A 55-year-old woman presents with BP 220/130 mmHg, papilloedema, serum creatinine 3.2 mg/dL (baseline 1.0), and 3+ proteinuria. Peripheral blood smear shows fragmented red cells (schistocytes). This represents which hypertensive emergency, and what is the target BP reduction in the first hour?
- A Hypertensive urgency; oral nifedipine to reduce BP to < 140/90 mmHg within 1 hour
- B Hypertensive emergency with malignant hypertension and MAHA; reduce MAP by 20–25% in the first hour with IV labetalol or sodium nitroprusside ✓
- C Hypertensive emergency; reduce BP to normal immediately with IV furosemide
- D Hypertensive nephropathy; oral ACE inhibitor as first-line treatment
Correct answer: B. Hypertensive emergency with malignant hypertension and MAHA; reduce MAP by 20–25% in the first hour with IV labetalol or sodium nitroprusside
Explanation
This presentation — severely elevated BP with papilloedema, acute kidney injury, proteinuria, and microangiopathic haemolytic anaemia (MAHA, evidenced by schistocytes) — defines malignant hypertension, a hypertensive emergency. Management requires IV antihypertensives (labetalol, nicardipine, or clevidipine) in an ICU setting, targeting a 20–25% reduction in MAP within the first hour to prevent further end-organ damage. Rapid normalisation causes cerebral hypoperfusion. Nitroprusside carries cyanide toxicity risk in renal failure.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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