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Malignant Hypertension

(Hypertensive Emergency; Hypertensive Crisis; Hypertensive Urgency)

Definition

Malignant hypertension is blood pressure that is so high that it is actually causing damage to organs, particularly in the nervous system, the cardiovascular system, and/or the kidneys. One type of such damage is called papilledema, a condition in which the optic nerve leading to the eye becomes dangerously swollen, threatening vision.
This is a serious condition that requires immediate care from your doctor. Rapid treatment can prevent long-term problems. Left untreated, damage from malignant hypertension occurs quickly and can be severe, involving organ damage to blood vessels, the eyes, heart, spleen, kidneys, and brain. In particular, kidney failure may develop since the blood vessels inside the kidneys are very sensitive to high blood pressure.
Cardiovascular System and Kidneys
Placement of Blood Pressure Cuff
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Causes

In addition to having high blood pressure , medical conditions leading to the development of malignant hypertension include:
  • History of kidney disorders or failure
  • Taking certain drugs or medications, including cocaine, amphetamines, monoamine oxidase inhibitors (MAOIs), and oral contraceptives
  • History of collagen vascular 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 prescribed antihypertensive medications, particularly beta-blockers or clonidine (Catapres), which can cause a rebound effect. Medication noncompliance is the most common reason for hypertensive emergencies.

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition. You are more likely to develop malignant hypertension if you have already have essential hypertension—high blood pressure of 140/90 or higher. Your risk may increase further if you are:
  • Male
  • African American
  • A smoker

Symptoms

Malignant hypertension produces noticeable symptoms, including:
  • Chest pain
  • Difficulty breathing
  • Headache
  • Visual problems
  • Nausea and vomiting
  • Numbness/weakness of the legs, arms, face
In particular, malignant hypertension can lead to a condition called hypertensive encephalopathy. Symptoms of this condition include: headache, vomiting, blurry vision with papilledema, mental changes like anxiety , confusion, fatigue, and seizure.
If you experience any of the above symptoms, do not assume it is due to malignant hypertension. These symptoms may be caused by other health conditions, including a heart attack or other less serious disorders. If you experience any one of them, see your physician.

Diagnosis

Your doctor will ask about your symptoms and medical history, and perform a physical exam. Your blood pressure readings will probably be very high. Readings will be taken in both arms, while lying down and while standing up. A careful stethoscope exam of your heart and a detailed neurological exam will be performed. An eye exam may show signs of high blood pressure, including swelling of the optic nerve or bleeding inside the eye.
Tests may include the following:
  • Blood tests for BUN and creatinine levels to check for kidney damage
  • Chest x-ray
  • Echocardiogram or ultrasound of the heart to look for heart damage
  • Urine tests for high levels of protein, small amounts of blood or abnormally high levels or certain hormones
  • EKG to look at the heart’s electrical functioning
  • Renal duplex or ultrasound test of the kidney's arteries to look for blockage

Treatment

Since malignant hypertension is a medical emergency, treatment needs to be received quickly. Treatment options include the following:
  • Intravenous high blood pressure medications–The specific medication will be chosen based on your specific situation, including whether you are suffering from damage to your kidneys or other organs. Possible medications may include:
    • Sodium nitroprusside or nitroglycerin
    • Beta-blockers
    • Hydralazine
    • Labetalol
    • Vasotec (enalapril) and ACE-inhibitor
  • Oral high blood pressure medicines once blood pressure has been lowered from dangerous levels
  • Dialysis
If you are diagnosed with malignant hypertension, follow your doctor's instructions .

Prevention

To help reduce your chance of developing malignant hypertension, take the following steps:
  • Frequently check your blood pressure levels.
  • Report any sustained high blood pressure to your healthcare provider.
  • Take all prescribed high blood pressure medicines regularly and avoid missing doses.

RESOURCES

American Heart Association http://www.americanheart.org

National Heart, Lung, and Blood Institute http://www.nhlbi.nih.gov

CANADIAN RESOURCES

The Canadian Hypertension Society http://www.hypertension.ca

The Society of Obstetricians and Gynaecologists of Canada (SOGC) http://www.sogc.org

References

Elliot WJ. Clinical features and management of selective hypertensive emergencies. J Clin Hypertens . 2004;6(10):587-92.

Tuncel M, Ram VC. Hypertensive emergencies: etiology and management. Am J Cardiovasc Drugs . 2003;3(1):21-31.

Van den Born BJ, Honnebier UP, Koppmans RP, van Montfrans GA. Microangiopathic hemolysis and renal failure in malignant hypertension. Hypertension . February 2005;45(2):246-51.

Revision Information

This content is reviewed regularly and is updated when new and relevant evidence is made available. This information is neither intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with questions regarding a medical condition.

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