Cardiovascular Critical Care II

B is incorrect). This patient’s D-dimer is normal as well,

but even if it were elevated, this is not a specific marker

of target organ damage (Answer D is incorrect). The

patient has significant elevations in her transaminases,

indicating injury to the liver and thus qualifying her for

hypertensive emergency (Answer C is correct).

Answer: C

The patient should be initiated on nitroprusside for BP

management (Answer C is correct). Although she has

transaminitis, nitroprusside can be used safely in the

first 24 hours in these patients. Cyanide accumulation

would be a concern with extended use, but for the first

24 hours, the patient will be at minimal risk, and the

benefit of rapid BP control outweighs any potential risk.

Phentolamine would be reserved for hypertensive crisis

that presents from a catecholamine crisis (Answer A

is incorrect). Oral metoprolol might be an appropriate

option to transition to after the emergency is resolved,

but because of the target organ damage, more rapid

reduction is needed using an intravenous agent such as

nitroprusside (Answer B is incorrect). Enalaprilat is an

option, but 10 mg every 6 hours would not be an appro-

priate starting dose because it would put the patient

at risk of overshooting and, given the long duration of

activity, could lead to unwanted consequences (Answer

D is incorrect).

Answer: A

The initial goal reduction for this patient’s BP, given that

she is experiencing a hypertensive emergency, is a 25%

reduction in MAP within the first 60 minutes (Answer

A is correct). More rapid BP reductions may result in a

lack of cerebral perfusion; therefore, they are not rec-

ommended (Answer B is incorrect). The patient is not

experiencing any of the specific hypertensive emergen-

cies (e.g., aortic dissection) that would call for a more

rapid BP reduction. In addition, she is not experiencing a

hypertensive emergency that would require a slower BP

reduction (e.g., stroke) (Answers C and D are incorrect).