A 55-year-old man presents with BP 220/130 mmHg, headache, and papilledema on fundoscopy, but is otherwise neurologically intact. Serum creatinine is 1.8 mg/dL (baseline 1.0). This is classified as hypertensive emergency. What is the target BP reduction in the first hour?

• A Reduce BP to normal (<120/80) as quickly as possible
• B Reduce systolic BP to <140 mmHg within 30 minutes
• C Reduce mean arterial pressure (MAP) by no more than 25% in the first hour ✓
• D Reduce diastolic BP to <90 mmHg within 2 hours

Explanation

In hypertensive emergencies, overly rapid BP reduction can lead to hypoperfusion of vital organs (brain, heart, kidneys) due to impaired autoregulation. The JNC 8 and ACC/AHA 2017 guidelines recommend reducing MAP by no more than 25% in the first hour, then to 160/100–110 over the next 2–6 hours, and normalizing over 24–48 hours. IV agents such as labetalol, nicardipine, or clevidipine are used for BP control. Exception: aortic dissection requires more rapid reduction (SBP <120 mmHg within 20 min using esmolol + nitroprusside).

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

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Written and medically reviewed by the StethoPrep medical team.