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Revision as of 18:13, 22 February 2013

For patient information, click here

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]

Overview

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.

Causes

Natural history , Complications and Prognosis

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.

Diagnosis

Symptoms

The most common presentations of hypertensive emergencies at an emergency department are

  • Neurologic deficit (21%)

The primary cardiac symptoms are

Physical examination

Vital Signs

Eyes

  • A funduscopic examination may reveal silver wiring (Grade I retinopathy), AV nipping (Grade II) flame-shaped retinal hemorrhages, soft exudates (Grade III), or papilledema (Grade IV)

Head and Neck

  • Examination of jugular veins
  • Carotid bruits

Heart

  • Third or fourth heart sound or murmurs.

Lungs

Abdomen

  • Renal bruits
  • Assessment of liver size

Extremities

Neurologic

  • Focal neurologic signs

Laboratory Findings

Urinalysis may reveal

In patients with hyperaldosteronism (a secondary cause of hypertension), aldosterone promotes renal potassium wasting, resulting in low serum potassium.

Electrocardiogram

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

Chest X ray

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.

Treatment

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.

References

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