Fewer labetalol titrations may be the result of the difficulty in performing frequent bolus therapy in a sellekchem busy ED, or the fear of iatrogenic hypotension and bradycardia with too frequent bolus therapy. Therefore the lack of rapid BP decline in the labetalol cohort may be a result of insufficient dosing by a physician hesitant to aggressively administer successively increasing boluses of labetalol as is recommended by the FDA.Although the six-hour observation period of our study can be criticized, this must be considered in view or our primary endpoint which was to determine which agent was most effective when rapid BP control was required. As an IV agent that requires more than six hours to control BP would have little use in the emergent scenario, we limited the time of evaluation to a period we felt was clinically relevant for rapid BP reduction.

Finally, the 30 minute definition of BP control may be questioned. However, we felt that agents requiring longer than this to control BP would be of lesser value in clinical settings where rapid BP control may be required to improve clinical outcomes. Furthermore, since the BP goals were determined by the treating ED physicians who were aware of the dosing parameters of both study drugs and the study timelines, we feel that our 30 minute goal to blood pressure control was a reasonable time limit.We did not complete a cost analysis of the two agents. Although cost is also considered when an anti-hypertensive agent is selected, such an analysis was beyond the scope of this initial investigation.

ConclusionsIn this, the first randomized comparative effectiveness trial directly evaluating the use of a nicardipine infusion to bolus labetalol in the ED management of acute hypertension, we demonstrated that patients receiving nicardipine are more likely to have their BP controlled (OR 2.73, 95% CI 1.1 to 6.7), defined as within the physician’s prospectively defined target range, than patients treated with labetalol. Although this may be the result of administration differences, this reflects actual clinical practice in how these medications are utilized. Furthermore, the need for rescue medications, or excessive BP lowering, did not appear to differ between the two cohorts. Future investigation is needed to place our findings within the context of hospital costs and resource allotment.

Key messages? Hypertensive emergencies require immediate, controlled BP reduction to avoid or limit end-organ damage.? In sufficient doses, both labetalol and nicardipine lower BP.? Patients treated with nicardipine were 2.7 times Carfilzomib more likely to be in the target range within 30 minutes, than those treated with labetalol.? Overshoot of BP below the specified range occurred in less than 15% of patients treated with either nicardipine or labetalol.