Emergency medicine: hypertensive emergency: practice question

A General Medicine question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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General Medicine · Emergency medicine: hypertensive emergency

Sample item

A 45-year-old man has severe headache, confusion and a seizure. Blood pressure is 230/136 mmHg, fundoscopy shows papilloedema with flame haemorrhages and exudates, and CT head shows no haemorrhage. Aortic dissection and pre-eclampsia are excluded. What is the appropriate blood pressure target and approach during the first hour?

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

C. Lower mean arterial pressure by no more than about 25% using an intravenous agent such as labetalol or nicardipine

Hypertensive emergency with encephalopathy needs controlled reduction with a titratable intravenous agent, lowering mean arterial pressure by about 20 to 25% in the first hour and then towards 160/100 mmHg over the next 2 to 6 hours. Chronic hypertension shifts the cerebral autoregulation curve to the right, so an abrupt fall causes cerebral, myocardial and renal hypoperfusion. Exceptions needing faster or different targets are aortic dissection and pre-eclampsia.

Option by option

  • A. Normalise the pressure to 120/80 mmHg within minutes using sublingual nifedipine

    Rapid normalisation and unpredictable sublingual nifedipine can cause stroke, myocardial ischaemia and renal injury.

  • B. Lower mean arterial pressure by more than 50% in 30 minutes with intravenous nitroprusside

    A fall of more than half in 30 minutes exceeds the autoregulatory limit and risks watershed cerebral infarction.

  • C. Lower mean arterial pressure by no more than about 25% using an intravenous agent such as labetalol or nicardipine (correct)

    Correct. A controlled fall of no more than about 25% preserves cerebral perfusion while relieving encephalopathy.

  • D. Use oral amlodipine alone and aim for a gradual fall over 48 hours

    Slow oral therapy does not control a hypertensive emergency with ongoing end-organ damage.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

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Questions about this General Medicine question

What is the answer to this General Medicine question?

The best answer is C, Lower mean arterial pressure by no more than about 25% using an intravenous agent such as labetalol or nicardipine. Hypertensive emergency with encephalopathy needs controlled reduction with a titratable intravenous agent, lowering mean arterial pressure by about 20 to 25% in the first hour and then towards 160/100 mmHg over the next 2 to 6 hours.

Why is "Normalise the pressure to 120/80 mmHg within minutes using sublingual…" not the answer?

Rapid normalisation and unpredictable sublingual nifedipine can cause stroke, myocardial ischaemia and renal injury.

Why is "Lower mean arterial pressure by more than 50% in 30 minutes with intr…" not the answer?

A fall of more than half in 30 minutes exceeds the autoregulatory limit and risks watershed cerebral infarction.

Why is "Use oral amlodipine alone and aim for a gradual fall over 48 hours" not the answer?

Slow oral therapy does not control a hypertensive emergency with ongoing end-organ damage.

What concept does this question test?

It tests Emergency medicine: hypertensive emergency in General Medicine. Chronic hypertension shifts the cerebral autoregulation curve to the right, so an abrupt fall causes cerebral, myocardial and renal hypoperfusion. Exceptions needing faster or different targets are aortic dissection and pre-eclampsia.

How hard is this question?

We tag it as a multi-step question: it asks you to combine more than one idea. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Emergency medicine: hypertensive emergency?

For each disease know the classic presentation, the best test, and the first-line treatment. Then use the flashcards and the other General Medicine questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.