A 55-year-old man presents to the emergency department with a blood pressure of 225/140 mmHg, altered sensorium, papilloedema, and serum creatinine rising from 1.1 to 3.8 mg/dL over 72 hours. Peripheral smear shows schistocytes. The CORRECT initial blood pressure management strategy is:

• A Reduce mean arterial pressure (MAP) by no more than 25% within the first hour using IV nicardipine or labetalol ✓
• B Reduce BP to < 120/80 mmHg within the first hour using IV labetalol boluses
• C Oral amlodipine 10 mg stat; allow gradual BP reduction over 48 hours
• D Use IV sodium nitroprusside to achieve immediate normalisation and prevent further renal injury

Explanation

Hypertensive emergency with end-organ damage (encephalopathy, AKI, MAHA with schistocytes = thrombotic microangiopathy) requires careful BP reduction. JNC 8 and ACC/AHA 2023 guidelines recommend reducing MAP by no more than 25% in the first hour to avoid precipitous ischaemia from impaired autoregulation (cerebral, coronary, renal). Target < 160/100 mmHg within 2–6 hours, then normalise over 24–48 hours. IV agents (nicardipine, clevidipine, labetalol) are preferred over sodium nitroprusside due to cyanide toxicity risk from prolonged nitroprusside use.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.