A 58-year-old man presents to the emergency department with blood pressure 215/135 mmHg and acute pulmonary edema. He has no aortic dissection on imaging. Which intravenous antihypertensive is the preferred first-line agent in this setting?

• A Sodium nitroprusside
• B Nicardipine
• C Esmolol
• D Nitroglycerin with IV furosemide ✓

Explanation

In hypertensive emergency with acute pulmonary edema, intravenous nitroglycerin combined with a loop diuretic such as furosemide is the preferred initial therapy. Nitroglycerin reduces preload and coronary ischemia while furosemide addresses volume overload. Sodium nitroprusside is second-line due to cyanide toxicity risk and coronary steal. Nicardipine is excellent for most hypertensive emergencies but does not specifically target pulmonary congestion. Esmolol is contraindicated in acute decompensated heart failure.

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

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