A 55-year-old man presents with BP 220/130 mmHg, acute confusion, bilateral papilloedema, and creatinine rising from baseline 1.0 to 3.4 mg/dL over 48 hours. There is no aortic dissection on imaging. What is the target BP reduction in the first hour?
- A Reduce systolic BP to < 120 mmHg within 1 hour
- B Reduce diastolic BP to < 70 mmHg within 30 minutes
- C Reduce mean arterial pressure by no more than 25% in the first hour ✓
- D Normalise BP to < 140/90 mmHg within 2 hours
Correct answer: C. Reduce mean arterial pressure by no more than 25% in the first hour
Explanation
In hypertensive emergency (acute target organ damage without aortic dissection), the 2019 ESC/ACC guidelines recommend reducing MAP by no more than 25% in the first hour, then targeting 160/100–110 mmHg over the next 2–6 hours, with normalisation over 24–48 hours. Excessive rapid lowering can precipitate cerebral, coronary, or renal ischaemia due to impaired autoregulation. Aortic dissection (type A) is the exception where rapid BP reduction to SBP < 120 mmHg within minutes is required. IV labetalol, nicardipine, or clevidipine are preferred agents.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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