral resistance at rest, during two moderately stressful behavioural tasks and up to 45 min post-stress. Stress reactivity was defined as the difference in values between tasks and baseline, and post-stress recovery as the difference between recovery levels and baseline. OUTCOME MEASURES: Resting blood pressure measured at baseline and 3 years later. Seven individuals had been prescribed hypertensive medication on follow-up. RESULTS: Increases in systolic blood pressure (SBP) were predicted by impaired post-stress recovery of SBP (P < 0.001), diastolic blood pressure (DBP) (P < 0.001) and total peripheral resistance (P = 0.003), independently of baseline blood pressure, age, gender, socio-economic status, hypertensive medication, body mass and smoking. The adjusted odds of an increase in SBP > or = 5 mmHg were 3.50 [95% confidence interval (CI) 1.19 to 10.8] for individuals with poor compared with effective post-stress recovery of SBP. Three-year increases in diastolic pressure were predicted by impaired recovery of SBP (P < 0.001) and DBP (P = 0.009) pressure and by heart rate variability during tasks (P = 0.002), independently of covariates. CONCLUSIONS: Impaired post-stress recovery and less consistently heightened acute stress reactivity may index disturbances in the regulation of cardiovascular stress responses that contribute to longitudinal changes in blood pressure in middle-aged men and women.     

Lack of control of high blood pressure and treatment recommendations in Canada

BACKGROUND: Hypertension is a major risk factor for death that affects many Canadians, but only 16% of hypertensive Canadians are treated and have their hypertension controlled. While the control rate is very low, the 2001 Canadian Hypertension Recommendations do not recommend that low risk hypertensive patients be started on pharmacotherapy, and pharmacotherapy is not recommended for people for whom there is no demonstrable benefit from randomized, controlled trails. OBJECTIVES: To determine the proportion of hypertensive patients who are appropriately managed according to the 2001 Canadian Hypertension Recommendations. METHODS: Data from the Canadian Heart Health Survey, which surveyed a cross-sectional population (n=23,129) between 1986 and 1992, were used to determine the proportion of nondiabetic hypertensive patients who are managed according to the 2001 Canadian Hypertension Recommendations. Hypertensive patients not recommended to receive pharmacotherapy include those without risk factors and target organ damage, with a diastolic blood pressure of 90 to 99 mmHg and a systolic blood pressure of less than 160 mmHg. People with diastolic blood pressures of less than 90 mmHg who have systolic blood pressures of 140 to 159 mmHg are also not recommended to have pharmacotherapy. Patients prescribed antihypertensive therapy who had blood pressure controlled to less than 140/90 mmHg were assessed as having their hypertension managed appropriately, as were those who were not treated and were not recommended to be prescribed treatment. RESULTS: There were 58,813 (1.7%) hypertensive patients who did not have target organ damage or additional risk factors, and had a systolic blood pressure of less than 160 mmHg and a diastolic blood pressure between 90 and 99 mmHg. Twenty four per cent of hypertensive persons (831,787) had a systolic blood pressure of 140 to 160 mmHg and a diastolic blood pressure of less than 90 mmHg. About 25% (23.6%+1.7%) of hypertensive Canadians in the Canadian Heart Health Survey are not recommended to be prescribed antihypertensive therapy according to the 2001 Canadian Hypertension Recommendations. Sixteen per cent of hypertensive patients were treated and had their blood pressures controlled (blood pressure less than 140/90 mmHg). Therefore, about 41% (ie, 16%+25%) of hypertensive patients are appropriately managed according to the 2001 Canadian Hypertension Recommendations. CONCLUSIONS: The results of the Canadian Heart Health survey indicate that there are a striking number of Canadians with untreated high blood pressure (59%) who probably do not have their hypertension managed according to the 2001 Canadian Hypertension Recommendations. Greater efforts are required to identify people with hypertension, and to ensure that they are managed according to the best available evidence.     

Dose-response evaluation of oral labetalol in patients presenting to the emergency department with accelerated hypertension

STUDY OBJECTIVE: Dose-response evaluation of oral labetalol (100, 200, or 300 mg) on heart rate and systemic blood pressure in emergency department patients with hypertensive urgency (diastolic blood pressure, 110 to 140 mm Hg, and no end-organ evidence of hypertensive emergency). METHODS: This acute-treatment, dose-ranging study used a randomized, double-blind, parallel design. Patients with supine diastolic blood pressure of 110 to 140 mm Hg after 30 minutes of bedrest received an oral dose of labetalol. Supine blood pressure and heart rate were measured manually and recorded hourly for four hours after dose. Diastolic blood pressure of 100 mm Hg or less or a 30-mm Hg reduction in diastolic blood pressure was considered a treatment success. RESULTS: Two hundred fifty-five patients were evaluated for inclusion, and 36 patients (19 women and 17 men; mean age, 44 years; age range, 23 to 67 years) were studied. The most frequent reason for exclusion was a spontaneous decrease in diastolic blood pressure to less than 110 mm Hg (31%) with bedrest. There were 12 patients in each treatment group. Compared with baseline, the 100-mg dose significantly (P less than .05) reduced heart rate at three and four hours after dose, and the 300-mg dose significantly (P less than .05) reduced heart rate at one, two, and three hours after dose; the 200-mg dose did not significantly affect heart rate. All doses produced a significant decrease in systolic and diastolic blood pressures at one, two, three, and four hours after dose compared with baseline. There were no statistically significant differences between treatment groups with regard to systolic or diastolic blood pressure or heart rate at baseline or one, two, three, or four hours after dose. At two hours after dose, diastolic blood pressure control was observed in 75%, 58%, and 67% of patients receiving 100, 200, and 300 mg, respectively (P = .903). At four hours after dose, diastolic blood pressure control was observed in 50%, 64%, and 67% of patients receiving 100, 200, and 300 mg, respectively (P = .755). A comparison of treatment success rates between the two time periods showed a waning of response with the 100-mg dose of labetalol at hour 4 compared with hour 2 (P less than .05). No adverse effects were observed. CONCLUSION: Labetalol provides safe and effective treatment for hypertensive urgencies when administered orally in doses of 100 to 300 mg.     

Left ventricular dysfunction in hypertensive patients with Type 2 diabetes mellitus.

AIMS: To characterize left ventricular function in hypertensive patients with Type 2 diabetes and normal ejection fraction, and to relate these findings to pathogenic factors and clinical risk markers. METHODS: We examined 70 hypertensive patients with Type 2 diabetes mellitus with ejection fraction > 0.55 and fractional shortening > 0.25, all without any cardiac symptoms. Thirty-five non-diabetic subjects served as control subjects. Left ventricular longitudinal function was examined by tissue Doppler derived myocardial strain rate and peak systolic velocities. RESULTS: Hypertensive patients with diabetes had a significantly higher systolic strain rate (-1.1 +/- 0.3 s(-1) vs. -1.6 +/- 0.3 s(-1), P < 0.001) and lower systolic peak velocities (3.3 +/- 1.0 vs. 5.6 +/- 1.0 cm/s, P < 0.001) compared with control subjects. Myocardial systolic strain rate correlated significantly to left ventricular mass (r = 0.40, P < 0.01) and to both HbA1c (r = 0.43, P < 0.01), and fructosamine (r = 0.40, P < 0.01), but was not related to serum levels of carboxymethyllysine, albuminuria, blood pressure (dipping/non-dipping), or oral hypoglycaemic therapy. Patients with diastolic dysfunction had significantly higher levels of urine albumin [21.0 (5-2500) mg/l, vs. 9.5 (1-360), P < 0.01], heart rate (78 +/- 13 vs. 67 +/- 10 b.p.m., P < 0.005), and seated diastolic blood pressure (85 +/- 6 vs. 81 +/- 7 mmHg, P < 0.05) and non-dipping diastolic blood pressure was more frequent. CONCLUSIONS: Long axis left ventricular systolic function was significantly decreased in hypertensive patients with Type 2 diabetes mellitus, and is associated with hyperglycaemia and left ventricular hypertrophy. Diastolic dysfunction was closely related to increased diastolic blood pressure, non-dipping and increased urinary albumin excretion.     

Hypertension management in patients with stable coronary disease

AIMS: To assess hypertension control in patients with stable coronary disease in France. DESIGN: A cross sectional study was conducted in a representative sample of 794 cardiologists. PARTICIPANTS: The first 6 patients with coronary disease received at practitioner's office were included. MAIN OUTCOME MEASURES: Cardiovascular risk factors, antihypertensive drugs, cardiovascular history were reported. BP was measured. Patients considered as hypertensive by his cardiologist and receiving antihypertensive drugs were considered as hypertensive. Controlled hypertension was defined as a blood pressure < 140/90 mmHg. Uncontrolled hypertension was defined as blood pressure > or = 140/90 mmHg. Among the uncontrolled hypertensives we distinguished patients with isolated systolic hypertension: diastolic blood pressure < 90 mmHg and systolic blood pressure > or = 140 mmHg. RESULTS: All variables were available in 6,349 patients who form the basis of this report. 3,161 patients were hypertensive. Of them, 1,846 (58.4%) were uncontrolled hypertensives, whom 1,280 (69.3%) were uncontrolled on the basis of systolic blood pressure alone. CONCLUSION: This study conducted in a representative sample of French cardiologists indicates that there is a considerable potential to further reduce cardiovascular morbidity in patients in secondary prevention.