A 52-year-old man is brought in with BP 230/140 mmHg, new grade IV hypertensive retinopathy, and serum creatinine rising from 110 to 185 µmol/L over 12 hours. Urinalysis shows proteinuria 2+, haematuria 2+. The MOST appropriate management strategy for BP control in this hypertensive emergency is:
- A Reduce MAP by 10-15% in the first hour with IV nitroglycerin (glyceryl trinitrate)
- B Reduce MAP by ≥25% in the first hour, then to 160/110 mmHg over the next 2-6 hours using IV labetalol or clevidipine ✓
- C Aggressively normalise BP to <120/80 mmHg within 6 hours to protect renal function
- D Oral nifedipine and oral captopril for rapid BP reduction within 1 hour
Explanation
In hypertensive emergency with end-organ damage (encephalopathy, AKI, retinopathy), the target is: reduce MAP by no more than 25% in the first hour, then to 160/100-110 mmHg over the next 2-6 hours (not to normal), then cautious normalisation over 24-48 hours. Overly rapid reduction risks ischaemia in autoregulation-impaired organs (brain, kidney). IV labetalol (alpha and beta blockade) and IV clevidipine (dihydropyridine calcium channel blocker) are preferred for their titratable, predictable effects. IV nitroprusside is used for aortic dissection (with extreme caution due to cyanide toxicity risk). Sublingual/oral nifedipine is dangerous due to unpredictable rapid drop in BP. Nitroglycerin is preferred for ACS/APO hypertensive emergencies.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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