Ktenopoulos N, Milaras N, Apostolos A, Tsioufis K, Toutouzas K, Sideris S. Letter to the Editor: Reassessing intravenous antihypertensive choice in coronary artery disease-related hypertensive emergencies. World J Cardiol 2026; 18(7): 118635 [DOI: 10.4330/wjc.118635]
Corresponding Author of This Article
Nikias Milaras, MD, First Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, Vasilisis Sofias 14, Athens 11527, Greece. nikiasmilaras@gmail.com
Research Domain of This Article
Cardiac & Cardiovascular Systems
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letter
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Ktenopoulos N, Milaras N, Apostolos A, Tsioufis K, Toutouzas K, Sideris S. Letter to the Editor: Reassessing intravenous antihypertensive choice in coronary artery disease-related hypertensive emergencies. World J Cardiol 2026; 18(7): 118635 [DOI: 10.4330/wjc.118635]
Nikolaos Ktenopoulos, Nikias Milaras, Anastasios Apostolos, Konstantinos Tsioufis, Konstantinos Toutouzas, First Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
Skevos Sideris, First Department of Cardiology, “Hippokration” General Hospital, Athens 11527, Greece
Author contributions: Ktenopoulos N and Milaras N contributed to the conceptualization and drafting of the manuscript; Apostolos A and Toutouzas K performed the literature search and provided critical revisions of the text; Tsioufis K and Sideris S provided senior oversight, supervised the project, and gave final approval for the version to be published.
Conflict-of-interest statement: All authors declare no conflict of interest in publishing the manuscript.
Corresponding author: Nikias Milaras, MD, First Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, Vasilisis Sofias 14, Athens 11527, Greece. nikiasmilaras@gmail.com
Received: January 7, 2026 Revised: February 7, 2026 Accepted: April 13, 2026 Published online: July 26, 2026 Processing time: 191 Days and 16.1 Hours
Abstract
Hypertensive emergencies in patients with established coronary artery disease (CAD) present a therapeutic paradox, that blood pressure must be lowered rapidly to limit end-organ damage, yet excessive or poorly selected pharmacologic intervention risks myocardial ischemia and adverse cardiovascular outcomes. In this context, a study by Chaudhary et al, published in the recent issue of the World Journal of Cardiology, provide novel and clinically interesting real-world data comparing intravenous nitroglycerin and labetalol in a large retrospective cohort of CAD patients presenting with hypertensive emergency. Their analysis demonstrates a nuanced trade-off between hemodynamic speed and cardioprotective benefit. While labetalol achieved target blood pressure more rapidly, nitroglycerin was associated with greater absolute blood pressure reduction, fewer bradyarrhythmic events, attenuated cardiac biomarker elevation, shorter intensive care unit and hospital stays, and lower 30-day readmission rates. Although major adverse cardiovascular events did not differ significantly, the observed trends favoring nitroglycerin underscore the importance of ischemia-sensitive blood pressure management in this high-risk population. Importantly, these findings align with the contemporary guideline principles that prioritize myocardial perfusion and preload reduction in CAD-associated hypertensive crises. Despite the inherent limitations of the retrospective, single-center analyses, this study advances the evidence base by focusing specifically on CAD patients in a resource-constrained setting and by incorporating clinically meaningful utilization outcomes. Collectively, the data support a more deliberate, phenotype-driven approach to agent selection in hypertensive emergencies, positioning nitroglycerin as a preferential option when myocardial ischemia is a central concern, while reinforcing the need for prospective, randomized validation.
Core Tip: Chaudhary et al provide large real-world evidence in coronary artery disease-associated hypertensive emergency comparing intravenous nitroglycerin with labetalol. Labetalol achieved target blood pressure faster, but nitroglycerin produced greater blood pressure reduction, fewer bradycardic events, smaller biomarker rises, shorter intensive care unit/hospital stays, and fewer 30-day readmissions. These results support phenotype-driven therapy, that labetalol when heart rate control is paramount, and nitroglycerin when ischemia, pulmonary congestion or myocardial injury risk dominate. Prospective validation is required before practice-changing recommendations.
