Severe hypertension: in emergencies captopril may be as good as nifedipine.

Clinical bottom line (level 1b)

  1. Sublingual captopril was probably as effective as sublingual nifedipine in reducing severe hypertension in emergencies.
  2. There were fewer side effects with captopril (NNT = 3 at 60 minutes) .
Angeli et al: Archives of Internal Medicine 1991; 151: 678-682
Expires August 2003

The study

Single-blinded concealed randomised trial with intention-to-treat
Setting: emergency department, university hospital, Italy

20 patients (aged range 28 to 77 years; mean 58, 65% male) with hypertensive emergencies defined as:
  • diastolic blood pressure >140 mmHg after 20 minutes of bed rest (mean bp 250/150)
  • associated with symptoms and signs of end organ damage (angina, acute heart failure, transient ischaemic attack, hypertensive encephalopathy)


Excluded if
  • overt pulmonary oedema
  • valvular heart disease
  • serious disturbance of consciousness
  • history of myocardial infarction
  • refusal to give informed consent
  • drop of blood pressure after placebo


    • Control Group: (n = 10, 10 analysed): sublingual nifedipine 10 mg. Patients were told to swallow their saliva.
    Experimental Group: (n = 10, 10 analysed): sublingual captopril 25 mg. Patients were told to swallow their saliva.
    All patients initially received placebo. If no response after 20 minutes, patients were enrolled into study. If patients failed to respond after 20 minutes (after study drug), intravenous labetalol and diazoxide was started. In incomplete responders, adequate therapy was started
    100% followed for 60 minutes
    Outcome notes:
    • incomplete response : complete response: diastolic blood pressure <120 mmHg or blood pressure <150mmHg and resolution of signs and symptoms of end-organ damage
    • side effects : headache, facial flushing

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    incomplete response 60 minutes 5
    (50.0%)    		 3
    (30.0%)    		 40%
    (-86% to 81%)    		 20.0%
    (-22.0% to 62.0%)    		 5
    (NNT = 2 to infinity;
    NNH = 5 to infinity)
    side effects 60 minutes 3
    (30.0%)    		 0
    (0.00%)    		 100%
    (% to %)    		 30.0%
    (1.60% to 58.4%)    		 3
    (2 to 63)

  • There were no significant differences in magnitude nor duration of effect of lowering the blood pressure.

    • Comments

    1. Well designed study which lacked numbers and length of follow-up to make any statistical significance.
    2. Both drugs are about 80-90% effective within 20 minutes.

    Citation

    1. Angeli P, et al: Comparison of sublingual captopril and nifedipine in immediate treatment of hypertensive emergencies: A randomized, single-blind clinical trial. Archives of Internal Medicine 1991; 151: 678-682
    Contributor: Nick Shenker and Chris Ball, August 2000
    Reviewer:

    Clinical Question.
    Patient severe hypertension
    Intervention or Exposure captopril
    Comparison nifedipine
    Outcome reduction in blood pressure