HDCN Article Review/Hyperlink

Rehman F, Mansoor GA, White WB

"Inappropriate" physician habits in prescribing oral nifedipine capsules in hospitalized patients

Am J Hypertens (Oct) 9:1035-1039 1996

This study by Rehman et al. begins with the observation that no FDA approved indication exists for the use of nifedipine for acute treatment of hypertension. It then documents the widely disparate and apparently arbitrary use of nifedipine for the acute treatment of hypertension. Certainly, the last three decades have brought us a wide variety of antihypertensive agents which have made the treatment of hypertension relatively simple and convenient. Perhaps too convenient. Hypertensive emergencies or urgencies are clear defined and understood by many physicians. Unfortunately most situations in which the question of acute treatment for hypertension arises do not fall within these definitions. Nevertheless the need for treatment is often felt to be compelling, if not by the physician then by the nurse, the patient or the family. All of these people have their differing constructs concerning hypertension and its treatment, which almost certainly contributes directly to the diversity of clinical situations in which nifedipine is used.

For this study data was collected on all hospitalized patients receiving oral nifedipine for an 8 week period. Emergency department patients were excluded. Nifedipine was prescribed by phone in 63% of cases for "arbitrary and asymptomatic" levels of blood pressure elevation. In one-third of patients the diastolic pressure was normal at the time of treatment. Only in exceptional cases was a bedside evaluation performed before administration of nifedipine. Documention of follow-up by a clinicinan was noted in 51% of patients within one hour and an additional 24% at two hours. Nifedipine effectively lowered the systolic and diastolic blood pressure by 32 and 22 mmHg respectively. One patient was noted to become hypotensive with a subsequent anterior myocardial infarction which was attributed to the administration of nifedipine.

Comment: Rehman et al. evaluated the quality of care given to patients receiving nifedipine. The level of care that was found compared unfavorably with that level considered appropriate by the authors. Would the inclusion of emergency room patients have decreased this apparent clinical delinquency? In the emergency room setting, where a significant amount of oral nifedipine is used, follow-up blood pressure measurements and clinical evaluations by the nurse and physician are more frequent. (Greg Cowell, M.D., University of Illinois at Chicago)