A 52-year-old woman presents with BP 220/130 mmHg, severe headache, blurring of vision and confusion. Fundoscopy shows flame-shaped haemorrhages, cotton-wool spots and papilloedema. Creatinine has risen from baseline of 1.0 to 2.8 mg/dL over 2 weeks. Blood film shows schistocytes. This represents:

• A Hypertensive emergency with end-organ damage (hypertensive encephalopathy, microangiopathic haemolytic anaemia, AKI); IV labetalol or nicardipine targeting 20–25% MAP reduction in first hour ✓
• B Hypertensive urgency; oral labetalol and discharge with follow-up
• C Malignant hypertension; BP should be normalized to <130/80 mmHg within 30 minutes
• D TTP; plasma exchange is the priority over antihypertensive therapy

Explanation

Malignant hypertension (hypertensive emergency) is defined by severe hypertension with acute end-organ damage. This patient has hypertensive encephalopathy (confusion), hypertensive retinopathy Grade IV (papilloedema), acute renal impairment and MAHA (schistocytes from fibrin deposition in arterioles). Management requires IV antihypertensive therapy (labetalol, nicardipine or sodium nitroprusside) with a controlled reduction in MAP by no more than 20–25% in the first hour to prevent watershed ischaemia; overshooting causes stroke, MI or blindness. Target BP 160/100 in the first hour. Normalising BP too rapidly is harmful.

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

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Written and medically reviewed by the StethoPrep medical team.