Hypertension: crises: intravenous enalaprilat lowered the blood pressure.

Clinical bottom line (level 1b-)

  1. Around two thirds of patients with hypertensive crises had a significant fall in their blood pressure when given intravenous enalaprilat.
  2. Lower doses were probably as effective as higher doses.
Hirschl et al: Archives of Internal Medicine 1995; 155: 2217-2223
Expires August 2003

The study

Unblinded concealed randomised trial with intention-to-treat
Setting: emergency department, university hospital, Germany

65 patients (aged range 34 to 82 years; mean 57, 57% male)
  • hypertensive urgency (systolic blood pressure > 210 mmHg, diastolic blood pressure > 110 mmHg)
or
  • hypertensive emergency (diastolic blood pressure > 100 mmHg, and evidence of end-organ damage: e.g. hypertensive encephalopathy, acute congestive heart failure, angina pectoris)


Excluded if
  • >80 years old
  • evidence of renal failure (Cr > 177 mmol/dl)
  • unilateral or bilateral renal artery stenosis


    • Control Group: (n = 15, 15 analysed): 0.625 mg enalaprilat iv
    Experimental Group: (n = 17, 17 analysed): 1.25 mg enalaprilat iv
    Experimental Group: (n = 17, 17 analysed): 2.5 mg enalaprilat iv
    Experimental Group: (n = 16, 16 analysed): 5 mg enalaprilat iv
    All patients rested supine for 15 minutes before receiving medication: they had history and examination, ECG, creatinine, urea, CK and electrolytes. If there was no response 45 minutes after the study drugs were taken, patients had rescue medication.
    100% followed for 90 minutes

    The evidence

  • overall response (stable reduction of systolic bp < 180mmHg, and diastolic bp < 95 mmHg): 41/65: 63% (95% CI: 51% to 75%)
  • overall side-effects (headache, vertigo): 3/65: 4.6% (0.0% to 9.7%)
  • There was no significant difference between any group in response rate, side-effects, or fall in systolic or diastolic blood pressures.

    • Comments

    1. The study was too small to show small differences between the small dose changes used.
    2. How does this compare with other medication used for hypertensive emergencies and urgencies (e.g. labetalol)?

    Citation

    1. Hirschl MM, Binder M, Bur A, et al: clinical evaluation of different doses of intravenous enalaprilat in patients with hypertensive crises. Archives of Internal Medicine 1995; 155: 2217-2223
    Contributor: Chris Ball and Clare Wotton, August 2000
    Reviewer:

    Clinical Question.
    Patient hypertensive crisis
    Intervention or Exposure enalaprilat
    Outcome lowering blood pressure