What is the appropriate management for a patient with Atherosclerotic heart disease, Alcoholic hepatitis, Essential hypertension, Pruritus ani, and Herpesviral infection, presenting with a Hypertensive emergency and chronic foot sores?

Management of Hypertensive Emergency in a Patient with Multiple Comorbidities and Foot Sores

Immediate treatment of this patient's hypertensive emergency requires IV labetalol or another rapidly-acting antihypertensive medication with gradual blood pressure reduction to prevent organ damage, while addressing the underlying comorbidities including alcoholic hepatitis and atherosclerotic heart disease. 1, 2

Initial Assessment and Management of Hypertensive Emergency

Immediate Management:

• Admit to intensive care unit for continuous monitoring of blood pressure and parenteral administration of appropriate antihypertensive agent 1, 2
• Initial goal is to reduce blood pressure by approximately 25% within the first 1-2 hours, not necessarily to normal levels 2, 3
• Avoid precipitous drops in blood pressure which can cause renal, cerebral, or coronary ischemia 1, 4

First-line IV Medication Options:

• Labetalol IV: Initial dose of 20 mg (0.25 mg/kg for an 80 kg patient) followed by additional doses of 40-80 mg at 10-minute intervals to achieve desired effect or up to cumulative dose of 300 mg 4, 3
• Alternative options include nicardipine, fenoldopam, or sodium nitroprusside (with caution due to toxicity concerns) 2, 3

Special Considerations for This Patient:

• Caution with labetalol in alcoholic hepatitis: Severe hepatocellular injury has been reported with labetalol therapy; consider alternative agents given this patient's liver disease 4
• Atherosclerotic heart disease: Consider nitroglycerin if coronary ischemia is present 5
• Monitor for cardiac failure: Beta-blockers can depress myocardial contractility 4

Addressing Comorbidities After Stabilization

Alcoholic Hepatitis:

• Assess severity with laboratory tests (liver function tests, coagulation profile) 4
• Alcohol cessation counseling and nutritional support are essential 4

Atherosclerotic Heart Disease:

• Evaluate for acute coronary syndrome if chest pain or ECG changes develop during treatment 2
• Continue or initiate appropriate antiplatelet therapy and statins after stabilization 1

Chronic Foot Sores:

• Comprehensive foot examination to assess for:
  • Peripheral arterial disease (check pulses, ankle-brachial index) 1
  • Diabetic neuropathy (though diabetes not mentioned in history) 1
  • Infection requiring antibiotics 1
• Consider vascular surgery consultation if ischemic ulcers are suspected 1

Follow-up Management

Blood Pressure Goals After Acute Phase:

• Target systolic BP 130-139 mmHg for patients with atherosclerotic disease 1
• Avoid excessive BP lowering (not below 120 mmHg systolic) 1, 2

Outpatient Medication Regimen:

• Consider combination therapy including:
  • RAS blockers (ACE inhibitor or ARB) 1
  • Calcium channel blocker 1
  • Diuretic 1
• Avoid abrupt discontinuation of beta-blockers in patients with coronary artery disease 4

Common Pitfalls to Avoid

• Overly rapid BP reduction: Can lead to cerebral infarction, optic nerve infarction, or angina 4, 6
• Misclassification of urgency vs. emergency: Hypertensive emergency requires immediate IV therapy, while urgency can be managed with oral medications 7, 8
• Failure to monitor for end-organ damage: Regular reassessment of cardiac, neurologic, and renal function is essential 2, 3
• Neglecting underlying causes: Address potential triggers such as medication non-adherence, substance use, or secondary hypertension 6

Special Monitoring Requirements

• Continuous blood pressure monitoring, preferably with arterial line 2, 3
• Cardiac monitoring for arrhythmias and signs of ischemia 2
• Frequent neurological checks 2
• Urine output and renal function monitoring 2
• Daily liver function tests given alcoholic hepatitis 4