Malignant hypertension

Alternative Names

Accelerated hypertension; Arteriolar nephrosclerosis; Nephrosclerosis - arteriolar; Hypertension - malignant; High blood pressure - malignant

Definition

Malignant hypertension is very high blood pressure that comes on suddenly and quickly. The lower (diastolic) blood pressure reading, which is normally less than 80 mmHg, is often above 130 mmHg.

Causes

The disorder affects about 1% of people with high blood pressure, including both children and adults. It is more common in younger adults, especially African-American men.

It also occurs in people with:

• Collagen vascular disorders (such as systemic lupus erythematosus, systemic  sclerosis,and periarteritis nodosa)
• Kidney problems
• Toxemia of pregnancy

You are at high risk for malignant hypertension if you have had:

• Kidney failure
• Renal hypertension caused by renal artery stenosis

Symptoms

• Blurred vision
• Change in mental status, such as: Anxiety, confusion, decreased alertness, decreased ability to concentrate, fatigue, restlessness, sleepiness, stupor, lethargy
• Chest pain (feeling of crushing or pressure)
• Cough
• Headache
• Nausea or vomiting
• Numbness of the arms, legs, face, or other areas
• Reduced urine output
• Seizure
• Shortness of breath
• Weakness of the arms, legs, face, or other areas

Exams and Tests

Malignant hypertension is a medical emergency.

A physical exam commonly shows:

• Extremely high blood pressure
• Swelling in the lower legs and feet
• Abnormal heart sounds and fluid in the lungs
• Changes in thinking, sensation, muscle ability, and reflexes

An eye examination will reveal changes that indicate high blood pressure, including:

• Bleeding of the retina (back part of the eye)
• Narrowing of the blood vessels in the retina
• Swelling of the optic nerve
• Other problems with the retina

Kidney failure, as well as other complications, may develop.

Tests to determine damage to the kidneys may include:

• Arterial blood gas analysis
• BUN
• Creatinine
• Urinalysis

A chest x-ray may show congestion in the lung and an enlarged heart.

This disease may also affect the results of the following tests:

• Aldosterone level
• Cardiac enzymes (markers of heart damage)
• CT scan of the brain
• Electrocardiogram (EKG)
• Renin level
• Urinary sediment

Treatment

You will need to stay in the hospital until the severe high blood pressure is under control. Medications will be given through a vein to reduce your blood pressure.

If there is fluid in your lungs, you will be given medicines called diuretics, which help the body remove fluid. Your doctor will consider giving you medications to protect the heart if there is evidence of heart damage.

After the severe high blood pressure is brought under control, blood pressure medicines taken by mouth can control blood pressure. Your medication may need to be changed sometimes. High blood pressure can be difficult to control.

Outlook (Prognosis)

Many body systems are at serious risk from the extreme rise in blood pressure. Many organs, including the brain, eyes, blood vessels, heart, and kidneys may be damaged.

The blood vessels of the kidney are very likely to be damaged by pressure. Kidney failure may develop, which may be permanent and need dialysis (kidney machine).

If treated right away, malignant hypertension can often be controlled without causing permanent problems. If it is not treated right away, complications may be severe and life-threatening.

Possible Complications

• Brain damage (stroke, seizures)
• 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)

When to Contact a Medical Professional

Go to the emergency room or call your local emergency number (such as 911) if you have symptoms of malignant hypertension. This is an emergency condition and it can be life-threatening.

Call your health care provider if you know you have poorly controlled high blood pressure.

Prevention

If you have high blood pressure, carefully monitor your blood pressure and take your medicines properly to help reduce the risk. Eat a healthy diet that is low in salt and fat.

References

Badr KF, Brenner BM. Vascular injury to the kidney. In: Fauci A , Kasper D, Longo DL, et al, eds. Harrison's Principals of Internal Medicine. 17th ed. New York, NY: McGraw Hill; 2008:chap 280.

Shayne P, Stettner E. Hypertension. In: Wolfson AB, Hendey GW, Ling LJ, et al, eds. Harwood-Nuss' Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009:chap 89.