What Is Malignant Hypertension

Overview

Blood pressure (BP) plays an essential part in the functioning of the body; it is the measure of the force that is used by the heart to pump blood around the body.¹ A lot of individuals across society experience health problems related to blood pressure. One of them is malignant hypertension. Malignant hypertension is a term used to report patients with elevated blood pressure and multiple complications (end organ damage) with poor prognoses.⁴  Individuals with problems related to high pressure are vulnerable to experiencing a hypertensive crisis, which is a sudden increase in blood pressure.¹ The measurements of BP elevation are: 

• Systolic blood pressure (SBP) greater than 180 mmHg
• Diastolic blood pressure (DBP) greater than 120 mmHg

There are two types of malignant hypertension: hypertensive emergency and hypertensive urgency.¹ Malignant hypertension is only diagnosed if papilledema is presented.² Papilledema is the presence of swelling of the optic nerve, the one that connects the eye and brain.² The most important thing to do when dealing with an episode of malignant hypertension is to lower the blood pressure within a few hours.³ 

Types of malignant hypertension

The two forms of malignant hypertension are known as: 

• Hypertensive emergency. This takes place when there is a severe elevation in blood pressure and is associated with end-organ damage.¹
• Hypertensive urgency. This happens when there are abnormally high levels of blood pressure but there are no signs of organ damage.¹

Causes of malignant hypertension

In many cases, uncontrolled high blood pressure is the main cause of malignant hypertension. However, there are also other causes, such as:^{1, 3}  

• Presence of central nervous system disorders, including traumatic brain injuries, brain bleeding or stroke. 
• Drug or medication intake. 
• Medication compliance -substance and medication withdrawal. 
• A structural heart disease takes place when there is a defect or abnormality in a part of the structure of the heart.^{1, 4} 
• Presence of adrenal disorders including renin-secreting tumour, pheochromocytoma, Conn’s syndrome and Cushing’s syndrome. 
• Renovascular diseases, including Takayasu arteritis, renal artery stenosis and polyarteritis nodosa (artery inflammation). 
• Amphetamines
• Renal parenchymal diseases, such as systemic sclerosis, systemic lupus erythematosus, tubulointerstitial nephritis, glomerulonephritis and hemolytic-uremic syndrome.
• Having comorbidities such as diabetes, obesity, history of heart disease and the use of tobacco. 

Signs and symptoms of malignant hypertension

The signs and symptoms of malignant hypertension mainly depend on each individual and the organ that has been affected. Some of the symptoms are:^1,3 

• Mood changes
• Lower back pain
• Blurred vision or other kind of vision changes
• Nausea and vomiting
• Headaches 
• Increased the temperature 
• Decreased urine output 
• Chest pain
• Delirium 

It is important to discard the possibility that the symptoms are related to other diseases such as

• Eclampsia, 
• Aortic coarctation
• Acute kidney injury
• Renal artery stenosis
• Subarachnoid haemorrhage
• Aortic dissection
• Hyperthyroidism
• Chronic kidney disease
• Hypercalcemia
• Pheochromocytoma
• Subarachnoid haemorrhage.³ 

Management and treatment for malignant hypertension

For patients with malignant hypertension, it is important to receive adequate and quick treatment to prevent end organ damage.¹ According to studies, the prognosis for patients with malignant hypertension is varied, and it depends on the response to the treatment.¹ Studies stated that there have been reported five-year survivals of 75% to 84% with the treatment and without treatment, a life expectancy of less than 24 months.¹ 

In the case of most hypertensive emergencies, the mean arterial pressure must be reduced by 10 to 20% within the first hour and by another 5 to 15% over the next 24 hours.¹ It is important to remark that the blood pressure should not be decreased too fast or too much due to the risk of ischemic damage.¹ This means that the usual target is to have a blood pressure of less than 180/120 mmHg within the first hour and less than 160/110 mmHg in the following 24 hours.¹    

The treatment for malignant hypertension will vary depending on whether it is a hypertensive emergency or a hypertensive urgency.¹ In the case that we are dealing with the first one, it requires medical intervention; a patient with a hypertensive emergency should go straight to the emergency room of a healthcare practice.¹ The treatment consists of medication to lower the blood pressure, usually given intravenously.¹ After the blood pressure is controlled within safe ranges, the treatment must continue orally.¹ In the case of hypertensive urgency, the treatment consists of taking oral medication until the blood pressure gets into a safe range.¹ Patients will not need hospitalisation or intravenous treatment.¹

Diagnosis

The process of diagnosis for malignant hypertension includes taking the patient's medical history and conducting physical examinations.¹ Those exams are necessary to determine the presence of end-organ damage associated with clinical symptoms or signs of malignant hypertension. Among those exams, we have: 

• Chest X-ray
• Levels of electrolytes and creatinine 
• Toxicology screen
• Electrocardiology
• Urinalysis 
• Cardiac biomarkers, in the case of acute coronary syndrome suspicion 
• CT/MRI of the brain when there is the presence of vomiting, nausea, neurologic symptoms, hypertensive, retinopathy, or head injury
• In case of aortic dissection, contrast CT/MRI of the chest or TEE

Complications

Most of the complications that can take place around malignant hypertension are related to the possible internal damage to organs in the body.³ Some of the complications that can take place are:³

• Intracerebral haemorrhage
• Encephalopathy
• Acute myocardial infarction
• Pulmonary edema 
• Unstable angina 
• Acute heart failure 
• Vision loss 
• Acute kidney injury
• Dissecting aortic aneurysm
• Ischemic damage due to decreasing blood pressure too quickly 

FAQs

How can I prevent malignant hypertension?

Malignant hypertension is a health condition that can be prevented; some of the following measures are:^1,3

• Regular Check-ups
• Manage high blood pressure 
• Comply with medication regimens
• Adopt a healthier lifestyle
• Reduce sugar and salt intake
• Stress management 
• Reduce alcohol and caffeine intake 
• Maintaining proper levels of hydration

Who is at risk of malignant hypertension?

Some of the patients who are at risk of experiencing malignant hypertension are the ones who have other comorbidities or health conditions, such as:^1,3

• Renal transplant
• Inadequately treated hypertension
• Renal artery stenosis
• Chronic kidney disease (CKD)

What can I expect if I have malignant hypertension?

If you or a person that you know has malignant hypertension, you might expect to experience acute and severe symptoms, hospitalisation, constant monitoring of the levels of blood pressure, studies to assess organ damage and emergency medical care.¹ 

When should I see a doctor?

You should seek medical help if you experience sudden and severe symptoms mentioned earlier in the article, especially chest pains, severe headaches and shortness of breath.¹ 

Summary

Malignant hypertension is a term used to report patients with elevated blood pressure and multiple complications (end organ damage), each with poor prognoses.¹  Individuals with problems related to high pressure are vulnerable to experiencing a hypertensive crisis, which is a sudden increase in blood pressure. The measurements of BP elevation are systolic blood pressure (SBP) greater than 180 mmHg and diastolic blood pressure (DBP) greater than 120 mmHg. Malignant hypertension is only diagnosed if papilledema is presented. There are two types of malignant hypertension: hypertensive emergency and hypertensive urgency. A hypertensive emergency takes place when there is a severe elevation in blood pressure and is associated with end-organ damage. Hypertensive urgency happens when there are abnormally high levels of blood pressure but there are no signs of organ damage. It is important to discard the possibility that the symptoms are related to other diseases such as eclampsia, aortic coarctation, acute kidney injury, or others. The treatment for malignant hypertension will vary depending on whether it is a hypertensive emergency or a hypertensive urgency. The process of diagnosis for malignant hypertension includes the patient's medical history and physical examinations. Most of the complications that can take place around malignant hypertension are related to the possible internal damage to organs in the body. You should seek medical help if you experience sudden and severe symptoms, especially chest pains, severe headaches and shortness of breath.