A 36 year old woman on chronic cyclosporine treatment for bilateral lung transplantation visits the emergency department complaining of extreme headache, nausea and vomiting. Her exam is notable for BP 239/165, normal cardiac exam, bibasilar pulmonary rales, and 1+ lower extremity edema. EKG showed asymmetric inverted T-waves in I, aVL, and V4-6. In an effort to acutely control her blood pressure, which of the following is TRUE?
A. Hydralazine decreases myocardial oxygen demand by decreasing afterload and would not be useful in this setting
B. Nitroprusside would be contraindicated in this patient due to its relatively slow onset of action
C. Nitroglycerin decreases BP by decreasing venous return and cardiac output
D. Prolonged nitroprusside therapy may potentially cause methemoglobinemia
E. Esmolol works through both alpha-1 and selective beta-2 blockade

Relative to other anti-hypertensive agents, nitroprusside has an extremely rapid onset of action. Although rare, long-term nitroprusside treatment may lead to cyanide toxicity in renal failure patients secondary to the presence of cyanide as an intermediate metabolite. A history of long-term cyclosporine treatment suggests this patient likely has some degree of renal insufficiency.