A 55-year-old hypertensive man presents with BP 210/128 mmHg, severe headache, and papilledema. Serum creatinine is 2.8 mg/dL (baseline 1.1 mg/dL). ECG shows LV strain pattern. This constitutes a hypertensive emergency. The most appropriate immediate management is:

• A Oral amlodipine 10 mg and observe for 4–6 hours
• B Reduce BP to normal within 1 hour using IV sodium nitroprusside
• C IV labetalol or nicardipine to reduce MAP by 25% within the first hour ✓
• D IV furosemide as the primary antihypertensive agent

Explanation

Hypertensive emergency with end-organ damage (hypertensive encephalopathy/retinopathy, AKI) requires ICU admission and IV antihypertensives to reduce MAP by no more than 25% within the first hour, followed by gradual reduction to 160/100–110 mmHg over 2–6 hours. Overly rapid reduction risks cerebral ischemia, renal infarction, and coronary events due to loss of autoregulation. IV labetalol (preferred in most emergencies) or nicardipine are first-line IV agents. Nitroprusside is reserved for specific situations but carries cyanide toxicity risk. Oral therapy is for hypertensive urgency (no end-organ damage).

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

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Written and medically reviewed by the StethoPrep medical team.