Table 3.
Hypertensive Urgencies
| Authors | Patients | Intervention | Outcomes | NNT | AE* | RR | |
|---|---|---|---|---|---|---|---|
| Habib et al.,26 (Evidence 1b) | DBP >120 mm Hg (n = 53) | NCN PO 30 mg vs placebo | Goal: DBP <100 mm Hg | 1. NNT 2 (95% CI, 1 to 5) for NCN | No increase AE in NCN group | RR for placebo to achieve target BP compared to NCN, 0.45 (95% CI, 0.25 to 0.78) | |
| Komsuoglu et al.,11 (Evidence 1b) | DBP ≥120 mm Hg (n = 66) | NIF PO 20 mg vs NCN PO 20 mg vs C PO 25 mg | 1. DBP ≤110 mm Hg | NIF vs NCN NNT 24 (95% CI, NNH 5 to NNT 9) | No difference in adverse effects except NIF increased heart rate compared with other agents | 1. RR for NIF vs NCN, 1.91 (95% CI, 0.19 to 19.63) P= .97 | |
| 2. Adverse effects | NCN vs CPL NNT 18 (95% CI, NNH 4 to NNT 9) | 2. RR for NIF vs captopril, 0.87 (95% CI, 0.14 to 5.62) | |||||
| NIF vs CPL NNT 77 (95% CI, NNH 5 to NNT 6) | |||||||
| Gonzalez et al.,20 (Evidence 1b) | DBP 110 to 140 mm Hg (n = 36) | LBL PO 100 mg vs LBL PO 200 mg vs LBL PO 300 mg | DBP ≤100 mm Hg or 30 mm Hg reduction in DBP | 1. 100 vs 200 mg: NNT 6 (95% CI, NNH 1 to NNT 4) | No adverse events | 1. RR for LBL 100 mg vs 200 mg dose, 1.2 (95% CI, 0.5 to 2.88) | |
| 2. 100 vs 300 mg: NNT 12 (95% CI, NNH 2 to NNT 3) | 2. RR for LBL 100 mg vs 300 mg dose, 1.5 (95% CI, 0.56 to 4.0) | ||||||
| Sanchez et al.,25 (Evidence 1b) | DBP ≥120 mm Hg (n = 29) | LCN PO 4 mg vs NIF PO 20 mg | 1. Decrease in DBP >25% of baseline at 8 and 24 hr | NNT 2 (95% CI, 1 to 8) for LCN | 1 Patient in NIF group had a stroke 30 min after the dose, blood pressure decreased from 210/125 mm Hg to 120/80 mm Hg | RR for NIF compared to LCN to reach the target BP, 0.37 (95% CI, 0.15 to 0.92) | |
| 2. Adverse effects | |||||||
| Jaker et al.,12 (Evidence 1b) | DBP ≥120 mm Hg (n = 51) | NIF PO 20 mg vs CLN PO 0.1 mg repeated every hr | 1. DBP ≤100 mm Hg | NNT 2 (95% CI, 1 to 2) for NIF | Significant increase in heart rate in NIF group, no clinical sequelae; 59% sedation in CLN patients | RR for NIF compared to CLN to reach the target BP, 0.2 (95% CI, 0.03 to 1.57) | |
| 2. Adverse effects | |||||||
| Zeller et al.,13 (Evidence 1b) | DBP 116 to 139 mm Hg (n = 15). | 3 Different combinations of chlorthalidone and CLN | Fall in DBP of 20 mm Hg or DBP <105 mm Hg | No differences between groups | 11 Patients had hypotension evenly distributed in 3 groups, no clinical sequelae | No difference | |
| Rutledge et al.,14 (Evidence 1b) | DBP 100 to 114 mm Hg (n = 65). | Moderate hypertension group (DBP 100 to 114): ENL 1.25 mg IV every 6 hr vs placebo; severe hypertension (DBP 115 to 130): ENL 1.25 mg IV every 6 hr vs FSM | DBP <95 mm Hg | NNT 4 (95% CI, NNH 1 to NNT 19) for ENL | 2 Patients in severe hypertension stratum treated with ENL developed hypotension, had no clinical sequelae | 1. RR for placebo compared to ENL to reach the target BP at 24 hr, 0.58 (95% CI, 0.33 to 1.04) and 0.61 (95% CI, 0.26 to 1.4) at 48 hr | |
| 2. RR for FSM compared to ENL to reach the target BP at 24 hr, 0.82 (95% CI, 0.5 to 1.33) and 0.69 (95% CI, 0.2 to 2.41) | |||||||
| Hirschl et al.,24 (Evidence 1b) | SBP >200 mm Hg and/or DBP >110 mm Hg (n = 53) | URP IV 25 mg, then 12.5 mg if no response vs NIF sublingual 10 mg, repeated if no response | SBP<180 mm Hg or DBP <100 mm Hg | NNT 5 (95% CI, 2 to 55) for URP | No AE. | RR for NIF compared to URP to achieve target BP, 0.12 (95% CI, 0.01 to 2.04) | |
| Rohr et al.,15 (Evidence 2b) | SBP 200 to 250 mm Hg or DBP 110 to 140 mm Hg (n = 161) | NIF PO 10 mg vs NIT PO 5 mg | Decrease of ≥20 mm Hg SBP and of ≥15 mm Hg DBP | NNT 1,000 (95% CI, NNH 7 to NNT 7) for NIT | No major AE | 83% of patients had effective blood pressure control in 4 hr in both groups | |
| McDonald et al.,16 (Evidence 2b) | DBP ≥120 mm Hg (n = 20) | NIF PO 10 mg repeated 2 times if necessary vs LBL PO 200 mg followed by 100 mg or 200 mg at 2 hr if necessary | DBP ≤110 mm Hg | NNT 6 (95% CI, NNH 2 to NNT 10) for NIF | No AE | RR for LBL to reach the target BP compared to NIF, 0.2 (95% CI, 0.01 to 3.71) | |
| Panacek et al.,17 (Evidence 2b) | DBP ≥120 mm Hg (n = 183). | FNP 0.1 μg/kg/min vs NTP 0.1 μg/kg/min and titrated to target BP of DBP<140 mm Hg or maximum reduction of 40 mm Hg in DBP | 1. Time to reach the initial goal induction DBP | No significant difference in time to reach goal DBP: 1 hr, 25 min in FNP-treated group, vs 1 hr, 34 min in NTP-treated group (NS) | 22 Patients (10 FNP, 12 NTP) withdrawn due to clinical events: hypotension in 5 FNP patients and 11 NTP patients (NS). None had clinical sequelae from the hypotension | ||
| 2. BP reduction during 6- to 24-hr maintenance phase | |||||||
| 3. Adverse effects | |||||||
| Pilmer et al.,18 (Evidence 1b) | DBP ≥120 mm Hg (n = 33) | FNP 0.1 μg/kg/min vs NTP 0.1 μg/kg/min and titrated to target BP of DBP 95 to 110 mm Hg or maximum reduction of 40 mm Hg in DBP | 1. Time to reach the initial goal induction DBP | 1. All patients reached goal DBP during initial 6-hr titration period | 4 Patients (2 FNP, 2 NTP) withdrawn due to hypotension (NS). None had clinical sequelae from the hypotension | NA | |
| 2. BP reduction during 6- to 24-hr maintenance phase | 2. No significant difference in time to reach goal DBP: 1.5 ± 1.4 hr in FNP-treated group, vs 2 ± 2.5 hr in NTP-treated group (NS). | ||||||
| 3. Adverse effects | 3. Re-elevation in DBP 1 hr after NTP infusion termination (103 ± 1.8 mm Hg vs 111 ± 3.0 mm Hg) P < .03 | ||||||
| Reisin and Huth,19 (Evidence 2b) | DBP ≥120 mm Hg and <170 mm Hg (n = 18) | FNP 0.1 μg/kg/min vs NTP 0.5 μg/kg/min and titrated to target BP of DBP <110 mm Hg if initial DBP 120 to 149 mm Hg or by at least 40 mm Hg if initial DBP was 150 to 190; after goal DBP achieved, maximum infusion rate maintained for at least 2 hr then titrated off over 2 hr | 1. Compare the efficacy of FNP vs NTP in DBP reduction | 1. All patients reached goal DBP by the end of the maintenance period | No patients had hypotension due to FNP or NTP. 2 NTP patients had toxic thiocyanate levels but no clinical manifestations of toxicity | NA | |
| 2. Adverse effects | 2. No mention of any difference in time to reach goal DBP or re-elevation in DBP infusion termination | ||||||
| Hirschl et al.,9 (Evidence 2b) | SBP >210 mm Hg or DBP >110 mm Hg or patients with DBP >100 mm Hg AND evidence of end-organ dysfunction (∼1:1 ratio of urgencies and emergencies) (n = 168) | ENL 5 mg IV vs URP 25 mg IV or NIF 10 mg capsule SL or NIF 10 mg SL spray | SBP <180 mm Hg and DBP <95 mm Hg and resolution of end-organ dysfunction in hypertensive emergencies | NNT for URP compared to ENL and NIF 4 (95% CI, NNT 3 to NNT 6) | 1 NIF patient had hypotension and a TIA | RR for ENL/NIF to reach the goal BP compared to URP, 0.73 (95% CI, 0.64 to 0.83) | |
| Wallin et al.,22 (Evidence 1b) | SBP >200 mm Hg or DBP >120 mm Hg; study included a mixture of urgency and emergency patients (n = 123) | NCN IV 5.0 mg/hr with titration vs placebo | SBP ≤160 mm Hg or DBP ≤110 mm Hg or decrease DBP ≥25 mm Hg | NNT for NCN compared to placebo 1 (95% CI, 1 to 1) | 7 NCN patients developed hypotension, 4 had to stop drug, 2 had dose decreased (no clinical sequelae) | RR for placebo to reach goal BP compared to NCN, 0.01 (95% CI, 0.001 to 0.017) |
*
Comparing adverse effects was difficult due to the inconsistent methods of reporting adverse effects among different studies. AEs, when documented, were included in Tables 2 Tables 3.
SBP, systolic blood pressure; DBP, diastolic blood pressure; TIA, transient ischemic attack; NNT, number needed to treat; NNT is the number of patients needed to treat in order to prevent 1 negative outcome; in the context of this study, the NNT is the number of patients needed to treat in order for 1 patient to achieve the target blood pressure; NNH, number needed to harm; NNH is the number of patients needed to treat in order to harm 1 patient inadvertently; in the context of this study, the NNH is the number of patients needed to treat in order for 1 patient to miss achieving the target blood pressure; RR, relative risk; AE, adverse effects; SBP, systolic blood pressure; DBP, diastolic blood pressure; CLN, clonidine; FNP, fenoldopam; NTP, nitroprusside; NIT, nitrendipine; NIF, nifedipine; URP, urapidil; LCN, lacidipine; FSM, furosemide; ENL, enalaprilat; NCN, nicardipine; SL, sublingual; IM, intramuscular; NA, not applicable.