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I n their thorough analysis of the treatment of hypertension in elderly nursing home residents, Gambassi and colleagues concluded that the current prescription pattern with a predominance of calcium antagonists and angiotensin-converting enzyme inhibitors at the expense of b-blockers did not follow recommended guidelines. As an explanation for this discrepancy, they suggest that “the present findings may reflect appropriate prescribing by an enlightened physician facing the difficult applicability of the guidelines to the frail, very old nursing home resident with multiple comorbid conditions and concomitant, complex pharmacological regimens.” We can only reemphasize these thoughts. As can be seen in the Table, there is a distinct difference between the “healthy” elderly patients with hypertension (such as those included in the SHEP [Systolic Hypertension in the Elderly Program], Syst-Eur [Systolic Hypertension in Europe], or Syst-China [Systolic Hypertension in the Elderly Chinese Trial] studies) and even the normotensive elderly population, not to speak of nursing home residents. It must be remembered that in the SHEP trial, of each 100 screened patients with isolated systolic hypertension, only 1 was randomized. Thus, most of the clinical trials in the elderly are not dealing with populations that are representative of the general elderly population with hypertension. In addition, the previous Joint National Committee (JNC), the JNC V, has erroneously promoted b-blockers as first-line therapy in the elderly, although since then it has become clear that, in the elderly, b-blockers are inappropriate and should no longer be used as initial antihypertensive therapy. This means that in the United States alone more than 7 million elderly patients with hypertension still are exposed to the cost, inconvenience, and adverse effects of b-blockers without having any benefits whatsoever. This also means, “mirabile dictu,” that we are currently unable to provide evidence-based therapy in the majority of elderly patients with hypertension. The evidence on which the JNC guidelines are based originates from a completely different patient subset and therefore cannot be extrapolated to the 99% of patients who were for one reason or another excluded from participating in the SHEP study. It is perhaps reassuring to note that in the study of Gambassi and colleagues, the percentage of patients (8%) receiving b-blockers was remarkably small. Perhaps physicians in that study are trying to teach physicians who write guidelines a lesson on how to more appropriately treat hypertension in the elderly.

To the Editor. —In their meta-analysis of the effect of antihypertensive therapies on preventing disease end points, such as stroke, coronary heart disease, congestive heart failure, and total and cardiovascular mortality, Dr Psaty and colleagues 1 concluded that the data provide strong support for the use of β-blockers and diuretics as first-line agents. However, after a closer look at their data, these conclusions are not supported by the data in the case of β-blockers. When calculating the relative risk associated with β-blocker therapy, the authors used 4 studies: (1) Medical Research Council trial of treatment of mild hypertension (MRC) 2 ; (2) Medical Research Council trial of treatment of hypertension in older adults (MRC-O) 3 ; (3) Swedish Trial in Old Patients With Hypertension (STOP-H) 4 ; and (4) Coope and Warrender. 5 By doing so, they glossed over the fact that in STOP-H, two thirds of the patients in the active treatment

In Reply. —Not unexpectedly, our article on short-acting nifedipine for hypertensive emergencies has stirred some strong reactions to the notion that nifedipine capsules no longer have a place in the treatment of hypertension, on an emergency basis or not. Additional case reports documenting morbidity and mortality from the use of nifedipine capsules would bring fatalities to a total of 11. As Dr Meggs points out, we do not know the denominator of our study, but the numerator almost certainly is underestimated because of the reluctance of physicians to report strokes, MI, and death—adverse effects for which they can be held responsible. More important, however, the benefits of abruptly (as opposed to gradually) lowering arterial pressure, especially in patients in whom blood pressure probably has been elevated for hours if not for days, has never been documented. Given the complete lack of data attesting to benefits, any data, however imperfect, attesting to serious

Over the past 2 decades, nifedipine in the form of capsules has become widely popular in the treatment of hypertensive emergencies. Unlike other agents, such as sodium nitroprusside, nicardipine hydrochloride, diazoxide, and nitroglycerin— which require intravenous administration and monitoring of blood pressure— nifedipine can be given orally, and close monitoring is said not to be necessary. Although administration of nifedipine capsules has been reported to be expedient and safe, it has not been approved by the Food and Drug Administration for labeling for treatment of hypertensive emergencies or of any other form of hypertension because of lack of outcome data. A review of the literature revealed reports of serious adverse effects such as cerebrovascular ischemia, stroke, numerous instances of severe hypotension, acute myocardial infarction, conduction disturbances, fetal distress, and death. Sublingual absorption of nifedipine has been found to be poor; most of the drug is absorbed by the intestinal mucosa. Given the seriousness of the reported adverse events and the lack of any clinical documentation attesting to a benefit, the use of nifedipine capsules for hypertensive emergencies and pseudoemergencies should be abandoned.