Malignant hypertension

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Malignant hypertension is a complication of hypertension characterized by very elevated blood pressure, and organ damage in the eyes, brain, lung and/or kidneys. It differs from other complications of hypertension in that it is accompanied by papilledema. Systolic and diastolic blood pressures are usually greater than 200 and 140, respectively.

The ECG is necessary to screen for ischemia, infarct, or evidence of electrolyte abnormalities or drug overdose.

The chest radiograph is useful for assessment of cardiac enlargement, pulmonary edema, or involvement of other thoracic structures, such as rib notching with aortic coarctation or a widened mediastinum with aortic dissection. Other tests, such as head CT scan, transesophageal echocardiogram, and renal angiography, are indicated only as directed by the initial workup.

The most commonly used intravenous drug is nitroprusside. An alternative for patients with renal insufficiency is intravenous fenoldopam. Labetalol is another common alternative, providing easy transition from IV to oral (PO) dosing. Beta-blockade can be accomplished intravenously with esmolol or metoprolol. Hydralazine is reserved for use in pregnant patients, while phentolamine is the drug of choice for a pheochromocytoma crisis. iv sodium nitroprusside should be used with caution as it can cause a rapid uncontrollable drop in blood pressure.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• Cocaine
• Monoamine oxidase inhibitors (MAOIs)

• Oral contraceptives

• Withdrawal of beta-blockers

• Alpha-stimulants (such as clonidine)

• Alcohol

• Steroids

• Renal disease

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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• Brain damage
• Heart damage, including:
  • Heart attack
  • Angina (chest pain due to narrowed blood vessels or weakened heart muscle)
  • Heart rhythm disturbances

• Kidney failure
• Permanent blindness
• Pulmonary edema (fluid in the lungs)

Prior to effective therapy, life expectancy was less than 2 years, with most deaths resulting from stroke, renal failure, orheart failure. The survival rate at 1 year was less than 25% and at 5 years was less than 1%. With current therapy, including dialysis, the survival rate at 1 year is greater than 90% and at 5 years is 80%. The most common cause of death is cardiac, with stroke and renal failure also common. The single greatest prognostic factor in malignant hypertension is renal function, with renal insufficiency secondary to malignant nephrosclerosis being strongly associated with poorer outcomes.

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