This is a life-threatening situation that requires immediate lowering of BP usually with parenteral therapy. Grade 3-4 hypertensive retinopathy is usually present with impaired renal function and proteinuria.The true emergency situation should preferably be treated by an appropriate specialist.

Life-threatening complications include:

» Hypertensive encephalopathy, i.e. severe headache, visual disturbances, confusion, seizures and coma that may result in cerebral haemorrhage.

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»     Unstable angina or myocardial infarction.

» Acute left ventricular failure with severe pulmonary oedema (extreme breathlessness at rest).

»      Eclampsia and severe pre-eclampsia.

»      Acute kidney failure with encephalopathy.

»      Acute aortic dissection.


Admit the patient to a high-care setting for intravenous drug therapy and close monitoring. Do not lower the BP by >25% within 30 minutes to 2 hours.

In the next 2–6 hours, aim to decrease BP to 160/100 mmHg.

This may be achieved by the use of intravenous or oral drugs.

Intravenous therapy

  • Labetalol, IV, 2 mg/minute to a total dose of 1–2 mg/kg.
    • Caution in acute pulmonary oedema. OR

If myocardial ischaemia and CCF:

  • Glyceryl trinitrate, IV, 5–10 mcg/minute.
  • Furosemide, IV, 40–80 mg.
    • Duration of action: 6 hours. o Potentiates all of the above drugs.

Oral therapy

ACE inhibitor, e.g.:

  • Enalapril, oral, 2.5 mg as a test dose o Increase according to response, to a maximum of 20 mg daily.
    • Monitor renal function.
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