Review Question - QID 103333

This patient is suffering from a hypertensive emergency given her elevated blood pressure and signs of end organ damage (headache, vomiting, neck stiffness, chest pain, hematuria/proteinuria, and papilledema). Blood pressure should initially be lowered with a beta-blocker such as esmolol in the setting of this patient's tachycardia.

A hypertensive emergency is defined as hypertension with concomitant signs and symptoms of end organ damage, notably cardiovascular, renal, and neurologic disease. Symptoms may include headache, blurry vision, abdominal pain, confusion, weakness, chest pain, and dyspnea. The best initial step in management in a hypertensive emergency is administration of a beta blocker (typically esmolol or labetalol) followed by a second anti-hypertensive medication (such as nicardipine or nitroprusside). In general, a medication with beta-blocking capability should be chosen first if the patient is tachycardic (especially if there is chest pain which raises concern for an aortic dissection).

Incorrect Answers:
Answer 2: Hydralazine is a vasodilator with a less predictable response than other blood pressure medications. It could be given after a beta-blocker but is not preferred when compared to nitroprusside or nicardipine as a second agent.

Answer 3: Lisinopril is an ACE inhibitor which this patient should be on as a home medication given her diabetes and hypertension. It would not acutely be useful in a hypertensive emergency when rapid correction of blood pressure is needed.

Answer 4: Nitroprusside is a potent vasodilator that should be given after esmolol or labetalol has been given to avoid a reflex tachycardia (in particular in this patient who is already tachycardic).

Answer 5: Propranolol is a beta-blocker with a slower onset/offset than esmolol and is not a preferred initial beta-blocker when compared to esmolol or labetalol.

Bullet Summary:
The best initial step in management for a hypertensive emergency is administration of esmolol or labetalol followed by a vasodilator such as nitroprusside or nicardipine.