Malignant Hypertension

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Malignant Hypertension
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Specialty scores for Malignant Hypertension

Overview

Malignant hypertension is the medical condition of acute and sustained, significantly elevated blood pressure. Symptoms may include headache, vomiting, loss of balance, visual disturbances, and confusion. Disease onset is generally sudden and complications may include target organ damage, seizures, encephalopathy syndrome, and retinal hemorrhage. It is associated with the blood pressure greater than 200/130 mmHg. This can occur in cases of pheochromocytoma, kidney failure, rapid interruption of blood pressure medication, and in pregnancy, where it is known as eclampsia. Incidence is about 2-3 new cases per 1000 population per year.

Causes:

Malignant hypertension is caused by sudden and grave increase in blood pressure. Several conditions that cause this disease include acute nephritis, eclampsia, crises in essential hypertension, cushing's syndrome, renal artery thrombosis, pheochromocytoma, and sudden withdrawal of antihypertensive treatment. Secondary causes of malignant hypertension include renovascular hypertension, primary hyperaldosteronism, and renin-secreting tumors. Autoregulation mechanism exist in the body that cause dilatation of the arterioles in response to decrease in blood pressure and constriction of the arterioles in response to increase in blood pressure. This autoregulation fails when hypertension suddenly becomes excessive. In response to acute hypertension, brain vessels spasm which results in cerebral ischemia and edema.

Signs and symptoms:

Symptoms and signs of malignant hypertension usually start soon after an acute and sustained rise in blood pressure. Severe headache, present in greater than 75% of patients, is usually the first symptom. Other features may include restlessness, alterations in consciousness, impaired judgment and memory, confusion, somnolence, irritability, nausea, vomiting, diplopia (double vision), seizures, twitching of the limbs, vision blurring, one-sided visual field defects, color blindness and stupor. Complications may occur if timely intervention is not done and include hemiparesis, intracerebral hemorrhage and aphasia.

Diagnosis:

Diagnosis for malignant hypertension is made by conducting physical examination and blood pressure measurement. To identify the underlying causes and extent of damage produced in the body, several tests can be conducted, such as blood tests, ECG, EEG, chest radiography, urinalysis, arterial blood gas (ABG) analysis, and neuroimaging of the head (CT scan & MRI scan). Electroencephalographic examination is helpful in detection of the absence of alpha waves, signifying impaired consciousness. In the patients with visual disturbances, EEG reveals slow waves in the occipital areas.

Management:

The aim of treatment in accelerated hypertension is to rapidly lower the diastolic blood pressure to about 100-105 mmHg. Ideally this should be achieved within 2-6 hours. Efforts must be taken to ensure that maximum initial fall in blood pressure does not exceed 25% of the presenting value. Reduction in mean arterial pressure by no more than 25% during the acute phase must be targeted in order to avoid cerebral hypoperfusion. Aggressive hypotensive therapy may reduce the blood pressure below the autoregulatory levels, possibly triggering the ischemic events, such as stroke or coronary disease.

Several parenteral antihypertensive agents used in the treatment of malignant hypertension include Nitroprusside (arteriolar and venous dilator), Nicardipine (arteriolar dilator), Clevidipine (calcium channel blocker), Labetalol (alpha and beta-adrenergic blocker), Fenoldopam (peripheral dopamine-1 receptor agonist), sublingual nifedipine and sublingual captopril. In patients with eclampsia, magnesium sulfate may be used. Other treatments may include anti seizure medication.