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Malignant Hypertension

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Updated May 08, 2007

Malignant hypertension is a rare but very serious form of high blood pressure. Officially, malignant hypertension is defined as severe hypertension that occurs along with internal bleeding of the retinas in both eyes and swelling of optic nerves behind the retinas. Malignant hypertension must be treated quickly to avoid serious organ damage and, possibly, death. All the major organ systems are at risk from the severe blood pressure elevations present in malignant hypertension, but the kidneys, eyes, and brain seem to be most at risk. The kidneys are especially sensitive to increases in blood pressure and permanent kidney damage is a common complication of untreated malignant hypertension. Most of this organ damage is caused by ruptures in small blood vessels in places, which is why retinal bleeding (which has small blood vessels) is included in the diagnostic criteria for malignant hypertension.

What Causes Malignant Hypertension?

Like high blood pressure in general, the exact cause of malignant hypertension is not completely understood. The details of how malignant hypertension starts have been an important research topic for many years, and while the complete picture is still emerging, we do know a few important things:

  • Younger patients are at higher risk than older patients, which is the opposite of the risk profile for essential hypertension
  • Those of African heritage are at higher risk
  • Anyone with a history of kidney failure or a disease called renal artery stenosis (narrowing of arteries in the kidney) has a greatly increased risk
  • Pregnant women with gestational hypertension, or women experiencing certain pregnancy related complications (toxemia of pregnancy) appear to have an increased risk
Overall, malignant hypertension is very rare, affecting only about one percent of people with high blood pressure. The serious nature of the disease, however, makes it an important problem.

What are the Symptoms of Malignant Hypertension?

Because malignant hypertension affects organ systems that are directly sensitive to blood pressure (kidneys, eyes, brain, cardiovascular system), the symptoms of the disease tend to be those you would associate with problems in these other organ systems. For example, some symptoms include:

  • Blurry vision
  • Chest pain
  • Seizure
  • Decreased urine output
  • Weakness or strange tingling/numbness in the arms, legs, or face
  • Headache
  • Shortness of breath
These symptoms are not exclusive to malignant hypertension, but are generally associated with a number of potentially serious medical conditions like heart attack, stroke, or kidney problems. If you have any of these symptoms, you should seek medical care immediately.

How is Malignant Hypertension Treated?

People with malignant hypertension should always be admitted to the hospital for close observation and treatment. Depending on how serious the problem is in a particular patient, admission to the Intensive Care Unit (ICU) may be required. During the hospital stay, intravenous medications are the main focus of therapy. Some drugs commonly used to reduce blood pressure in this situation are nitroprusside and nitroglycerin. A number of blood tests will also be checked, probably several times, to assess the status of the kidneys and other organs. Sometimes, more complicated tests may be required, and pictures of the heart or other organs may be taken using an echo machine or an ultrasound machine. If treated quickly, malignant hypertension has a good prognosis. After leaving the hospital, it is common for patients prescribed medicines like beta blockers or ACE inhibitors to keep the blood pressure under control in the future.

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Sources:

Scarpelli PT, et al. Continuing Follow Up of Malignant Hypertension. Journal of Nephrology, 15(4):431-7.

Hsu, CY. Does Non-Malignant Hypertension Cause Renal Insufficiency? Evidence Based Perspective. Current Opinions in Nephrological Hypertension, 11(3):267-72.

Fleming, S. Malignant Hypertension - The Role of the Paracrine Renin-Angiotensin System. Journal of Pathology, 192(2):135-9.

Lip, GY, et al. Severe Hypertension with Lone Bilateral Papilloedema: A Variant of Malignant Hypertension. Blood Pressure, 4(6): 339-42.

Nadar S, et al. Echocardiographic Changes in Patients with Malignant Phase Hypertension: The West Birmingham Malignant Hypertension Register. Journal of Human Hypertension, 19(1):69-75.

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