Hypertensive emergencies in old age: effects of angiotensin converting enzyme inhibition. [Prevalence, forms of clinical presentation and treatment of arterial hypertension at an emergency unit]. 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 Blood pressure and isolated systolic hypertension and the risk of coronary heart disease and mortality in elderly men (the Zutphen Elderly Study) Dogma Disputed: Can Aggressively Lowering Blood Pressure in Hypertensive Patients with Coronary Artery Disease Be Dangerous? [Sublingually administered captopril versus nifedipine in hypertension emergencies]. Diclofenac sodium versus pethidine in acute renal colic. [The effect of an antihypertensive drug during psychological stress. A double-blind study]. Accelerated risk of hypertensive blood pressure recordings among Alzheimer caregivers. Central blood pressure measurements and antihypertensive therapy: a consensus document. Intensified antihypertensive therapy is associated with improved survival in type 1 diabetic patients with nephropathy Influence of diabetes and type of hypertension on response to antihypertensive treatment. SEVERITY OF EMERGENCY DEPARTMENT HYPOTENSION PREDICTS ADVERSE HOSPITAL OUTCOME Blood Pressure and Clinical Outcomes in the International Stroke Trial Response to Antihypertensive Therapy in Older Patients With Sustained and Nonsustained Systolic Hypertension Treatment of mild hypertension: a five year controlled drug trial. The Oslo study. Controlling hypertension and hypotension immediately post stroke (CHHIPS)--a randomised controlled trial.
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 In order to determine the prevalence of arterial hypertension and clinical presentation of the hypertensive crisis , as well as the need and efficacy of treatment , 3626 patients who were seen at an Emergency care Unit during a period of 37 r and omly chosen days in a total time period of three months , have been studied . Two hundred and fifty one patients presented arterial hypertension , defined as a systolic arterial pressure above 160 mmHg and /or diastolic above 95 mmHG , which represents 6,92 % of medical emergencies and 1.79 % of total emergencies . Only 104 patients ( 2.86 % ) seeked help for some pathology related to hypertension , of whom 49 ( 19.5 % of hypertense patients ) presented as a hypertensive emergency , being the acute lung edema and unstable angina the most frequently encountered emergencies . Nifedipine was the most frequently used drug in both groups and managed to control pressure levels in almost 90 % of patients with a hypertensive emergency in a mean time of less than one hour 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 Objective To investigate the associations of diastolic blood pressure ( DBP ) and systolic blood pressure ( SBP ) with the risk of coronary heart disease , sudden cardiac and all-cause death in elderly men . Design A cohort study . Setting The Dutch town of Zutphen . Subjects Eight hundred and eighty-five r and omly selected men , aged 64 - 84 years . Main outcome measures Relative risks adjusted for age , body mass index , total and high-density lipoprotein cholesterol , cigarette smoking , alcohol consumption , use of blood pressure-lowering medications without a specific indication for hypertension , and the physician who measured the blood pressure . Results Neither DBP nor SBP was associated significantly with the incidence of a first coronary heart disease event and no clear associations were observed with mortality from coronary heart disease . However , positive associations with sudden cardiac death were observed . The adjusted relative risk for men with definite isolated systolic hypertension was 9.20 . The risk of dying from coronary heart disease not recorded additionally as sudden death was highest in men at the lower end of the DBP and SBP distributions and in men using antihypertensives . DBP and SBP were positively associated with all-cause mortality when possible comorbidity at the time of the blood pressure measurement was accounted for . Overall , the highest risk for all endpoints was observed in men on antihypertensive medication , who formed a distinct group with a clustering of cardiovascular risk factors . Conclusion Elevated DBP and SBP , and especially isolated systolic hypertension , are important predictors of sudden cardiac death in elderly men . The highest risk of nonsudden coronary heart disease mortality was found at the lower end of the blood pressure distributions and among men on antihypertensive medication Context Experts debate the consequences of excessive lowering of diastolic pressure in patients with hypertension and coronary artery disease . Contribution This report is a secondary analysis of data from a large trial of 2 antihypertensive drug regimens in patients with known coronary artery disease . The authors found a J-shaped relationship between diastolic blood pressure and all-cause death and myocardial infa rct ion , with the increased risk occurring at diastolic blood pressures below 70 to 80 mm Hg , that is , the lower the diastolic pressure , the higher the risk . Caution s The study examined associations between blood pressure and outcomes ; it could not prove that the antihypertensive therapy that lowered diastolic pressure too much caused the adverse outcomes . The Editors For 2 decades , the hypertension literature has been haunted by the phenomenon of a paradoxical increase in morbidity and mortality with an excessive decrease in blood pressure ( J-curve ) . Indeed , several reports have shown that low diastolic pressure is associated with an increased risk for coronary heart disease and related mortality in older adults and in patients taking antihypertensive medications ( 1 - 13 ) . After doing a review and meta- analysis of pertinent studies , Farnett and colleagues ( 14 ) concluded that although there was no consistent J-shaped relationship between stroke and systolic or diastolic pressure , there was a consistent J-shaped relationship for cardiac events and diastolic pressure . These authors stated that this dichotomy in the relationship between diastolic pressure and target organ disease may leave a clinician with the uncomfortable choice of whether to prevent stroke or renal disease at the expense of coronary heart disease . These findings were at variance with the generally accepted dogma formulated by the sixth report of the Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure ( JNC VI ) ( 15 ) , which stated that the relationship between pressure and risk was strong , continuous , independent , predictive and etiologically significant . Within the past decade , the phenomenon of a J-curve has been studied in several large trials of normotensive and hypertensive patients ( 16 - 30 ) . Not surprisingly , arguments regarding whether a J-curve could be clinical ly significant have become somewhat contentious . That is , some rely on evidence that on-treatment diastolic pressure below 70 mm Hg does not increase risk for cardiovascular disease and thus deny an impairment of vital organ perfusion within the usual values achievable by antihypertensive treatment . Others , however , consider the J-curve a more real possibility , particularly for the heart . In contrast to other organs , the heart is perfused mostly during diastole and thus could be more vulnerable to diastolic pressure reduction . If a J-curve did exist , it should be most evident in patients with limited coronary perfusion , in other words , in those with manifest coronary artery disease ( CAD ) . Optimal blood pressure in patients with hypertension and CAD remains controversial because few r and omized clinical trials have been done in this population ( 31 , 32 ) . The International Verapamil-Tr and olapril Study ( INVEST ) ( 33 ) , a r and omized trial , evaluated more than 22000 patients with CAD and hypertension . This patient profile , together with unprecedented levels of blood pressure control , provided a unique opportunity to critically investigate the hypothesis that the risk for CAD would increase with an excessive decrease in diastolic pressure . Methods Study Design and Intervention The INVEST design , methods , and principal results have been previously published ( 33 ) . The trial used an open design with blinded end point assessment . In brief , clinical ly stable patients with CAD and hypertension were r and omly assigned to a verapamil sustained-releasebased or atenolol-based strategy .  Patients with previous myocardial infa rct ion ( MI ) within 3 months of enrollment or class IV or V congestive heart failure were excluded .  Blood pressure goals were based on JNC VI ( systolic pressure < 140 mm Hg and diastolic pressure < 90 mm Hg or systolic pressure < 130 mm Hg and diastolic pressure < 85 mm Hg in patients with diabetes or renal impairment ) ( 15 ) . The addition of tr and olapril or hydrochlorothiazide was recommended when necessary to achieve blood pressure goals . Tr and olapril was also recommended for patients with heart failure , diabetes , or renal impairment . Documented CAD was defined as any of the following : remote ( 3 months before enrollment ) confirmed MI , coronary angiography showing more than 50 % narrowing of at least 1 major coronary artery , diagnosis of classic angina pectoris , or concordant abnormalities on 2 different signals ( electrocardiography , echocardiography , or radionuclide scans ) from stress test findings concordant for ischemia ( for example , ST-segment depression or perfusion defects on radionuclide scanning or wall-motion abnormalities on echocardiography or radionuclide scanning ) . Patient Monitoring and Follow-up Protocol visits were scheduled every 6 weeks for the first 6 months and then biannually until 2 years after the last patient was enrolled . Patients were assessed for response to treatment , symptoms , treatment adherence , and adverse effects at each visit and at the end of the study as detailed elsewhere ( 33 ) . Patient follow-up was complete when we received a final assessment form through the online data system or a death report . The Internet-based electronic data collection method used in INVEST did not accept the entry until all required fields were complete . Blood pressure  was measured by using a st and ard mercury sphygmomanometer with an appropriately sized cuff applied to the upper nondominant arm at heart level . By auscultation at the brachial artery , systolic pressure was recorded at the first Korotkoff sound and diastolic pressure was recorded at the disappearance of the fifth Korotkoff sound . Blood pressure was measured twice , at least 2 minutes apart , and the measurements were averaged . Study Outcomes The primary outcome was the first occurrence of all-cause death , nonfatal MI , or nonfatal stroke by intention-to-treat analysis . The MI and stroke definitions are detailed elsewhere ( 34 ) . These 3 components individually were the main secondary outcomes . For this analysis , additional outcomes included fatal and nonfatal MI , fatal and nonfatal stroke , and average on-treatment blood pressure before outcome or censoring . Ascertainment and blinded adjudication of outcomes were described previously ( 32 ) . Follow-up data were available for 22008 ( 97.5 % ) patients . Statistical Analysis The main conclusions of INVEST were that the 2 treatment strategies were equivalent with respect to the primary outcome , main secondary outcomes , and on-treatment systolic and diastolic pressures . Thus , data for all enrolled patients were combined and included in these analyses following the intention-to-treat principle . A P value of 0.05 or less was considered statistically significant . Patients without a primary outcome event were censored at their latest follow-up visit . Average follow-up systolic and diastolic pressures were calculated for each patient by using all post-baseline results , up to the date of primary outcome or censoring . The baseline value was substituted for patients with no post-baseline data ( n= 1154 ) . In this exploratory analysis , the proportions of patients were pooled by 10 mm Hg strata of average follow-up systolic pressure , and the distribution of primary outcome event rate was evaluated to determine whether the relationship was linear . A similar presentation was prepared for diastolic pressure . Because the frequency distributions seemed consistent with a quadratic curve , a quadratic Cox proportional hazards model was formed for the time to primary outcome for each blood pressure variable , with factors for blood pressure and blood pressure squared . Similarly , the relationship between each 10 mm Hg stratum of average systolic pressure and diastolic pressure and all-cause death , fatal and nonfatal MI , and fatal and nonfatal stroke was evaluated . For the time to primary outcome , a second model was fitted , adjusting for the following baseline covariates : age ( 10-year increments ) , sex , race and ethnicity ( white , Asian , black , Hispanic , multiracial , or other ) , previous MI , heart failure ( classes I to III ) , body mass index in increments of 5 kg/m2 , U.S. residency , renal impairment , peripheral vascular disease , left ventricular hypertrophy , smoking history , coronary revascularization , dyslipidemia , stroke or transient ischemic attack , angina pectoris , arrhythmia , diabetes , cancer , aspirin use , and average systolic pressure or diastolic pressure and systolic pressure squared or diastolic pressure squared . To identify clinical ly relevant interactions between the J-shaped curve and baseline diastolic pressure , demographic characteristics , and comorbid conditions for the primary outcome , a 2-step procedure was used . First , baseline covariates were tested individually by adding the variable and 2 interaction terms ( variablediastolic pressure and variable[diastolic pressure squared ] ) to the Cox proportional hazards model . Variables included were age older than 70 years , sex , previous MI , heart failure ( classes I to III ) , previous stroke or transient ischemic attack , diabetes , cancer , renal impairment , hypercholesterolemia , peripheral vascular disease , smoking history , U.S. residency , body mass index greater than 29 kg/m2 ( mean baseline body mass index ) , and diastolic pressure greater than 86 mm Hg ( mean baseline diastolic pressure ) . The change in log likelihood was used to assess the significance of simultaneously adding the 2 interaction terms . The second step in identifying clinical ly relevant interactions between the J-shaped curve and baseline covariates was to plot the hazard ratios for the primary outcome versus diastolic pressure in the 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 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 A sample of 20 patients suffering hypertension ( with a moderate rise in blood pressure ) was r and omly divided into two treatment groups of equal size . The patients of one group received antihypertension treatment with the combination drug Briserin ¿ ( containing 0.1 mg reserpine , 5 mg clopamide , 0.5 mg dihydroergocristin/per tablet ) ; the other patients who served as  control group  , received a matched placebo . After a fortnight 's treatment , the responsiveness of both groups to five different psychologically stressing situations ( those with cognitive and /or emotional overload ) was tested . Analysis of covariance revealed clinical ly significant differences in the mean systolic and diastolic pressure scores of the two groups . The scores of the treatment group were lower not only under stress but also at rest . There was in interaction between rise of blood pressure under stress and kind of stress in the two groups , i.e. , in situations with heavy emotional and /or cognitive load the differences in the pressure scores of the two groups were less substantial than in situations with a low or medium load . The treatment had no systematic effect on heart rate in this sample . In the treatment group reaction time , perceptual speed , and short-term memory were impaired as compared with the control group ; but these differences did not reach a level of significance 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 The 2003 European Society of Hypertension/European Society of Cardiology guidelines for the management of arterial hypertension1 included 2 important novel recommendations : assessment of the total cardiovascular risk should be taken into account in the management of the hypertensive patient , and quantification of risk should include sub clinical target organ damage . These guidelines acknowledged that central ( aortic ) blood pressure ( BP ) , which is the pressure exerted on the heart and brain , may be different from the pressure that is measured at the arm . They also recognized that central pressure may be predictive of outcome in specific population s2 and differently affected by antihypertensive drugs . However , although these guidelines accepted that central augmentation index and pulse wave velocity may be important as measures of sub clinical organ damage , they also stressed the need for prospect i ve trials to establish their predictive values given that such studies were lacking at that time ( 2003 ) . After publication of these guidelines , additional data have strengthened the pathophysiological importance of central BP . Clinical studies have indicated that central BP may have predictive value independent of the corresponding peripheral ( brachial ) BP . More importantly , recent large-scale trials have shown that central hemodynamics may provide a worthwhile treatment target . In addition , central hemodynamics can now be reliably assessed noninvasively with a number of devices . Accordingly , because arterial stiffening and central hemodynamics are markers and manifestations of organ damage , the pertinent key question is whether the balance of evidence on their importance and issues related to clinical practice allows for implementation in patient management . Central ( aortic and carotid ) pressures are pathophysiologically more relevant than peripheral pressures for the pathogenesis of cardiovascular disease.3,4 It is aortic systolic pressure that the left ventricle encounters during systole ( afterload ) , and the aortic pressure during diastole is a determinant of coronary perfusion . Furthermore , the distending pressure in the 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 aim of our investigation was to determine whether the presence of additional risk factors or type of hypertension ( diastolic or isolated systolic ) influences blood pressure ( BP ) response to treatment . The International Nifedipine GITS Study : Intervention as a Goal in Hypertension Treatment ( INSIGHT ) study is a double-blinded outcome comparison of calcium channel blockade with diuretics in high-risk patients aged 55 to 80 years . Dynamic r and omization between nifedipine once daily and hydrochlorothiazide/amiloride was performed to ensure that approximately equal numbers of patients in the 2 groups had each of the major cardiovascular risk factors . Patients with isolated systolic hypertension were also separately r and omized . Atenolol or enalapril was the m and atory second-line drug . In 5669 patients who completed the 18-week titration , BP fell from 172+/-15/99+/-9 mm Hg ( mean+/-SD ) while receiving placebo to 139+/-12/82+/-7 mm Hg . Twenty-six percent of patients required 2 drugs , and 4 % required 3 drugs . Patients with diabetes were the most resistant to treatment , requiring second and third drugs 40 % and 100 % more frequently than patients without diabetes and achieving marginally the highest final BP , for any risk group , of 141+/-13/82+/-8 mm Hg . Age , smoking , gender , hypercholesterolemia , left ventricular hypertrophy , and existing atherosclerosis had little ( < 1 mm Hg ) or no influence on BP at the end of titration , but all except smoking slightly reduced the initial response of either systolic or diastolic BP . Patients with isolated systolic hypertension were slightly more responsive than average to treatment . Our findings suggest that in patients at high absolute risk of cardiovascular complications from hypertension , the risk factors themselves do not prevent the recommended BP targets from being achieved Arterial hypotension often signifies inadequate systemic perfusion . We hypothesize that in a heterogeneous emergency department ( ED ) population with clinical ly suspected circulatory shock , the severity of hypotension on presentation predicts in-hospital outcome . We performed a secondary analysis of patients with nontraumatic shock enrolled in a noninterventional , r and omized , controlled trial . The setting was an urban , tertiary ED , census > 100,000 visits per year . Patients included nontrauma ED patients , aged > 17 years , with initial ED vital signs consistent with shock ( systolic blood pressure < 100 mmHg or shock index > 1.0 ) , and agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion . Measurements included interobserver agreement for signs and symptoms of shock , relationship between the depth and duration of ED hypotension and adverse hospital outcome ( in-hospital mortality , need for intensive care unit services , and acute organ failure ) and logistic regression analysis for independent predictors of adverse hospital outcome . Of 202 patients who qualified , 190 patients were included ;  the in-hospital mortality rate was 15 % . The sign or symptom of shock with the highest interobserver agreement was “ unresponsive ” ( κ = 0.74 ) . The adverse hospital outcomes increased with each decile decrease in the lowest ED systolic blood pressure ( SBP ) from 17 % if SBP > 89 mmHg versus 50 % if SBP < 80 mmHg . Forty percent of patients with an adverse hospital outcome had sustained hypotension ( all ED SBP < 100 mmHg for ≥60 min ) . Sustained hypotension was the strongest independent predictor of an adverse hospital outcome ( odds ratio 3.1 ; 95 % CI 1.5–7.1 ) . Mortality among patients who present to the ED with undifferentiated shock is high . The depth and duration of systolic blood pressure appears to have a dose – response relationship to adverse hospital outcome Background and Purpose — Among patients with acute stroke , high blood pressure is often associated with poor outcome , although the reason is unclear . We analyzed data from the International Stroke Trial ( IST ) to explore the relationship between  systolic blood pressure ( SBP ) , subsequent clinical events over the next 2 weeks , and functional outcome at 6 months in patients with acute stroke . Methods — We included in the analysis 17 398 patients from IST with confirmed ischemic stroke . A single measurement of SBP was made immediately before r and omization . Clinical events within 14 days of r and omization were recorded : recurrent ischemic stroke , symptomatic intracranial hemorrhage , death result ing from presumed cerebral edema , fatal coronary heart disease , and death . Survival and dependency were assessed at 6 months . Outcomes were adjusted for age , sex , clinical stroke syndrome , time to r and omization , consciousness level , atrial fibrillation , and treatment allocation ( aspirin , unfractionated heparin , both , or neither ) . Results — A U-shaped relationship was found between baseline SBP and both early death and late death or dependency : early death increased by 17.9 % for every 10 mm Hg below 150 mm Hg ( P < 0.0001 ) and by 3.8 % for every 10 mm Hg above 150 mm Hg ( P = 0.016 ) . The rate of recurrent ischemic stroke within 14 days increased by 4.2 % for every 10–mm Hg increase in SBP ( P = 0.023 ) ; this association was present in both fatal and nonfatal recurrence . Death result ing from presumed cerebral edema was independently associated with high SBP ( P = 0.004 ) . No relationship between symptomatic intracranial hemorrhage and SBP was seen . Low SBP was associated with a severe clinical stroke ( total anterior circulation syndrome ) and an excess of deaths from coronary heart disease ( P = 0.002 ) . Conclusions — Both high blood pressure and low blood pressure were independent prognostic factors for poor outcome , relationships that appear to be mediated in part by increased rates of early recurrence and death result ing from presumed cerebral edema in patients with high blood pressure and increased coronary heart disease events in those with low blood pressure . The occurrence of symptomatic intracranial hemorrhage within 14 days was independent of SBP Background The goal of the present study was to assess the effect of antihypertensive therapy on clinic ( CBP ) and ambulatory ( ABP ) blood pressures , on ECG voltages , and on the incidence of stroke and cardiovascular events in older patients with sustained and nonsustained systolic hypertension . Methods and Results Patients who were ≥60 years old , with systolic CBP of 160 to 219 mm Hg and diastolic CBP of < 95 mm Hg , were r and omized into the double-blind placebo-controlled Systolic Hypertension in Europe ( Syst-Eur ) Trial . Treatment consisted of nitrendipine , with the possible addition of enalapril , hydrochlorothiazide , or both .  Patients enrolled in the Ambulatory Blood Pressure Monitoring Side Project were classified according to daytime systolic ABP into 1 of 3 subgroups : nonsustained hypertension ( < 140 mm Hg ) , mild sustained hypertension ( 140 to 159 mm Hg ) , and moderate sustained hypertension ( ≥160 mm Hg ) . At baseline , patients with nonsustained hypertension had smaller ECG voltages ( P < 0.001 ) and , during follow-up , a lower incidence of stroke ( P < 0.05 ) and of cardiovascular complications ( P = 0.01 ) than other groups . Active treatment reduced ABP and CBP in patients with sustained hypertension but only CBP in patients with nonsustained hypertension ( P < 0.001 ) . The influence of active treatment on ECG voltages ( P < 0.05 ) and on the incidence of stroke ( P < 0.05 ) and cardiovascular events ( P = 0.06 ) was more favorable than that of placebo only in patients with moderate sustained hypertension . Conclusions Patients with sustained hypertension had higher ECG voltages and rates of cardiovascular complications than did patients with nonsustained hypertension . The favorable effects of active treatment on these outcomes were only statistically significant in patients with moderate sustained hypertension In 1972 - -1973 , 785 symptom-free men , aged 40 to 49 years , without target organ damage , with systolic blood pressures between 150 and 179 mm Hg and diastolic blood pressure below 110 mm Hg , were assigned at r and om to one of two groups : ( 406 to a drug treatment group and 379 to a control group ) for a five-year controlled drug treatment trial to evaluate the effect of therapy on cardiovascular complications . Drug treatment started with hydrochlorothiazide . If systolic blood pressure remained above 140 mm Hg and /or diastolic blood pressure above 90 mm Hg , alphamethyldopa was added . If there were side effects , methyldopa was replaced with propranolol . The control group was not given a placebo . The mean observation time was 66 months ( range 60 to 78 months ) . A difference in blood pressure between groups of about 17 mm Hg systolic and 10 mm Hg diastolic was maintained throughout the study . The study protocol had a rather low " ethical " blood pressure roof , 180 mm Hg systolic and /or 110 mm Hg diastolic . Seventeen percent of the control group had an increase in blood pressure above this level during the trial , and drug treatment was started . There was no effect on major cardiovascular morbidity comparing groups as established by r and omization , with 18 events in the treatment group and 20 events in the control group . There was no difference between the groups in total mortality and mortality from cardiovascular events . However , in the subgroups with diastolic blood pressure greater than or equal to 100 mm Hg before r and omization , there was a probable reduction in total morbidity from cardiovascular events in favor or the group receiving drug therapy , 7.6 and 16.4 percent events in the treated and control groups , respectively . Cerebrovascular events occurred only in the control group , 7 versus 0 . Two cases of fatal aortic aneurysms also occurred in the control group . Other " pressure " complications , such as marked left ventricular hypertrophy in the electrocardiogram and left ventricular failure , occurred only in the control group . However , regarding coronary heart disease , including sudden death , the incidence tended to be higher in the treated group , although it was not statistically significant . Only 13 men ( 1.7 percent ) failed to meet for regular examinations . At the end of the study these men were also followed up with regard to possible cardiovascular events 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
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 .
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 .