A 55-year-old hypertensive woman presents with BP 210/130 mmHg, sudden severe headache, confusion, papilloedema, and serum creatinine 2.8 mg/dL rising over 24 hours. She has Grade IV hypertensive retinopathy and microangiopathic haemolytic anaemia (MAHA) on peripheral smear. Which is the most appropriate initial management?
- A Immediate BP normalization to <120/80 mmHg within 1 hour with IV nitroprusside
- B IV labetalol or sodium nitroprusside targeting 25% BP reduction within first hour, then gradual normalization over 24–48 hours ✓
- C Oral amlodipine 10 mg immediately with repeat dose in 30 minutes
- D Emergency haemodialysis first, then antihypertensive therapy
Explanation
Hypertensive emergency with encephalopathy and TMA/MAHA (thrombotic microangiopathy-like picture) requires controlled BP reduction. JNC 8, ESH 2018, and AHA guidelines recommend reducing MAP by no more than 25% in the first hour, then to 160/100 over the next 2–6 hours, with normalization over 24–48 hours. Excessive rapid reduction risks watershed cerebral infarction and coronary/renal ischaemia due to impaired autoregulation. IV labetalol, nicardipine, and sodium nitroprusside are agents of choice. Oral nifedipine is contraindicated due to uncontrolled BP drops. Emergency dialysis is reserved for established AKI with fluid overload.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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