A 55-year-old man presents with BP 210/125 mmHg, severe headache, blurred vision, and papilloedema. ECG shows LVH. Serum creatinine has risen from 1.0 to 2.8 mg/dL over 48 hours. CT head is normal. This represents malignant hypertension. What is the most appropriate initial blood pressure management target?
- A Reduce mean arterial pressure (MAP) by 25% in the first hour using IV labetalol or nicardipine ✓
- B Normalise blood pressure to <120/80 mmHg within 2 hours using sodium nitroprusside
- C Reduce BP to <160/100 mmHg over 24 hours with oral antihypertensives only
- D Immediate thrombolysis if no haemorrhage on CT, followed by antihypertensives
Explanation
In hypertensive emergency (target organ damage: AKI, retinopathy with papilloedema), the goal is to reduce MAP by no more than 25% within the first hour, then to ~160/100-110 mmHg over the next 2–6 hours. Overly rapid reduction risks cerebral, coronary, and renal hypoperfusion due to impaired autoregulation (brain and kidneys are adapted to high pressures). IV labetalol (alpha+beta blocker) or nicardipine (dihydropyridine calcium channel blocker) are preferred agents. Sodium nitroprusside is an alternative but causes cyanide toxicity with prolonged use and increases intracranial pressure. Oral antihypertensives alone are inadequate for hypertensive emergency.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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