A 52-year-old man presents with BP 228/134 mmHg, confusion, retinal haemorrhages and papilloedema, serum creatinine 2.8 mg/dL (baseline 1.0), and proteinuria. Which is the CORRECT approach to BP reduction in this hypertensive emergency?
- A Reduce BP to normal (< 130/80 mmHg) within the first hour
- B Start oral antihypertensives and reassess in 24 hours
- C Reduce mean arterial pressure by no more than 25% in the first hour using IV labetalol or nicardipine, then gradually over 24-48 hours ✓
- D Administer sublingual nifedipine for rapid BP reduction
Correct answer: C. Reduce mean arterial pressure by no more than 25% in the first hour using IV labetalol or nicardipine, then gradually over 24-48 hours
Explanation
In hypertensive emergency with target organ damage, the recommended goal is to reduce mean arterial pressure by ≤25% in the first hour, using titratable IV agents (labetalol, nicardipine, clevidipine). Overly rapid BP reduction risks cerebral, coronary, and renal hypoperfusion due to loss of autoregulation. After stabilisation, gradual reduction over 24-48 hours toward a safer target (e.g., 160/100 in the first 24 hours) is appropriate. Sublingual nifedipine causes uncontrolled rapid drops and is absolutely contraindicated in hypertensive emergency.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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