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Malignant Hypertension Management — EECC MCQ

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ModerateHypertension & Preventive CardiologyMalignant Hypertension ManagementEECC

A 55-year-old man with hypertension is found to have a BP of 200/120 mmHg with papilloedema, acute kidney injury (creatinine 250 micromol/L), and microangiopathic haemolytic anaemia on blood film. What is the diagnosis and immediate management?

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Correct answer: A — Hypertensive emergency with malignant hypertension — requires immediate but controlled BP reduction with IV antihypertensives (labetalol, nicardipine, or sodium nitroprusside) targeting 20-25% BP reduction in the first hour

Malignant (accelerated) hypertension is defined by severe hypertension (typically >200/120 mmHg) with evidence of acute target organ damage: (1) retinal haemorrhages/exudates/papilloedema (grade 3-4 retinopathy); (2) acute kidney injury (from fibrinoid necrosis of renal arterioles); (3) microangiopathic haemolytic anaemia (MAHA — fragmented red cells from shear stress in damaged arterioles). The 2024 ESC Hypertension Guidelines recommend: (1) ICU/HDU admission; (2) IV antihypertensive (labetalol or nicardipine infusion); (3) target: 20-25% BP reduction in first 1-2 hours (NOT normalisation, which risks cerebral/renal/coronary hypoperfusion); (4) then gradual reduction to <160/100 over 24-48 hours; (5) oral agents introduced once stable. Investigation for secondary hypertension after stabilisation.

Reference: ESC (2024): Guidelines for Hypertension