Journal of Human Hypertension (1997) 11, 471–476
 1997 Stockton Press. All rights reserved 0950-9240/97 $12.00
ORIGINAL ARTICLE
Efficacy of captopril and nifedipine in
black and white patients with hypertensive
crisis
A Damasceno1, B Ferreira1 , S Patel1, E Sevene1 and J Polónia2
1
Faculdade Medicina Universidade Eduardo Mondlane, Maputo, Mozambique; and 2Unidade
Farmacologia Clı́nica, Faculdade de Medicina do Porto, Porto, Portugal
We examined the antihypertensive efficacy of:
(1) sublingual-oral single doses of captopril (25 mg) and
nifedipine-capsules (10 mg) in 9 + 9 white patients and
in 9 + 8 black patients with hypertensive crisis; and (2) a
single oral dose of the slow-acting preparation of nifedi-
pine-retard (20 mg) in another 10 black patients. Blood
pressure (BP) was assessed at 10 min intervals for 6 h
after administration. After 6 h, the BP falls induced by
these drugs were still significantly lower than the base-
line placebo values. Hypotensive effect of nifedipine-
capsules was established more rapidly than that of cap-
topril in both white and black patients, and of nifedipine-
retard in black patients. Considering the area under the
curve of BP values during the 6-h treatment, the overall
hypotensive effect of nifedipine-capsules was similar to
captopril in white patients, but significantly more pro-
nounced than captopril and nifedipine-retard in black
patients. In white patients similar maximal drops of BP
(mean ± s.e.m.) were obtained with nifedipine-capsules
(71 ± 4/52 ± 4 mm Hg) and with captopril (69 ± 4/50 ±
Keywords: captopril; nifedipine-capsules; nifedipine-retard; hypertensive crisis; white patients; black patients
Introduction
Acute severe elevation of arterial blood pressure
(BP) is a common clinical problem that in most con-
ditions requires immediate treatment with antihy-
pertensive drugs.1,2 At least theoretically, ideal treat-
ment would involve non-parenteral administration
and a tendency to lower BP gradually towards a
stable plateau and safety.3 This may be especially
important in Africa since these circumstances are
common and conditions for a continuous haemody-
namic monitoring of these patients are difficult.
Thus, there is a practical tendency in these situ-
ations to avoid intravenous agents and to prefer the
use of oral agents, providing their safety and efficacy
profile is fairly proven. Several studies have shown
that in white, severely hypertensive patients, cal-
cium antagonists and angiotensin-converting
enzyme (ACE) inhibitors have approximately equal
Correspondence: Professor J Polonia, Unidade de Farmacologia
Clinica da Faculdade de Medicina do Porto, 4200 Porto, Portugal
Received 12 February 1996; revised 15 January 1997; accepted 22
January 1997
3 mm Hg). In black patients the maximal drop of BP of
nifedipine-capsules (70 ± 4/52 ± 4 mm Hg) was greater
(P , 0.02) than that of captopril (48 ± 4/32 ± 3 mm Hg)
but similar to that of nifedipine-retard (71 ± 4/49 ± 4
mm Hg). However, in contrast to nifedipine-capsules
and captopril, nifedipine-retard produced a slower drop
in BP. The time of peak drop in BP of both nifedipine-
capsules and captopril occurred within the first 2 h
whereas with nifedipine-retard it occurred only between
4 and 6 h after administration. Fewer patients reported
side effects with nifedipine-retard as compared with the
other two preparations. We conclude that single doses
of captopril and nifedipine reduces BP for at least 6 h in
both white and black patients with hypertensive crisis,
but nifedipine is more potent than captopril in black
patients. The slow release form of nifedipine-retard
effectively and safely lowers BP while achieving a rapid
enough effect without the critical rapid falls in BP that
occur with nifedipine-capsules.
efficacy and favourable side effect profiles.4–9 How-
ever, a randomised controlled trial comparing the
efficacy of these two groups of agents in black and
white patients with hypertensive crisis is lacking.
The reason for this is probably the assumption that
in severe hypertension in black patients the ACE
inhibitors would be less effective than the calcium
antagonists, as it has been suggested to occur in less
severe forms of hypertension.10–12 In the present
study we compare the acute hypotensive effective-
ness and safety of the sublingual-oral administration
of captopril and of nifedipine-capsules in the treat-
ment of hypertensive crisis in black and white
patients. Since concern has arisen recently about the
potential hazard of a rapid reduction of BP,13,14
particularly by short-acting calcium antagonists,15
we also evaluated the efficacy of a sustained release
preparation of nifedipine in black patients with
hypertensive crisis.
Patients and methods
Patients
This was a randomised, parallel-group, placebo
controlled study, in which the acute efficacy of
 Captopril vs nifedipine in hypertensive crises
A Damasceno et al
472
single sublingual-oral doses of captopril (25 mg) and
nifedipine-capsules (10 mg) were evaluated in
populations of white and black patients with
hypertensive crisis. Black and Caucasian patients
with severe hypertension that were admitted to our
institution since 1993 were enrolled in the study
after informed consent. Additionally, we also evalu-
ated in a third group of 10 black patients with hyper-
tensive crisis the efficacy of a single oral dose of
nifedipine-retard (20 mg, sustained release). All
patients were submitted to a period of observation
on placebo for at least 30 min. BP was evaluated
every 3 min during this placebo phase. Additional
screening procedures included a comprehensive
story and physical examination on admittance, chest
radiography, ECG, standard blood chemical tests,
urine tests and optic fundi examination.
Inclusion criteria were: previously untreated
patients or known hypertensive patients without
any therapy for at least 2 weeks, aged 20–60 years,
men and non-pregnant women of non-childbearing
potential with an average supine diastolic BP (DBP),
and with an average supine diastolic BP .120
mm Hg as a mean of the last three automatic read-
ings over the last 10 min of the placebo period.
Excluding criteria were: aortic dissection; recent
myocardial infarction or cerebrovascular accident;
hypertensive encephalopathy; known renal artery
stenosis or renovascular hypertension; acute or
chronic heart failure and a serum creatinine value
of more than twice the upper limit of normal.
After the placebo phase, eligible patients within
each black or white group were randomly assigned
to either captopril or nifedipine-capsule treatment.
Captopril (25 mg) or nifedipine-capsules (10 mg)
were chewed and saliva swallowed after 5 min.
Although still controversial16,17 this method gives a
rapid rise in blood levels of nifedipine and, in the
case of captopril, should correspond to oral adminis-
tration which can reduce BP within 30 min.7 Black
patients of a third group swallowed a tablet of nifed-
ipine-retard (20 mg, sustained release). At the time
of drug administration BP monitoring was started
using a Spacelabs 90207 which was programmed to
record BP and heart rate every 10 min during the
following 6 h of duration of the trial.
BP measurement
BP was evaluated every 3 min during each 30-min
placebo phase with a Dinamap (Critikon 1846 SX
vital signs monitor) to avoid observer bias. The
machine was calibrated against a mercury sphygmo-
manometer before use in each patient with a
maximum acceptable difference of ±5 mm Hg. At the
moment of administration of captopril, nifedipine-
capsules or nifedipine-retard continuous BP was
recorded using an automated non-invasive device
(SpaceLabs: Model 90207, SpaceLabs, Redmont,
WA, USA). For each patient BP readings were taken
at 10-min intervals thereafter for the next 6 h with
patients supine. When the instrument was fitted,
automatic BP had to be within 5 mm Hg of three
simultaneous readings obtained on the same arm
with a standard mercury sphygmomanometer using
a t-tube connector. Recordings were accepted only
if more than 90% of raw data were valid. From the
curve of BP values of each patient we calculated the
area under the curve of BP (measured according to
the trapezoid rule).
Statistical analysis
Results are mean ± s.e.m. We used Student’s paired
and unpaired t-test with the Bonferroni correction
for multiple comparisons when necessary, using a
specific software developed for analysis of Space-
labs 90207 data.18 Probability of 5% was the level
adopted for statistical significance.
Results
The demographic characteristics and baseline data
of both black and white populations that were
included in the study are summarised in Table 1.
There were no significant differences between the
treatment groups within each population, or
between the treatment groups of each population for
age, gender, of plasma creatinine values and of BP
values (Table 2) after placebo period. In all patients
the dissolution under the tongue and the swallow-
ing of either captopril tablet or nifedipine-capsule
always took less than 5 min. The tablets of nifedi-
pine-retard were swallowed immediately after
administration.
Heart rate did not significantly change with any
of the drugs studied. In white patients, captopril
produced a fall in BP that on average reached sig-
nificance for systolic BP (SBP) at 20 min (from 224
± 7 to 210 ± 6 mm Hg, P , 0.05), and for DBP at 30
min (from 139 ± 3 to 129 ± 3 mm Hg, P , 0.03) after
drug administration, whereas nifedipine-capsules
produced a fall in BP that on average reached sig-
nificance for SBP at 10 min (from 222 ± 5 to 196 ±
6 mm Hg, P , 0.02) and for DBP at 10 min (from
141 ± 2 to 124 ± 3 mm Hg, P , 0.01) after drug
administration.
In black patients, captopril produced a fall in BP
that on average reached significance for SBP at 20
min (from 223 ± 7 to 207 ± 5 mm Hg, P , 0.05) and
for DBP at 30 min (from 140 ± 5 to 134 ± 3 mm Hg,
P , 0.05) after drug administration, whereas nifedi-
pine-capsules produced a fall in BP that on average
reached significance for SBP at 20 min (from 221 ±
7 to 197 ± 6 mm Hg, P , 0.02) and for DBP at 10
min (from 151 ± 3 to 132 ± 3 mm Hg, P , 0.01) after
administration. With nifedipine-retard, the fall in
BP reached significance for SBP at 20 min (from 228
± 6 to 203 ± 6 mm Hg, P , 0.05) and for DBP at
30 min (from 151 ± 3 to 139 ± 3 mm Hg, P , 0.02)
after administration.
Table 2 shows for white and black populations
and for all treatments the average BP values at base-
line, at the moment of the maximal effect and at 2
and 6 h after drug administration, as well as the
values of the area under the curves of BP values cal-
culated from the time of administration up to 2 and
6 h after. In white patients captopril and nifedipine-
capsules produced similar maximal drops of SBP
(on average 31% for nifedipine and 30% for captop-
 Captopril vs nifedipine in hypertensive crises
A Damasceno et al

473
Table 1 Demographic characteristics of the study groups

No. Age Gender Discontinued Plasma Retinopathy:

(years) (Female/Male) previous creatinine Haemorrhages
antihypertensive (mmol/L) and/or
treatment Papilledema
No. No.

White patients
nifedipine-capsules 8 43 (3) 4/4 4 124 (17) 2
captopril 9 42 (3) 4/5 5 116 (18) 2
Black patients
nifedipine-capsules 9 38 (3) 3/6 4 118 (35) 2
captopril 9 43 (3) 4/5 3 137 (39) 2
nifedipine-retard 10 44 (2) 4/6 5 128 (26) 3

Table 2 BP values and areas under the curves of BP values during the study

No. Baseline Peak 2 h after 6 h after

value administration administration

SBP/DBP SBP/DBP SBP/DBP AUC from SBP/DBP AUC from

(mm Hg) (mm Hg) (mm Hg) 0 to 2 h (mm Hg) 0 to 6 h

White patients
nifedipine-capsules 9 222/141 155/106 166/109 20325/14144 180/122 62150/41205
(5/2) (3/2)† (4/3)† (512/342) (5/3)† (1107/1022)
captopril 9 224/139 157/108 168/111 21844/15421 179/115 64162/41986
(7/2) (4/3)† (6/3)† (662/387) (4/3)† (1375/1049)

Black patients
nifedipine-capsules 8 221/151 153/105 162/107 22134/15066 181/123 60596/40472
(7/3) (7/3)†,* (6/3)†,* (835/299)* (5/4)† (1575/1131)*
captopril 9 223/140 174/115 179/119 25893/16986 190/120 67546/44015
(7/5) (5/2)† (5/5)† (512/404) (5/4)† (1269/1292)
nifedipine-retard 10 228/152 156/102 176/120 26436/17071 164/105 65138/42764
(6/5) (6/5)†,* (4/4)†,** (527/409)** (5/5)†,*,** (963/1261)**

AUC = area under curve of BP values.

Results are mean (s.e.m.).
†P , 0.01 vs baseline (placebo) values; *P , 0.04 vs captopril values of black patients; **P , 0.02 between nifedipine-retard and
nifedipine-capsule values of black patients.

ril, vs placebo values) and of DBP (on average 25%
for nifedipine and 23% for captopril vs placebo
values). The magnitude of the mean peak drop in
SBP/DBP of nifedipine-capsules (71 ± 4/52 ± 4
mm Hg) was similar to that of captopril (69 ± 4/50
± 3 mm Hg). On average the peak effect occurred for
nifedipine-capsules by 60 min (range 40 to 90) after
drug administration (for both SBP and DBP), and for
captopril by 100 min (range 80 to 160) after adminis-
tration (for both SBP and DBP).
In black patients, nifedipine-capsules vs placebo
produced a maximal drop of SBP (on average 31%)
and of DBP (on average 31%) that were similar to
the maximal drop of SBP (on average 31%) and of
DBP (on average 32%) induced by nifedipine-retard,
but higher (Table 2) than the maximal drop induced
by captopril on SBP (on average 22%) and on DBP
(on average 18%). The magnitude of the mean peak
drop in SBP/DBP of nifedipine-capsules (70 ± 4/52
± 3 mm Hg) was greater (P , 0.02) than that of capto-
pril (48 ± 4/32 ± 3 mm Hg) but not different from
that of nifedipine-retard (71 ± 4/49 ± 4 mm Hg). On
average the peak effect occurred for nifedipine-cap-
sules by 90 min (range 70 to 130) after adminis-
tration (for both SBP and DBP), and for captopril by
120 min (range 70 to 180) after administration (for
both SBP and DBP). For nifedipine-retard peak
effect occurred later, ie, by 270 min (range 260 to
330) after administration (for both SBP and DBP).
Two hours after administration nifedipine-capsules
and captopril produced a fall in BP that was roughly
similar to their peak effect, whereas at that time, the
fall in BP induced by nifedipine-retard was only
70% of its maximal effect. Also the area under the
curve of the BP values during the first 2 h of treat-
ment was significantly higher with nifedipine-cap-
sules than with nifedipine-retard. At 6 h after
administration, the BP falls induced by nifedipine-
capsules, captopril and nifedipine-retard in both
populations were still significantly lower than the
pretreatment placebo values. The BP falls induced
by nifedipine-capsules and by captopril at 6 h were
similar in white patients (on average 19% for nifedi-
pine-capsules and 20% for captopril for SBP, and
14% for nifedipine-capsules and 17% for captopril
for DBP) as well as in black patients (on average
18% for nifedipine-capsules and 15% for captopril
for SBP, and 19% for nifedipine-capsules and 14%
 Captopril vs nifedipine in hypertensive crises
A Damasceno et al
474
for captopril for DBP). BP falls at 6 h induced by
nifedipine-retard in black patients were on average
30% for SBP, and 29% for DBP.
In white patients, for nifedipine-capsules and cap-
topril, the values of the area under the curves of the
SBP and DBP values measured during the first 2 and
6 h after administration were not statistically differ-
ent. In black patients, for the first 2 h after drug
administration, the values of the area under the
curves of SBP and DBP were significantly higher for
captopril and for nifedipine-retard than for treat-
ment with nifedipine-capsules. For the 6 h after
administration the areas under the curves of the SBP
and DBP were higher for captopril than for nifedi-
pine-capsules and nifedipine-retard, and higher for
nifedipine-retard than for nifedipine-capsules.
Figure 1a and 1b shows the evolution of mean
values of SBP and DPB measured at 10 min intervals
that were observed before and up to 6 h after the
administration of captopril or nifedipine-capsules in
white and black patients, after these two prep-
Figure 1 Average values of BP (systolic upper panel, diastolic
lower panel) measured at 10 min intervals, in patients with
hypertensive crisis during placebo (PL) and 6 h after:
(a) sublingual-oral administration of single doses of captopril
25 mg in nine white patients (P), and of nifedipine capsules
10 mg in nine white patients (L); (b) sublingual-oral adminis-
tration of single doses of captopril 25 mg in nine black patients
(P), of nifedipine capsules 10 mg in eight black patients (L), and
of nifedipine-retard 20 mg in 10 black patients (1).
arations and after nifedipine-retard. In white
patients, captopril provided a slower drop in BP
than nifedipine-capsules. After 90 min from admin-
istration the BP fall was almost identical with both
drugs. In black patients captopril produced a slower
drop in BP than nifedipine-capsules. Also, captopril
hypotensive effect was kept along the first 6 h after
administration in higher BP levels than nifedipine-
capsules. From 60 min after nifedipine-capsules and
captopril the hypotensive effect of both drugs were
maintained relatively stable for the next 5 h. In com-
parison with nifedipine-capsules, with nifedipine-
retard the BP fell much more slowly and continu-
ously up to 6 h after administration and was main-
tained for the first 4 h on a higher level than the
effect of nifedipine-capsules.
No significant side effects were observed in both
populations with both drugs. Headache was more
frequently reported after nifedipine both in white
(four patients) and in black patients (three patients),
whereas bad taste was reported more frequently
with captopril (by three white and by two black
patients). Two patients on nifedipine-retard
reported a mild transitory flush.
Discussion
In black populations, hypertension occurs with
higher frequency than in non-black populations and
is associated with an accelerated target-organ dam-
age.1,19–22 Also, black patients with hypertensive
crisis may present a worse prognosis as compared
with white patients.23 Recently, evidence has been
accumulated suggesting that black hypertensive
patients respond less effectively to antihypertensive
drugs like beta-blockers or angiotensin-converting
enzyme inhibitors than do non-black hypertensive
patients,11,24,25 and that diuretics and calcium antag-
onists may be particularly more effective in black
hypertensive patients than antihypertensive
agents.11,24,25 Moreover, it has been shown in black
hypertensive patients that chronic nifedipine mono-
therapy was more efficient in controlling BP than
captopril monotherapy.10
The present study was a randomised placebo-con-
trolled parallel study aimed to compare the effect of
nifedipine-capsules and captopril in black or non-
black populations with hypertensive crisis. Over the
last few years several studies have demonstrated the
acute efficacy of either nifedipine-capsules or capto-
pril administered sublingually and orally in the
urgent treatment of hypertension.4–9,26–29 To our
knowledge only a few placebo-controlled studies
have compared the efficacy of both drugs as an acute
treatment of hypertension.
Our present study shows that in white patients
with hypertensive crisis, single doses of nifedipine-
capsules and captopril produced a similar drop in
BP during the next 6 h after administration, as
assessed by the measurement of the area under the
curve of BP values. In contrast, under the same
therapeutic protocol, in black patients nifedipine-
capsules was clearly more potent than captopril
concerning both the peak effect and BP control
throughout the period of 6 h after administration.

Thus, we may conclude that similarly to what has
been described for chronic therapy with captopril
and nifedipine in black hypertensive patients,10–12
the acute antihypertensive efficacy of nifedipine-
capsules in black patients is also greater than capto-
pril. This greater responsiveness of hypertensive
black subjects to nifedipine than to captopril could
be related to a more salt-sensitive status, to a greater
tendency towards expanded plasma volume and to
a lower plasma renin activity. Whatever may cause
a lower efficacy of captopril in black patients as
compared with non-black hypertensive patients, our
results are in agreement to the previous finding that
greater doses of the ACE inhibitor trandolapril are
needed for the chronic control of BP in black com-
pared with white hypertensive patients.12 Although
in black patients nifedipine-capsules were found to
be more potent than captopril for the decrease of BP,
this does not allow us to conclude that nifedipine-
capsules is better than captopril for the treatment of
hypertensive crisis in blacks. In fact the level to
which BP should be reduced in patients with hyper-
tensive crisis is still controversial.30 When the ther-
apy-induced BP fall occurs, the adaptation of
cerebral blood flow works within the limits of the
autoregulatory curve31 and some patients may be
exposed to the hazards of a fall in cerebral blood
flow when systemic BP is lowered abruptly by more
than about 25%.
As reported by other authors4,7,8 in the present
study the hypotensive effect of nifedipine-capsules
was obtained earlier than captopril in both white
and black patients. In our study, both captopril and
nifedipine-capsules produced a profound acute
drop in BP although the BP fall induced by captopril
in black patients was significantly less than the
effect of nifedipine-capsules; from this point of view
captopril could be considered safer than nifedipine-
capsules for the treatment of hypertensive crisis in
black patients. Interestingly, we were unable to
detect in both white and black populations any
symptoms of cerebral hypoperfusion despite the
tremendous fall of BP that was found at the time of
peak effects. One factor that may be responsible for
the absence of symptoms of cerebral ischaemia with
both drugs in these circumstances may be the down-
ward shift of the lower limit of cerebral autoregu-
lation that has been claimed to be induced by both
ACE inhibitors32 and calcium antagonists.33
Although signs of cerebral ischaemia were not
observed during the study, there is still a major con-
cern that the acute fall of BP observed with the doses
of captopril and nifedipine-capsules that were used
may produce in some patients a critical reduction
in cerebral blood flow as reported by others.13,14
Moreover, although captopril has been widely used
for treatment of hypertensive urgencies, there is a
reasonable concern of using captopril because of the
risk of precipitating acute renal insufficiency in
patients having underlying renal artery stenosis.
Thus, because of these potential risks it may be
advisable to start therapy with lower doses of capto-
pril and of nifedipine-capsules than the ones used
in the present study or, alternatively, to prefer other
Captopril vs nifedipine in hypertensive crises
A Damasceno et al
475
preparations that may decrease BP more gradually
and slowly in patients with hypertensive urgencies.
In that context we studied in another group of
black patients with hypertensive urgencies the effi-
cacy of a single oral administration of a slow release
preparation of nifedipine. In these patients, a single
oral dose of nifedipine-retard slowly reduced BP up
to 6 h after administration in a more gradual way if
compared with either nifedipine-capsules or capto-
pril. The area under the curve of BP values during
the first 2 h of nifedipine-retard was higher than that
of nifedipine-capsules. Also, while the peak effect
of nifedipine-capsules and captopril occurred dur-
ing the first 2 h of treatment, the peak effect of nifed-
ipine-retard occurred clearly later, always after 4 h
of treatment. These data show that nifedipine-retard
produce a slower and less hypotensive effect within
the first hours of treatment as compared with the
other two preparations. Since in hypertensive crisis
the aim is to achieve a BP control within the next
12–24 h, it seems that our data support a rapid
enough BP-reducing effect of nifedipine-retard for
hypertensive crisis that is achieved more gradually
and within a safer profile.
In conclusion, the present study shows that in
both white and black patients with hypertensive
crisis, single doses of captopril and nifedipine-cap-
sules produce an over-rapid and profound acute
drop in BP to an extent that may potentially increase
the risk for the development of a critical reduction
in cerebral blood flow. Both drugs look equipoten-
tial in white patients whereas nifedipine-capsules
appears to be much more potent than captopril in
black patients, which reinforces the concept that
black hypertensive patients show a lower respon-
siveness to ACE inhibitors compared with non-black
hypertensive patients. A single dose of nifedipine-
retard produced a more gradual although rapid
enough BP-reducing effect for hypertensive
urgencies with a less potential risk of reducing cer-
ebral flow. Thus, for patients with hypertensive
urgencies that are suitable for treatment with nifedi-
pine, the nifedipine-retard formulation may be a
preferable choice.
Acknowledgements
Supported by PRAXIS XXI-SAU-1302/95, by a Grant
from Reitoria da Universidade do Porto, Portugal
and from the Portuguese Society of Pharmacology.
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