MEDizzy - A 55-year-old African American female presents to the ER

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Cardiology

A 55-year-old African American female presents to the ER with lethargy and blood pressure of 250/150. Her family members indicate that she was complaining of severe headache and visual disturbance earlier in the day. They report a past history of asthma but no known kidney disease. On physical examination, retinal hemorrhages are present. Which of the following is the best approach?

ExplanationMalignant hypertension occurs when diastolic blood pressure above 130 is associated with acute (or ongoing) target organ damage. This patient shows evidence of damage, namely hypertensive encephalopathy (headache, visual disturbance, and altered mental status). Immediate therapy with nitroprusside in the ICU setting is indicated, although renal insufficiency would be a contraindication. Other options include intravenous nitroglycerin, fenoldopam, or enalapril. Intravenous labetalol is often used in hypertensive urgencies but, as a nonselective beta-blocker, is relatively contraindicated in asthma. Oral medication such as clonidine would be slow acting and difficult to administer in a lethargic patient. Sublingual nifedipine is no longer advised because of the increased potential for over- shoot hypotension with adverse cardiovascular events such as MI, stroke, or ischemic optic neuropathy. Loop diuretics do not lower blood pressure rapidly.