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Malignant Hypertension

Malignant hypertension (MH) is a type of hypertension which results in the impairment of one or more systems, especially the central nervous system, the cardiovascular system, and the renal system [1]. It is also commonly known as hypertensive emergency.


Presentation

The presentation of MH underlines a condition of elevated blood pressure, like the appearance of exudates on pores and wounds of the body. Optic discs begin to swell, in a condition known as papilledema, frequently coupled with signs of retinal hemorrhage. The subjects also show signs of increased intracranial pressure, like headache and vomiting, which are frequently followed by faintness or vertigo, anxiety, or agitation in a general altered mental status. The damage in kidneys usually results in hematuria, proteinuria, and acute renal failure.

Other classical signs of MH include chest pain, arrhythmias, epistaxis, dyspnea, and paresthesias. Sometime, chest pain might be so severe to require immediate use of antihypertensive drugs such as nifedipine and calcium channel blockers.

Anemia
  • Although she was steroid-resistant, over the next subsequent three years, she maintained normal renal function without anemia and thrombocytopenia.[ncbi.nlm.nih.gov]
  • Carney's triad is a rare differential diagnosis for "idiopathic" hypertension or iron-deficiency anemia from chronic gastrointestinal bleeding.[ncbi.nlm.nih.gov]
  • Severe hypertension, renal dysfunction, thrombocytopenia, and anemia were present.[ncbi.nlm.nih.gov]
  • Thrombotic thrombocytopenia purpura (TTP) is a rare clinical syndrome characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia, neurologic symptoms, acute renal impairment, and fever.[ncbi.nlm.nih.gov]
  • We initially observed microangiopathic hemolytic anemia, thrombocytopenia and kidney damage, indicating he had thrombotic microangiopathy (TMA). We considered TMA was caused by malignant hypertension and therefore did not start plasma therapy.[ncbi.nlm.nih.gov]
Fatigue
  • […] cause: Chest pain Difficulty breathing Headache Visual problems Nausea and vomiting Numbness/weakness of the legs, arms, face Malignant hypertension can lead to hypertensive encephalopathy which can also cause: Mental changes like anxiety Confusion Fatigue[winchesterhospital.org]
  • Symptoms and Signs Change in GCS / mental status: anxiety , confusion , decreased alertness, decreased ability to concentrate, fatigue, restlessness, sleepiness, stupor, lethargy Sign of increased ICP: Headache N&V Subarachnoid/ cerebral haemorrhage Seizure[almostadoctor.co.uk]
  • Symptoms and Signs Change in GCS / mental status: anxiety, confusion, decreased alertness, decreased ability to concentrate, fatigue, restlessness, sleepiness, stupor, lethargy Sign of increased ICP: Headache N&V Subarachnoid/ cerebral haemorrhage Seizure[almostadoctor.co.uk]
  • […] you have had: Kidney failure Renal hypertension caused by renal artery stenosis Symptoms of malignant hypertension include: Blurred vision Change in mental status, such as anxiety , confusion , decreased alertness , decreased ability to concentrate, fatigue[medlineplus.gov]
  • […] had: Kidney failure Renal hypertension caused by renal artery stenosis Symptoms Symptoms of malignant hypertension include: Blurred vision Change in mental status, such as anxiety , confusion , decreased alertness , decreased ability to concentrate, fatigue[ufhealth.org]
Resistant Hypertension
  • Carotid baroreflex activation therapy for resistant hypertension. Nat Rev Cardiol . 2015 Aug. 12(8):451-63. [Medline] . [Guideline] Chobanian AV, Bakris GL, Black HR, et al, National Heart, Lung, et al.[emedicine.medscape.com]
  • Resistant hypertension. If your doctor has prescribed three different types of antihypertensive medications and your blood pressure is still too high, you may have resistant hypertension.[everydayhealth.com]
  • Resistant hypertension is often associated with secondary hypertension.”[healio.com]
Congestive Heart Failure
  • Thrombocytopenia and hemolytic anemia were immediately improved by the beginning of these treatments, however renal insufficiency and proteinuria were deteriorated and congestive heart failure developed.[ci.nii.ac.jp]
  • The kinetic profiles of enalapril and enalaprilat and their possible developmental changes in pediatric patients with congestive heart failure. Clin Pharmacol Ther 1994;56:160-8. 11. Wells TG, Bunchman TE, Kearns GL.[indianjnephrol.org]
  • heart failure (12%). [2] Less common presentations include intracranial bleeding, aortic dissection, and pre-eclampsia or eclampsia. [3] Massive, rapid elevations in blood pressure can trigger any of these symptoms, and warrant further work-up by physicians[en.wikipedia.org]
Weight Loss
  • Takayasu's arteritis was diagnosed on the basis of clinical symptoms of weight loss and low grade fever in conjunction with elevated sedimentation rate and radiographic evidence of aortic and renal artery stenosis.[ncbi.nlm.nih.gov]
  • If indicated, the patient should follow a diet that can induce weight loss. Activity Activity is limited to bedrest until the patient is stable. Patients should be able to resume normal activity as outpatients once their BP has been controlled.[emedicine.medscape.com]
Dyspnea
  • A 33-year-old male was admitted with a 6-day history of worsening dyspnea, chest distress, and diffused pitting edema accompanied by very high blood pressure (200/145 mm Hg).[ncbi.nlm.nih.gov]
  • A 34-year-old Japanese male was admitted to Okayama University Hospital with severe hypertension, rapidly progressive renal failure, blurred vision, dyspnea and hemoptysis.[ncbi.nlm.nih.gov]
  • Figure 1 A 41-year-old woman with blurred vision and dyspnea was found to have severe hypertension (blood pressure, 240/125 mm Hg in both arms) and grade IV hypertensive retinopathy.[nejm.org]
  • Cardiovascular damages include chest pain, orthopnea, paroxysmal nocturnal dyspnea, or edema. The most important sign of renal damage, instead, is the decrease in urine output.[symptoma.com]
  • Case # 2: A 36-year-old black patient presented to the hospital with dyspnea, headache and visual blurring, and with a BP of 230/130 mmHg. The blood urea nitrogen was 105 mg/dL and creatinine peaked at 11 mg/dL (968 µmol/L).[academic.oup.com]
Painful Cough
  • Common signs and symptoms of MH are: Headache Blurred vision Vomiting Chest pain Cough Shortness of breath Nose bleeds Faintness or vertigo Anxiety Agitation Altered mental status The use of antihypertensive drugs is the most important treatment for MH[symptoma.com]
Vomiting
  • An 11-month-old girl presented with a history of failure to thrive, vomiting, polydipsia, polyuria and visual inattention. She was found to have malignant hypertension due to unilateral renal artery stenosis.[ncbi.nlm.nih.gov]
  • A 38-year-old male presented with nausea, vomiting, loss of appetite and oliguria for 2 weeks. He was diagnosed with hypertensive emergency with cardiac and renal dysfunction.[ncbi.nlm.nih.gov]
  • The subjects also show signs of increased intracranial pressure, like headache and vomiting, which are frequently followed by faintness or vertigo, anxiety, or agitation in a general altered mental status.[symptoma.com]
  • […] complications -htn induced streoke -pregnancy associated htn clinical features of malignant hypertension: symptoms symptoms: confusion, headache,visual disturbance,seizures The brain shows manifestations of increased intracranial pressure, such as headache, vomiting[quizlet.com]
  • Clinical findings Headache, blurred vision, nausea, vomiting, lethargy. Risk groups Males, African Americans, hypertensive patients.[medical-dictionary.thefreedictionary.com]
Nausea
  • A 38-year-old male presented with nausea, vomiting, loss of appetite and oliguria for 2 weeks. He was diagnosed with hypertensive emergency with cardiac and renal dysfunction.[ncbi.nlm.nih.gov]
  • A 42-year-old woman presented with headache and nausea. Severe hypertension, renal dysfunction, thrombocytopenia, and anemia were present.[ncbi.nlm.nih.gov]
  • […] heart block& dizziness I: Syndromesof coronary insufficiency C: Greater than first- degree heartblock, CHF Labetalol HCl - blocker 20-80 mg IV bolus, (maxim um dose, 300 mg 2-10 min 2-4 hr Hypoten- sion, nausea, itching, scalp tingling& dizziness I[slideshare.net]
  • Clinical findings Headache, blurred vision, nausea, vomiting, lethargy. Risk groups Males, African Americans, hypertensive patients.[medical-dictionary.thefreedictionary.com]
  • Some of the more common signs include: Blurry vision Headache Chest pain Irregular heartbeat Nosebleed Shortness of breath Tingling, numbness, burning, or prickly skin sensations Faintness or dizziness Reduced urine output Nausea or vomiting Altered mental[verywellhealth.com]
Hypertension
  • Abstract Malignant hypertension and hypertensive encephalopathy are life-threating manifestations of hypertension. These syndromes primarily occur in patients with a history of poorly controlled hypertension.[ncbi.nlm.nih.gov]
  • Certainly, malignant hypertension still poses a clinically relevant and challenging form of hypertension and its possibility should be always considered during the assessment of patients with poorly controlled hypertension.[ncbi.nlm.nih.gov]
  • BACKGROUND: Malignant hypertension can be considered an extreme phenotype of renin-mediated hypertension.[ncbi.nlm.nih.gov]
  • BACKGROUND: Malignant hypertension is a renin-dependent form of hypertension. However, the variations in renin-angiotensin system (RAS) activation in malignant hypertension are not completely understood.[ncbi.nlm.nih.gov]
  • We propose to consider that malignant hypertension with retinopathy is only one of a number of possible presentation(s) of acute hypertension with multi organ damage (hypertension multi organ damage (MOD)) and that the recognition of these hypertensive[ncbi.nlm.nih.gov]
Chest Pain
  • Other classical signs of MH include chest pain, arrhythmias, epistaxis, dyspnea, and paresthesias. Sometime, chest pain might be so severe to require immediate use of antihypertensive drugs such as nifedipine and calcium channel blockers.[symptoma.com]
  • Chest pain requires lowering of BP. The former use of oral nifedipine, a calcium channel blocker , has been strongly discouraged because it has been noted to lead to serious and fatal hypotensive problems.[almostadoctor.co.uk]
  • Chest pain requires lowering of BP. The former use of oral nifedipine, a calcium channel blocker, has been strongly discouraged because it has been noted to lead to serious and fatal hypotensive problems.[almostadoctor.co.uk]
  • These complications may occur: Brain damage (stroke, seizures) Heart damage, including: heart attack , angina (chest pain due to narrowed blood vessels or weakened heart muscle), heart rhythm disturbances Kidney failure Permanent blindness Fluid in the[medlineplus.gov]
  • Possible Complications These complications may occur: Brain damage (stroke, seizures) Heart damage, including: heart attack , angina (chest pain due to narrowed blood vessels or weakened heart muscle), heart rhythm disturbances Kidney failure Permanent[ufhealth.org]
Vascular Disease
  • Both conditions may be associated with collagen vascular diseases, such as systemic lupus erythematosus. We report a case of acute cardiac tamponade associated with malignant hypertension secondary to lupus nephritis.[ncbi.nlm.nih.gov]
  • Malignant hypertension is a medical emergency and requires immediate therapy and… Read More excretory system In renal system disease: Vascular disease …is the condition known as malignant hypertension, or accelerated hypertension, which arises when the[britannica.com]
  • diseases Pregnant women with preeclampsia and eclampsia Pheochromocytoma Spinal cord disorders Coarctation or dissection of the aorta Renal artery stenosis or narrowing of the arteries to the kidneys Missing doses of medicine for high blood pressure,[winchesterhospital.org]
  • They include: Collagen vascular disease, such as scleroderma Kidney disease Spinal cord injuries Tumor of the adrenal gland Use of certain medications , including birth control pills and MAOIs Use of illegal drugs, such as cocaine Who's at Risk for Malignant[webmd.com]
Cardiomegaly
  • […] flame-shaped haemorrhages Narrowing of retinal blood vessels Papilloedema (this must be present for the diagnosis of malignant hypertension to be made) Hard exudates Cotton wool spots Investigations ABG BUN Creatinine Urinalysis CXR Congestion in the lung Cardiomegaly[almostadoctor.co.uk]
  • Chest x-ray showed cardiomegaly. A non-contrast computed tomography scan of the brain did not show any sign of stroke (haemorrhage).[bjmp.org]
Diastolic Hypertension
  • Full blown syndrome characterized by diastolic hypertension 130 mmHg, papilledema retinopathy, encephalopathy, cardiovascular abnormality, and renal failure. Image C Image D May have "hypertensive crises" such as loss of consciousness or convulsion.[auanet.org]
Hypertensive Retinopathy
  • These findings were compatible with high-grade hypertensive retinopathy. The patient consulted with pediatrics and a diagnosis of vesicourethral reflux and malignant hypertension was made.[ncbi.nlm.nih.gov]
  • Malignant hypertension is the clinical syndrome of severe elevations in blood pressure and funduscopic hypertensive retinopathy, including bilateral flame-shaped hemorrhage and papilledema.[ncbi.nlm.nih.gov]
  • Elevated diastolic blood pressure, hypertensive retinopathy and renal dysfunction indicated malignant hypertension. Adrenocorticotropic hormone (ACTH) and cortisol levels were high although there were no Cushingoid features.[ncbi.nlm.nih.gov]
  • Here, we report the case of a patient with SLE and malignant hypertension with hypertensive retinopathy that initially presented without clinical evidence of APS or hypertensive nephropathy.[ncbi.nlm.nih.gov]
  • Additionally, we considered that the possible cause of TMA was malignant hypertension according to the presence of hypertensive retinopathy and thrombocytopenia which remitted only with blood pressure control, hence, plasmapheresis was not given.[ncbi.nlm.nih.gov]
Blurred Vision
  • We report a clinical case of a Caucasian 41-year-old man with no previous history of blood hypertension seen at casualty because of blurred vision. Fundus examination disclosed optic disk swelling, retinal hemorrhages and infarcts.[ncbi.nlm.nih.gov]
  • A 34-year-old Japanese male was admitted to Okayama University Hospital with severe hypertension, rapidly progressive renal failure, blurred vision, dyspnea and hemoptysis.[ncbi.nlm.nih.gov]
  • Clinical findings Headache, blurred vision, nausea, vomiting, lethargy. Risk groups Males, African Americans, hypertensive patients.[medical-dictionary.thefreedictionary.com]
  • Figure 1 A 41-year-old woman with blurred vision and dyspnea was found to have severe hypertension (blood pressure, 240/125 mm Hg in both arms) and grade IV hypertensive retinopathy.[nejm.org]
  • He complained of blurred vision without photophobia, headache and mild chest discomfort. His past medical history was unremarkable. The patient did not have any significant family history.[bjmp.org]
Retinal Hemorrhage
  • Flame-shaped retinal hemorrhages, an early finding, are due to smooth muscle necrosis and bleeding along the nerve fiber layer. Cotton-wool spots, or cytoid bodies, are not exudates, but rather are retinal infarcts.[ncbi.nlm.nih.gov]
  • Fundus examination disclosed optic disk swelling, retinal hemorrhages and infarcts. The blood pressure was 220/130 mmHg.[ncbi.nlm.nih.gov]
  • One specific type of emergency is malignant hypertension, in which there are exudates and/or retinal hemorrhages or papilledema. Besides effective and prompt treatment, it is mandatory to screen for secondary causes of the hypertension.[ncbi.nlm.nih.gov]
  • Examination revealed bilateral 360 hemorrhagic choroidal detachments without retinal hemorrhage or detachment. Choroidal hemorrhages underwent prompt resolution with blood pressure control.[ncbi.nlm.nih.gov]
  • Malignant or accelerated hypertension is the most severe form of hypertension, defined clinically by very high blood pressure (diastolic above 130 mm Hg) accompanied by bilateral retinal hemorrhages and/or exudates, with or without papilledema.[ncbi.nlm.nih.gov]
Cotton Wool Spots
  • Cotton-wool spots, or cytoid bodies, are not exudates, but rather are retinal infarcts. Hypertensive optic neuropathy is a late finding.[ncbi.nlm.nih.gov]
  • Decrease in visual acuity (6/7 patients) and scotoma (5/7) were the main symptoms and Elschnig spot, flamed shaped haemorrhage, serous retinal detachment, cotton wool spots and optic nerve oedema were the five most frequently observed lesions.[ncbi.nlm.nih.gov]
  • It is defined clinically as high blood pressure (BP) levels associated with lesions of the retinal fundus (flame-shaped hemorrhages, exudates, or cotton wool spots, with or without papilledema).[ncbi.nlm.nih.gov]
  • wool spots Investigations ABG BUN Creatinine Urinalysis CXR Congestion in the lung Cardiomegaly Brain CT ECG U&E, renin and aldosterone levels Cardiac enzymes (markers of heart damage) Pathological hallmark fibrinoid necrosis Management Malignant hypertension[almostadoctor.co.uk]
Flame-shaped Hemorrhage
  • Malignant hypertension is the clinical syndrome of severe elevations in blood pressure and funduscopic hypertensive retinopathy, including bilateral flame-shaped hemorrhage and papilledema.[ncbi.nlm.nih.gov]
  • It is defined clinically as high blood pressure (BP) levels associated with lesions of the retinal fundus (flame-shaped hemorrhages, exudates, or cotton wool spots, with or without papilledema).[ncbi.nlm.nih.gov]
  • While Accelerated high blood pressure is condition with high blood pressure, target organ damage, on fundoscopy we have flame shaped hemorrhages, or soft exudates, but without papilledema. There are two things.[robertjrgraham.com]
  • Note the flame-shaped hemorrhages, soft exudates, and early disc blurring.[emedicine.medscape.com]
  • Physical examination showed hypertensive retinopathy with flame-shaped hemorrhages and exudates, but no papilledema. He had a serum creatinine level of 4 mg/dL (264 µmol/L), hemoglobin of 108 g/L and platelet count of 71 000.[academic.oup.com]
Kidney Failure
  • Related Information Preeclampsia Renovascular hypertension Acute kidney failure Stroke Seizures Decreased alertness Heart attack Angina Pulmonary edema References Archbold A, Naish J. The cardiovascular system. In: Naish J, Court DS, eds.[slu.adam.com]
  • Sudden kidney failure. Coma.[epainassist.com]
  • Kidney failure may develop, which may be permanent. If this happens, you may need dialysis (machine that removes waste products from blood). If treated right away, malignant hypertension can often be controlled without causing permanent problems.[medlineplus.gov]
Oliguria
  • He presented with oliguria, renal failure, thrombocytopenia and haemolytic anaemia. He required several sessions of renal replacement therapy.[ncbi.nlm.nih.gov]
  • A 38-year-old male presented with nausea, vomiting, loss of appetite and oliguria for 2 weeks. He was diagnosed with hypertensive emergency with cardiac and renal dysfunction.[ncbi.nlm.nih.gov]
  • Introduction Rapid in blood pressure due to vascular damage to renal vessels secondary to benign nephrosclerosis (most common cause) thrombotic thrombocytopenic purpura hemolytic-uremic syndrome Presentation Symptoms oliguria due to acute renal failure[step1.medbullets.com]
  • Damages mainly regard the central nervous system with injuries like encephalopathy and seizures, the cardiovascular system with injuries like chest pain and aortic dissection, and the renal system with like oliguria and azotemia.[symptoma.com]
Headache
  • A 62-year-old man with a history of hypertension was referred secondary to bilateral temporal scotomas and persistent headache for 3 days. Symptoms began during an inpatient admission for malignant hypertension.[ncbi.nlm.nih.gov]
  • The case of a 6-year-old girl who presented with a prolonged history of general malaise, headaches and abdominal pain is reported. On examination, she was noted to have malignant hypertension.[ncbi.nlm.nih.gov]
  • A 42-year-old woman presented with headache and nausea. Severe hypertension, renal dysfunction, thrombocytopenia, and anemia were present.[ncbi.nlm.nih.gov]
  • ,visual disturbance,seizures The brain shows manifestations of increased intracranial pressure, such as headache, vomiting, and/or subarachnoid or cerebral hemorrhage.[quizlet.com]
  • In February 2009, she had a severe headache and blurry vision and presented at a local hospital with severe hypertension. Blood pressure was 220/160 mmHg.[ncbi.nlm.nih.gov]
Stroke
  • Ea was calculated from stroke volume and systolic BP and adjusted by body area (EaI).[ncbi.nlm.nih.gov]
  • […] progressive and fatal disease Risk groups , African Americans, hypertensives Clinical Headache, blurred vision, N&V, lethargy Complications Stroke, MI, blindness, renal failure.[medical-dictionary.thefreedictionary.com]
  • Malignant hypertension may be responsible for several complications such as stroke, a rupture of the walls of the aorta (aortic dissection) or acute renal failure.[health.ccm.net]
  • This is because cerebral autoregulation is poor, so sudden drops in blood pressure increase the risk of stroke . Chest pain requires lowering of BP.[almostadoctor.co.uk]
Seizure
  • Abstract Malignant hypertension is an unusual but well described cause of seizures in pediatrics. It is a medical emergency that must be recognized and emergently treated to prevent morbidity and mortality.[ncbi.nlm.nih.gov]
  • We present a case of severe chronic hypertension in a pregnant patient with a seizure disorder and new finding of a basal transethmoidal encephalocele.[ncbi.nlm.nih.gov]
  • We report an unusual association of PRES and malignant hypertension secondary to focal segmental glomerulosclerosis in a young woman, presenting with sudden loss of vision and seizures.[ncbi.nlm.nih.gov]
  • Call 911 Call 911 if you have any of these: Chest pain or shortness of breath Seizure (with no history of seizure disorder) When to seek medical care Call your doctor right away if you have any of the following: Moderate to severe headache Weakness in[saintlukeskc.org]
  • Related Information Preeclampsia Renovascular hypertension Acute kidney failure Stroke Seizures Decreased alertness Heart attack Angina Pulmonary edema References Archbold A, Naish J. The cardiovascular system. In: Naish J, Court DS, eds.[slu.adam.com]
Papilledema
  • One specific type of emergency is malignant hypertension, in which there are exudates and/or retinal hemorrhages or papilledema. Besides effective and prompt treatment, it is mandatory to screen for secondary causes of the hypertension.[ncbi.nlm.nih.gov]
  • Malignant hypertension is the clinical syndrome of severe elevations in blood pressure and funduscopic hypertensive retinopathy, including bilateral flame-shaped hemorrhage and papilledema.[ncbi.nlm.nih.gov]
  • One child, presenting atypically with papilledema and fundal hemorrhages from malignant hypertension and benign intracranial hypertension from chronic iron-deficiency anemia, is the second patient ever to date be described with the complete Carney's triad[ncbi.nlm.nih.gov]
  • Optic discs begin to swell, in a condition known as papilledema, frequently coupled with signs of retinal hemorrhage.[symptoma.com]
  • Malignant or accelerated hypertension is the most severe form of hypertension, defined clinically by very high blood pressure (diastolic above 130 mm Hg) accompanied by bilateral retinal hemorrhages and/or exudates, with or without papilledema.[ncbi.nlm.nih.gov]
Dizziness
  • . & intracranial pressure C: hepatic,renal insufficiency Nitrogly- cerin (IV) 5-100 mcg/kg/ min 2-5 min 3-5 min Head ache, dizziness, vomiting, methemgl- obin &tolerance I: coronary dis.[slideshare.net]
  • Some of the more common signs include: Blurry vision Headache Chest pain Irregular heartbeat Nosebleed Shortness of breath Tingling, numbness, burning, or prickly skin sensations Faintness or dizziness Reduced urine output Nausea or vomiting Altered mental[verywellhealth.com]
  • When to seek medical care Call your doctor right away if you have any of the following: Moderate to severe headache Weakness in the muscles of your face, arms, or legs Trouble speaking Extreme drowsiness or confusion Restlessness, anxiety Fainting or dizziness[saintlukeskc.org]
  • Other symptoms of malignant hypertension include: Blurred vision Chest pain ( angina ) Difficulty breathing Dizziness Numbness in the arms, legs, and face Severe headache Shortness of breath In rare cases, malignant hypertension can cause brain swelling[webmd.com]

Workup

As MH is a dangerous condition, its evaluation should be rapid. Medical history can be useful for a correct diagnosis of MH, especially when it indicates previous cases of hypertension. Anyway, all the examples of previous damage to the central nervous system, cardiovascular system, and renal system can support the diagnosis of MH. The neurological damages include blurry vision, dizziness, and loss of movement or sensation. Cardiovascular damages include chest pain, orthopnea, paroxysmal nocturnal dyspnea, or edema. The most important sign of renal damage, instead, is the decrease in urine output. It should be noted that many of these clinical manifestations might be caused by sympathomimetic drugs such as cocaine and LSD. Therefore, an investigation on the use of these drugs by the patients is paramount.

The most important physical examination to diagnose MH is blood pressure measurement, which should be performed on both arms. If a marked difference in blood pressure between the two arms is noted, aortic dissection should be taken into consideration as alternative diagnosis. Fundoscopic examination is particularly useful to detect ocular signs such as retinal edema and papilledema, while bedside neurologic exam cab be used to measure nerve functions. Clinicians are also advised to perform an assessment of the cardiopulmonary status, to detect the presence of additional signs such as murmurs, hearts sounds, or jugular venous distension, which might help them reach the final diagnosis.

Laboratory evaluation includes complete blood count, blood biochemical panel, and analysis of urine, but sometime also plasma rennin activity and aldosterone or metanephrine levels, if aldosterone or pheochromocytoma are suspected to have caused hypertension. Imaging studies, instead, can be used when hypertension is suspected to have been caused by other conditions such as aortic dissection, ischemic stroke or intracranial hemorrhage.

Abnormal Renal Function
  • Abnormal renal function at presentation still predicts worse outcome. South Asian ethnicity is also associated with better outcome, although mechanisms involved are yet to be established.[ncbi.nlm.nih.gov]

Treatment

The use of antihypertensive drugs is the most important treatment for MH. There are many classes of antihypertensive drugs and their choice should be based on the etiology of the hypertensive crisis, the severity of the condition, and the usual blood pressure of the patient before the hypertensive crisis itself, as the patient can have a history of chronic hypertension and might not tolerate normal blood pressure. Sodium nitroprusside, injected intravenously, is especially used in the most urgent cases requiring immediate treatment, because of its prompt effect. Oral agents like captopril, clonidine, or prazosin are used instead in less urgent cases, because their action is much slower than that of sodium nitroprusside, even though it remains effective. If sodium nitroprusside is unavailable and the action of oral agents is not began yet, controlled bloodletting can be used as effective alternative measure.

MH might turn out to be particularly resistant when end stage renal failure occurs. In these cases the clinicians can consider non-pharmaceutical treatments such as surgical nephrectomy and laparoscopic nephrectomy. There is also a therapy under investigation based on the electrical stimulation of the carotid sinus which is showing promising results for the treatment of MH [18].

It should be remembered that blood pressure reduction should be smooth and limited to a certain range, otherwise it might precipitate coronary, cerebral, and renal ischemia as well as infarction [19].

Prognosis

If patients are treated in a proper manner with the appropriate antihypertensive therapy, the prognosis of MH is good, with a survival rate after 5 years from the MH episode of 70%. However, if treatment is neglected the prognosis of MH becomes bad, and patients have just a 10% to 20% survival rate after 1 year from the MH event. Mortality rate increases substantially when the MH is accompanied by renal failure [16] [17].

Etiology

Many are the causes of MH, the most common of which is essential hypertension frequently undiagnosed or not properly treated [2]. Very common are also clinical conditions secondary to renal diseases and procedures, such as kidney transplant, renal artery stenosis, or acute glomerulonephritis [3] [4]. Other causes of MH include pregnancy-related eclampsia, hyperaldosteronism, and the conditions triggering excess circulating catecholamines like sympathomimetic drug intake or autonomic dysfunction after spinal cord injury [5].

Epidemiology

The prevalence of hypertension is very high. In USA, 30% of the population suffer from hypertension [6] [7], while worldwide it has been estimated that around 26% of the population is affected by this cardiovascular condition. Statistical data show that 1% to 2% of these people will experience a hypertensive crisis at some point of their life [8] [9].

MH is much more frequent in men than women, and many studies reveal that it is more common in elderly and black people [2] [10] [11]. The prevalence of hypertension and MH is expected to increase substantially over the next few decades, due to aging of the global population. MH prevalence is also substantially favored by the lack of incurrence, absence of primary care and noncompliance with prescribed treatments [12] [13].

Sex distribution
Age distribution

Pathophysiology

The factors underlying the development of hypertension and MH are still unclear and poorly understood. However, it is believed that the starting point of this process is the rise of systemic vascular resistance which increases blood pressure. This in turn brings about a mechanical stress and an endothelial injury which increases permeability, activates coagulation cascade and platelets, and causes fibrin deposition. In this condition, ischemia begins to develop and additional vasoactive mediators are released, which foster the ongoing injury. The systemic vasoconstriction caused by the volume depletion due to pressure natriuresis and the renin-angiotensin system activation brings about a decrease in blood flow towards vital organs, which then leads to the final consequent injury of the organs concerned.

Damages mainly regard the central nervous system with injuries like encephalopathy and seizures, the cardiovascular system with injuries like chest pain and aortic dissection, and the renal system with like oliguria and azotemia [11] [5] [14] [15].

Prevention

Close outpatient follow-up for hypertension is the most important measure to avoid future episodes of MH. Therefore, patients are highly recommended to refer to a specialist to organize an effective preventive plan. The plan should also include a diet low in fat and daily physical activity, both well known to have beneficial effects on the entire cardiovascular system.

Summary

Malignant hypertension (MH) is defined by a systolic blood pressure greater than 210 mmHg and a diastolic blood pressure greater than 130 mmHg. It implies a rapid deterioration of vital organ function which brings about some severe clinical consequences such as encephalopathy, retinopathy, renal failure, and myocardial ischemia. MH is very similar to accelerated hypertension, both in terms of clinical outcomes and therapies involved, even though MH is characterized by the typical sign of papilledema, that is the swelling of the optic disc.

Patient Information

Malignant hypertension (MH) is a type of high blood pressure (hypertension) which results in the impairment of one or more organ systems, especially the central nervous system, the heart and vessels, and the kidneys. MH is defined by a systolic blood pressure greater than 210 mmHg and a diastolic blood pressure greater than 130 mmHg. There are many causes of MH, the most common of which is essential hypertension frequently undiagnosed or not properly treated. Very common are also clinical conditions secondary to kidney diseases and procedures, such as kidney transplant, artery stenosis, or acute glomerulonephritis.

Common signs and symptoms of MH are:

The use of antihypertensive drugs is the most important treatment for MH. There are many classes of antihypertensive drugs and their choice is based on the cause of the hypertensive crisis, the severity of the condition, and the usual blood pressure before the hypertensive crisis itself. 

Close follow-up for hypertension is the most important measure to avoid future episodes of MH. Therefore, patients are highly recommended to refer to a specialist to organize an effective preventive plan. The plan should also include a diet low in fat and daily physical activity, both well known to have beneficial effects on the entire cardiovascular system.

References

Article

  1. Thomas L. Managing hypertensive emergencies in the ED. Can Fam Physician 2011 57 (10): 1137–97. 
  2. Hyman DJ, Pavlik VN. Characteristics of patients with uncontrolled hypertension in the United States [published correction appears in N Engl J Med. 2002;346:544]. N Engl J Med. 2001;345:479-486. 
  3. Lip GY, Beevers M, Beevers G. The failure of malignant hypertension to decline: a survey of 24 years' experience in a multiracial population in England. J Hypertens. 1994;12:1297-1305. 
  4. Guerin C, Gonthier R, Berthoux FC. Long-term prognosis in malignant or accelerated hypertension. Nephrol Dial Transplant. 1988;3:33-37. 
  5. Kaplan NM. Kaplan's clinical hypertension, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006. 
  6. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA. 2003;290:199-200. 
  7. Ong KL, Cheung BM, Man YB, et al. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999-2004. Hypertension. 2007;49:69-75. 
  8. McRae RP Jr, Liebson PR. Hypertensive crisis. Med Clin North Am. 1986;70:749-767. 
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Last updated: 2019-06-28 10:36