[Sublingually administered captopril versus nifedipine in hypertension emergencies]. Evaluation of a pharmaceutical care program for hypertensive patients in rural Portugal. Treatment of Hypertensive Urgencies with Oral Nifedipine, Nicardipine, and Captopril Trial of Nonpharmacologic Intervention in the Elderly (TONE). Design and rationale of a blood pressure control trial. Controlling hypertension and hypotension immediately post stroke (CHHIPS)--a randomised controlled trial. Antihypertensive treatment efficacy in type II diabetes mellitus. Dissociation between casual and 24-hour ambulatory blood pressure. Spanish Multicenter Study Group. Renal denervation in treatment-resistant hypertension – Oslo RDN, Symplicity HTN-3 and INSPiRED randomized trials Captopril, nifedipine and their combination for therapy of hypertensive urgencies. Nonpharmacological control of hypertension. Comparison of sublingual captopril and nifedipine in immediate treatment of hypertensive emergencies. A randomized, single-blind clinical trial. A Simplified Approach to the Treatment of Uncomplicated Hypertension: A Cluster Randomized, Controlled Trial Diclofenac sodium versus pethidine in acute renal colic. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Does withdrawal of antihypertensive medication increase the risk of cardiovascular events? Trial of Nonpharmacologic Interventions in the Elderly (TONE) Cooperative Research Group. Intensified antihypertensive therapy is associated with improved survival in type 1 diabetic patients with nephropathy Accelerated risk of hypertensive blood pressure recordings among Alzheimer caregivers. Community-based education classes for hypertension control. A 1.5-year randomized controlled trial.
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 OBJECTIVES To evaluate the community pharmacist 's capacity to positively influence the results of antihypertensive drug therapy through a pharmaceutical care program and to determine what factors limit the program . DESIGN R and omized , controlled study . SETTING Private pharmacy caring for a semiliterate , rural Portuguese population . PATIENTS R and om sample of 100 patients with a diagnosis of essential hypertension who had been on drug treatment for less than 6 months . Patients were r and omly assigned to an intervention ( n = 50 ) or a control ( n = 50 ) group . INTERVENTION Individualized health promotion by a research pharmacist involving monthly appointments for 6 months to monitor blood pressure ; assess adherence to treatment ; prevent , detect , and resolve drug-related problems ( DRPs ) ; and encourage nonpharmacologic measures for blood pressure control . Control patients received traditional care . MAIN OUTCOME MEASURES Control of blood pressure ; decreases in systolic/diastolic blood pressure ; number of detected , resolved , and prevented DRPs . RESULTS From the initial sample of 100 patients , 41 patients in the intervention group and 41 patients in the control group completed the longitudinal study . After 6 months , prevalence of uncontrolled blood pressure decreased by 77.4 % in the intervention group ( P < .0001 ) and by 10.3 % in the control group ( P = .48 ) . Systolic blood pressure fell from a mean + /- st and ard deviation of 152 mm Hg + /- 23 mm Hg to 129 + /- 15 mm Hg in intervention patients and 148 + /- 16 mm Hg to 143 + /- 20 mm Hg in control patients ( P < .001 ) . Twenty-four of 29 ( 83 % ) detected actual DRPs were resolved . About 40 % of potential DRPs were prevented . CONCLUSION In this rural community , a pharmaceutical care program was associated with significant improvements in blood pressure control in hypertensive patients Sixty-five patients with unclomplicated hypertenive urgencies were treated in the emergency and cardiology departments with 20 mg nifedipine , 20 mg nicardipine , or 25 mg captopril in a r and omized 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 antihyper tensive 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 National and international policy-making organizations advocate nonpharmacologic therapies to reduce blood pressure ( BP ) . However , data to support such recommendations in older persons are virtually nonexistent . The Trials of Nonpharmacologic Intervention in the Elderly ( TONE ) is a r and omized , controlled trial that will test whether weight loss or a reduced sodium ( Na ) intake or both can maintain satisfactory BP control , without unacceptable side effects , after withdrawal of antihypertensive drug therapy . Medication-treated hypertensives ( aged 60 to 80 years ) with a systolic BP less than 145 mm Hg and a diastolic BP less than 85 mm Hg who are taking one antihypertensive medication are r and omly assigned to one of four groups : ( 1 ) weight loss alone , ( 2 ) reduced Na intake alone , ( 3 ) combined weight loss and reduced Na intake , or ( 4 ) usual life-style ( control group ) .  Overweight participants are r and omized to one of these four groups , while nonoverweight individuals are assigned to either the reduced Na intake or the usual life-style group . The interventions , tailored to the needs of older persons , use behavioral approaches to accomplish intervention-specific goals ( weight loss > or = 10 lb , daily Na intake < or = 80 mEqa ) . Three months after the start of intervention , antihypertensive drug therapy is withdrawn . The primary trial end point is a BP of 150/90 mm Hg or higher , resumption of antihypertensive drug therapy , or the occurrence of a BP-related clinical complication during 2 to 3 years of follow-up . It is anticipated that TONE findings may identify an effective and acceptable nonpharmacologic approach to control hypertension in the increasingly large number of older persons treated with antihypertensive drug therapy OBJECTIVES To assess the effects of acute pressor and depressor blood pressure ( BP ) manipulation on 2-week death and dependency following acute stroke and investigate the safety and efficacy of such treatments . DESIGN A multicentre , prospect i ve , r and omised , double-blind , placebo-controlled titrated-dose trial . SETTING Five hospitals in Engl and . PARTICIPANTS Patients over 18 years admitted to hospital with a clinical diagnosis of suspected stroke and either ( 1 ) symptom onset < 36 hours and hypertension , defined as systolic BP ( SBP ) < 160 mmHg ( depressor arm ) , or ( 2 ) symptom onset < 12 hours and hypotension , defined as SBP < or = 140 mmHg ( pressor arm ) . INTERVENTIONS Patients were allocated to either the pressor or the depressor arm depending on blood pressure at r and omisation . The ratio of allocation to active intervention versus matched placebo was 2:1 for the depressor arm and 1:1 for the pressor arm . MAIN OUTCOME MEASURES The primary end point was death and dependency at 2 weeks , with dependency defined as a modified Rankin score < 3 . Secondary end points were the safety of acute pressor  ( 0 - 12 hours post stroke ) and  depressor  ( 0 - 36 hours post stroke )  BP manipulation  in stroke patients ; whether effects of BP reduction are influenced by stroke type ( ischaemic versus haemorrhagic ) ; whether alternative routes for administration of antihypertensive therapy ( including sublingual and intravenous ) are effective in dysphagic stroke patients ; whether effects of BP manipulation are influenced by the time to treatment ; and the short- and medium-term cost-effectiveness of such therapy in the acute post-stroke period on subsequent disability or death . RESULTS 180 patients were recruited over the 36-month trial period , 179 in the depressor arm and one in the pressor arm ( who received placebo ) . No significant difference was found in death or dependency at 2 weeks between those receiving active depressor treatment with lisinopril or labetalol and those receiving placebo , although numbers recruited to the trial were lower than projected . Active treatment was not associated with an increase in early neurological deterioration despite significantly greater reductions in BP at 24 hours and 2 weeks with active therapy compared with placebo . Active treatment was generally well tolerated and treatment discontinuation rates were similar in active and placebo groups . Survival analysis showed that the active treatment group had a lower mortality at 3 months than the placebo group ( p = 0.05 ) . The pressor arm was closed early because of problems with recruitment , so no conclusions can be drawn regarding this therapy . CONCLUSIONS Oral and sublingual lisinopril and oral and intravenous labetalol are effective BP-lowering agents in acute cerebral infa rct ion and haemorrhage and do not increase the likelihood of early neurological deterioration . The study was not sufficiently powered to detect a difference in disability or death at 2 weeks . However , the 3-month difference in mortality in favour of active treatment is of interest , although care must be taken in interpretation of the results . Further work is needed to confirm this and to assess whether there are differences in the effectiveness of labetalol compared with lisinopril in terms of reducing death or dependency after acute stroke , and whether the introduction of treatment post stroke earlier than was achieved here would be of greater benefit Whole-day ambulatory blood pressure monitoring is used to confirm the diagnosis of hypertension and assess the response to antihypertensive therapy .  Neither of these has been applied to patients with type II diabetes mellitus , in whom it has been proposed that the desirable blood pressure should be lower than in nondiabetics . This multicenter study was design ed to examine whether there are differences in the efficacy of a first-line antihypertensive drug when assessed by casual and ambulatory blood pressure determinations in patients with type II diabetes mellitus in whom 24-hour ambulatory monitoring confirms or fails to confirm the diagnosis of hypertension . Forty-three patients ( mean age , 57.7 years ) with stable type II diabetes mellitus and mild hypertension ( casual diastolic pressure , 90 to 104 mm Hg on at least two visits ) were treated with an angiotensin-converting enzyme inhibitor ( benazepril , 10 to 20 mg , once a day ) for 8 weeks . Antihypertensive drug efficacy was assessed by casual ( trough ) and 24-hour ambulatory blood pressure monitoring . Diabetic patients were classified as nonconfirmed hypertensive if the mean 24-hour ambulatory diastolic pressure was below 85 mm Hg . Antihypertensive treatment significantly decreased both systolic and diastolic pressures when determined by either casual measurement ( from a mean of 162.7/98.0 to 153.9/89.2 mm Hg ; P < .001 ) or ambulatory monitoring ( from a mean of 143.1/84.4 to 137.0/81.5 mm Hg ; P < .05 ) . Twenty-one patients ( 49 % ) were classified as confirmed hypertensive and 22 as nonconfirmed hypertensive . In confirmed hypertensive patients benazepril significantly reduced systolic and diastolic pressures when assessed by either casual or 24-hour ambulatory monitoring . ( ABSTRACT TRUNCATED AT 250 WORDS More than 10 % of patients treated for hypertension have persistently uncontrolled blood pressure ( BP ) despite prescription of antihypertensive drugs ( 1 ) . Renal sympathetic denervation is an old concept that has been re-introduced as a new treatment for hypertension that is apparently resistant to drug treatment ( 2 ) . Patients considered eligible for this procedure populate the high end of the BP spectrum , where , for whatever reason , pharmacological treatment has failed to produce adequate BP control . Recent data suggest that patients suspected of having “ resistant hypertension ” in fact represent a mixed group that includes those with white coat hypertension , secondary forms of hypertension , inadequate dosing of medication and poor adherence to prescribed antihypertensive treatment , as well as true resistant hypertension ( 3 ) . Two out of every three patients referred for renal denervation ( RDN ) because of apparent resistant hypertension did not have true resistant hypertension and therefore were not considered eligible for the procedure . Non and poor adherence to prescribed treatment occurred frequently in this referral population , leading the authors to recommend careful screening of patients with apparent resistant hypertension before undertaking RDN procedures . The main aim of such a screening program is to confi rm the persistence of uncontrolled hypertension despite adequate medical treatment and to exclude secondary forms of hypertension . The Symplicity HTN-2 study ( 4 ) was the fi rst r and omized controlled trial of renal sympathetic denervation to be reported in the literature . Symplicity HTN-2 r and omized 106 patients with apparent treatment-resistant hypertension to renal sympathetic denervation or control and followed them for 6 months . Offi ce BPs were reduced by 32/12 mmHg in the intervention group at 6 months and remained unchanged in the control group . Reductions in ambulatory BP were much smaller , suggesting a “ white coat ” effect . Furthermore , drug adherence was not thoroughly investigated . Poor drug adherence is a common problem among patients with apparent treatment-resistant hypertension ( 5,6 ) . For example , a study of 84 patients taking on average fi ve antihypertensive drugs found no detectable blood levels of any antihypertensive drug in 34.5 % of the patients , and that 65.5 % of the patients fulfi lled the criteria of non-adherence ( 7 ) . It is not known to what extent the reduction in BP that is observed following RDN is caused by the denervation per se or by increased drug adherence . It is reasonable to postulate that patients with poor drug adherence who undergo RDN receive so much positive attention at follow-up that they become increasingly coherent to their antihypertensive medications and thus have enhanced BP reductions . Some patients may even discontinue their antihypertensive drugs prior to qualifi cation procedures for RDN and then resume their medication after the procedure . This could not be detected by the methods employed in Symplicity HTN-2 ( 4 ) , and these defi ciencies provided an impetus for the more tightly controlled Symplicity HTN-3 study in the USA , which included a sham operated control group ( 8,9 ) . Drug adherence can be assessed in several ways , e.g. by electronic pill boxes ,  blood and urine measurements  of prescribed drugs , or by written patient ’ s diaries . Measurement of drugs in blood or plasma can provide valuable information ( 7 ) , but is not available in most clinical practice s , and neither patient ’ s diaries as used in Symplicity HTN-2 nor electronic pill boxes are reliable enough to ensure drug intake . The only method that fully ensures true drug intake and permits documentation of the effects of the Blood Pressure , 2014 ; 23 : Twenty patients with acute severe hypertension were r and omised to therapy with either nifedipine capsules ( 10 mg ) or captopril tablets ( 25 mg ) given sublingually and the blood pressure recorded for 240 minutes . Oral monotherapy with either agent followed for 3 weeks , then the agents were combined for a further 2 weeks and in the final 6 weeks of the trial a beta-blocker and diuretic were added , if needed . Thirteen patients completed the trial . The major results were : ( i ) nifedipine decreased blood pressure more rapidly than captopril 60 minutes after first ingestion but at 240 minutes equal degrees of fall in blood pressure had been obtained ; ( ii ) neither agent given as sustained monotherapy was able to reduce blood pressure adequately , although nifedipine was better than captopril ; and ( iii ) combination therapy with both agents was conspicuously successful in achieving reduction in blood pressure . It is suggested that combination nifedipine-captopril therapy be subject to a formal trial for early therapy in acute severe hypertension Ability to safely withdraw well-controlled mild hypertensives from drugs is being tested in a three-group r and omized trial . Group I ( intervention ) was removed from drugs after the first 2 months of nutrition counseling . Counseling is continuing through the remaining years of the trial to achieve a minimum weight loss of 10 lb if overweight , reduction of sodium intake to less than 1,800 mg , and reduction of alcohol intake to not more than two drinks per day . Group II ( the first control group ) was also removed from drugs to see if previous long-term blood pressure control had a carryover effect without dietary change . Blood pressure is monitored frequently in both groups , with return to drug treatment in the event of specified blood pressure rise . Group III ( the second control group ) has remained on drugs for comparison of blood pressure and biochemical variables . In Group I mean 30-month weight loss was 8 lb , with 35 % losing 10 + lb ; sodium intake was reduced by 38 % . Blood pressure control without drugs was maintained for 47 % of Group I patients but only 16 % of group II patients ( P less than 0.05 ) . These findings indicate it may be possible , after establishing good blood pressure control , to maintain control in a sizable proportion without medication , when reduction of weight , sodium , and alcohol intake is achieved 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 Notwithst and ing the availability of antihypertensive drugs and practice guidelines , blood pressure control remains suboptimal . The complexity of current treatment guidelines may contribute to this problem . To determine whether a simplified treatment algorithm is more effective than guideline -based management , we studied 45 family practice s in southwestern Ontario , Canada , using a cluster r and omization trial comparing the simplified treatment algorithm with the Canadian Hypertension Education Program guidelines . The simplified treatment algorithm consisted of the following : ( 1 ) initial therapy with a low-dose angiotensin-converting enzyme inhibitor/diuretic or angiotensin receptor blocker/diuretic combination ; ( 2 ) up-titration of combination therapy to the highest dose ; ( 3 ) addition of a calcium channel blocker and up-titration ; and ( 4 ) addition of a non — first-line antihypertensive agent . The proportion of patients treated to target blood pressure ( systolic blood pressure < 140 mm Hg and diastolic blood pressure < 90 mm Hg for patients without diabetes mellitus or systolic blood pressure < 130 mm Hg and diastolic blood pressure < 80 mm Hg for diabetic patients ) at 6 months was analyzed at the practice level . The proportion of patients achieving target was significantly higher in the intervention group ( 64.7 % versus 52.7 % ; absolute difference : 12.0 % ; 95 % CI : 1.5 % to 22.4 % ; P=0.026 ) . Multivariate analysis of patient-level data showed that assignment to the intervention arm increased the chance of reaching the target by 20 % ( P=0.028 ) , when adjusted for other covariates . In conclusion , the Simplified Treatment Intervention to Control Hypertension Study indicates that a simplified antihypertensive algorithm using initial low-dose fixed-dose combination therapy is superior to guideline -based practice for the management of hypertension hypertension admitted at the same time because the latter tended to be admitted for other reasons , including vascular complications of hypertension , which might be related to smoking . The lack of association between hypertension and cigarette smoking is well documented,2 ' but inclusion ofcontrol cases with end organ damage might have shown a different trend . The smallireduction in cigarette smoking in the United Kingdom over the past 10 years can not account for the observed excess of smoking in patients with malignant hypertension , which has been confirmed elsewhere.14'6 We were unable to confirm the link of smoking with grade s III and IIa retinopathy , although smoking was slightly more common than in control patients . Other authors usually combined their patients with grade III and IV retinopathy in similar analyses . The prognosis of malignant hypertension , if left untreated , is worse than any form of cancer , with up to 90 % of patients dead in one year."2 Controlling blood pressure prolongs life , " and long term follow up studies have reported a dramatic reduction in mortality.'0 The results oftreatment in our patients were disappointing , but this may be because our cases date d back to 1960 , when effective antihypertensive treatment was not so enthusiastically prescribed . Furthermore , this series includes all patients seen in a district general hospital , some of whom were acutely ill and died within hours or days of admission . The Keith Wagener classification with its gradation of retinopathy from one to four suggests a gradation of risk that is not borne out by our findings . The clinical features ofhypertension in patients with grade s III and IV retinopathy are similar and quite distinct from those seen in patients without retinopathy . Although the severity of hypertension and quality of control of blood pressure with antihypertensive drugs are both potent predictors of risk,23 malignant hypertension seems to carry a particularly bad prognosis , probably related to renal damage due to fibrinoid necrosis of intrarenal arterioles . If control of blood pressure had been better mortality might have been further reduced . The Keith Wagener classification of hypertensive retinopathy , however , seems particularly unhelpful as grade -III and IV do not differ , so we suggest that is should be ab and oned . Malignant and accelerated hypertension are one and the same disease , which should be regarded as a medical emergency requiring accurate long term control of blood pressure . JMW was supported by a grant from ICI Pharmaceuticals and MB by the DHSS computer clinics project . We thank Dr J Mackinnon for providing data from the department of cardiology , Dr A Paton for access to his retinal photography archive , Mr Roy Haynesfor access to the Hospital Activity Analysis Archive , Mrs V L Stewart for secretarial help , and Mrs E Thomas for access to medical records Hypertension is the most common condition seen in primary care and leads to myocardial infa rct ion , stroke , renal failure , and death if not detected early and treated appropriately . Patients want to be assured that blood pressure ( BP ) treatment will reduce their disease burden , while clinicians want guidance on hypertension management using the best scientific evidence . This report takes a rigorous , evidence -based approach to recommend treatment thresholds , goals , and medications in the management of hypertension in adults . Evidence was drawn from r and omized controlled trials , which represent the gold st and ard for determining efficacy and effectiveness . Evidence quality and recommendations were grade d based on their effect on important outcomes . There is strong evidence to support treating hypertensive persons aged 60 years or older to a  BP goal  of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg ; however , there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal , or in those younger than 30 years for a diastolic goal , so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion . The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease ( CKD ) as for the general hypertensive population younger than 60 years . There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor , angiotensin receptor blocker , calcium channel blocker , or thiazide-type diuretic in the nonblack hypertensive population , including those with diabetes . In the black hypertensive population , including those with diabetes , a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy . There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes . Although this guideline provides evidence -based recommendations for the management of high BP and should meet the clinical needs of most patients , these recommendations are not a substitute for clinical judgment , and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient The Fifth Report of the Joint National Committee on Detection , Evaluation , and Treatment of High Blood Pressure recommends that attempts to discontinue antihypertensive drug therapy be considered after blood pressure ( BP ) has been controlled for 1 year . However , discontinuation of drug therapy could unmask underlying conditions and precipitate clinical cardiovascular events . The Trial of Nonpharmacologic Interventions in the Elderly ( TONE ) was a clinical trial of the efficacy of weight loss and /or sodium reduction in controlling BP after withdrawal of drug therapy in patients with a BP < 145/85 mm Hg on 1 antihypertensive medication . Of 975 participants , 886 entered the drug withdrawal phase of the trial and 774 were successfully withdrawn from their medications . Thirty-three events ( stroke , transient ischemic attack , myocardial infa rct ion , arrhythmia , congestive heart failure , angina , other ) occurred between r and omization and the onset of drug withdrawal ( median time 3.6 months ) , 57 events occurred either during or after drug withdrawal ( 14.0 months ) , and 36 events occurred after resumption of antihypertensive therapy ( 15.9 months ) . Event rates per 100 person-years were 5.5 , 5.5 , and 6.8 for the 3 time periods ( p=0.84 ) in the nonoverweight group and 7.2 , 5.2 , and 5.6 ( p=0.08 ) in the overweight group . The study shows that antihypertensive medication can be safely withdrawn in older persons without clinical evidence of cardiovascular disease who do not have diastolic pressure > or = 150/90 mm Hg at withdrawal , providing that good BP control can be maintained with nonpharmacologic therapy Objective : To determine the prognosis of treated hypertensive type 1 ( insulin-dependent ) diabetic patients with overt nephropathy . Design : A controlled , prospect i ve , parallel , 5-year follow-up trial . Setting : The tertiary care centre of the Heinrich Heine University Hospital in Dusseldorf , Germany . Patients and interventions : A sequential sample of 91 hypertensive patients with overt diabetic nephropathy participated in a diabetes treatment programme . Thereafter 45 patients received intensified antihypertensive therapy including blood pressure self-monitoring and self-adjustment of antihypertensive drug treatment with the goal of permanent normalization of blood pressure values below 140/90 mmHg . The remaining 46 patients were administered routine antihypertensive therapy and formed the control group . At baseline both groups were comparable in age , sex , metabolic control and renal function . The groups differed at baseline in their duration of diabetes and blood pressure values , which were higher in the intensified antihypertensive therapy group . Outcome measures : Total mortality and the need for renal replacement therapy . Main results : Blood pressure control was significantly improved in patients who were subjected to intensified antihypertensive therapy , whereas it deteriorated in the group of patients who received routine antihypertensive therapy . At follow-up , primary end points of the study occurred in five ( 11 % ) patients of the intensified therapy group and in 19 ( 41 % ) patients of the routine therapy group . According to life table analysis , intensified antihypertensive therapy was associated with less frequent primary end points ( P= 0.0058 ) and longer survival ( P=0.01 ) . The differences between the groups remained significant after adjustment for covariates in the proportional hazards model . Conclusion : Participation in a treatment programme aim ed at intensification of antihypertensive therapy is associated with a reduction of mortality in hypertensive type 1 diabetic patients with overt nephropathy The purpose of this study was to determine whether the stress of caregiving for the Alzheimer 's disease ( AD ) patient accelerates the likelihood of exceeding hypertensive blood pressure ( BP ) criteria in periodic longitudinal home assessment s. In this cohort study , participants consisted of spousal caregivers of AD patients ( n = 144 ) and demographically equivalent non-caregiving controls ( n = 47 ) . Thirty percent of caregivers and 33 % of controls were receiving antihypertensive treatment at study entry .  Supine systolic and diastolic blood pressure ( SBP and DBP ) was assessed by semi-automated recordings taken in the home every 6 months for 2 to 6 years . Survival analyses ( Cox proportional hazards models ) were used to determine whether the hazard for developing hypertension ( DBP>140 , SBP>90 ) was greater in caregivers than in controls , and whether increased hazards were related to background characteristics or the extent of caregiving dem and s. Based on periodic 6-month assessment s of BP over 6 years , the hazards of meeting criteria for borderline hypertension were greater for caregivers than for controls ( Cox Proportional Hazards , chi2 [ 1 , N = 174 ] = 4.86 , p = 0.03 ) . This difference remained statistically significant ( p<0.05 ) after controlling for age , gender , education , socioeconomic status , body mass index , and use of antihypertensive medications . Increased risk of hypertension was not related to the extent of daily living assistance provided , patient problem behaviors , or caregiver distress . The chronic stress of caring for an AD spouse may have adverse effects on blood pressure ; however , the mechanism for this relationship remains unclear Community-based hypertension control is important for primary prevention of cardiovascular disease . In this study , untreated men and women aged 35 to 69 years were r and omly assigned to an  intervention ( n=56 ) or control ( n=55 ) group in a 1.5-year community-based education program .  Subjects had no evidence of hypertensive end-organ defects and had screening blood pressures of 140 to 179 mm Hg systolic and /or 90 to 109 mm Hg diastolic , with no difference in mean blood pressure between groups ( 148 to 150 mm Hg for mean systolic and 83 to 84 mm Hg for mean diastolic pressures ) . The intervention group took four education classes in the first 6 months and four classes during the next year , and the control group took two classes . Health education focused on reduced dietary sodium and increased milk intake , brisk walking , and , if necessary , reduction of alcohol and sugar intakes . Antihypertensive medication was started less often in the intervention than in the control group at 1.5 years ( 9 % versus 24 % , P < .05 ) . Mean systolic pressure was 5 to 6 mm Hg less in the intervention than in the control group at both 6 months and 1.5 years ( P < .05 ) , with or without inclusion of those subjects who began antihypertensive medication . Diastolic pressure and body mass index did not change significantly between groups . Urinary sodium excretion declined in the intervention but not in the control group ( differences between groups : P=.04 at 6 months and P=.07 at 1.5 years ) . According to a behavioral question naire , sodium reduction and milk increase were greater in the intervention than the control group ( sodium : P < .01 at 6 months and P=.08 at 1.5 years ; milk : P < .001 at 6 months and P < .01 at 1.5 years ) . Mean ethanol intake was reduced in the intervention but not the control group ( P=.04 at 1.5 years ) . This community-based hypertension control program was effective in reducing systolic pressure levels by nonpharmacological means during the first 6 months and maintaining the reduction for 1.5 years
There is important evidence in favor of the use of angiotensin-converting enzyme inhibitors for treating hypertensive urgencies , compared with calcium channel blockers , considering the better effectiveness and the lower frequency of adverse effects ( like headache and flushing )
CONTEXT AND OBJECTIVE Hypertensive urgencies are defined as severe elevations in blood pressure without evidence of acute or progressive target-organ damage .
The need for treatment is considered urgent but allows for slow control using oral or sublingual drugs .
If the increase in blood pressure is not associated with risk to life or acute target-organ damage , blood pressure control must be implemented slowly over 24 hours .
For hypertensive urgencies , it is not known which class of antihypertensive drug provides the best results and there is controversy regarding when to use antihypertensive drugs and which ones to use in these situations .
The aim of this review was to assess the effectiveness and safety of oral drugs for hypertensive urgencies .