Comparative effectiveness and safety of oral antihypertensive agents for severe asymptomatic hypertension: A systematic review and network meta-analysis of randomized controlled trials

Severe asymptomatic hypertension is a common presentation in acute care, yet the optimal choice of oral antihypertensive therapy remains uncertain due to limited comparative evidence. We performed a systematic review and network meta-analysis of randomized controlled trials evaluating oral antihypertensive agents in adults with severe asymptomatic hypertension. Electronic databases (PubMed, Embase, CENTRAL, and CINAHL) were searched from inception to December 2025. The primary outcome was short-term treatment success, defined as a clinically meaningful reduction in blood pressure within 4 h. Random-effects models were used to estimate risk ratios (RRs) with 95% confidence intervals (CIs), and treatments were ranked using P-scores. Certainty of evidence was assessed using the GRADE approach. Five trials were included. All pharmacologic treatments reduced blood pressure in the short term. Compared with the remaining interventions, beta blockers (RR 1.07, 95% CI 0.59–1.92), calcium channel blockers (RR 1.02, 95% CI 0.59–1.78), and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (RR 1.01, 95% CI 0.64–1.58) were associated with a higher likelihood of treatment success at 120–240 min, although these were not statistically significant. Both direct and indirect comparisons showed no significant differences among treatments. Ranking analyses suggested beta-blockers had the highest probability of effectiveness (P-score 0.63), but with substantial uncertainty. Adverse events were infrequently reported and generally mild. Overall certainty of evidence was very low. Oral antihypertensive agents lower blood pressure in the short term, but no single class demonstrates clear superiority, underscoring the need for individualized management and larger, high-quality comparative trials.