Malignant Hypertension

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Malignant Hypertension

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Malignant hypertension, also known as a hypertensive emergency, is high blood pressure together with acute impairment of one or more organ systems of the body. Those most commonly involved are the central nervous, cardiovascular, and renal (kidney) systems.

The condition is characterized by a systolic blood pressure of at least 180 or a diastolic pressure of over 120 and it can cause irreversible organ damage.


Around 50 million American adults suffer from hypertension every year and of those, one percent (500,000 individuals) develops malignant hypertension. Although this is a relatively low complication percentage, it does cause severe morbidity in these patients.


Stopping the use of anti-hypertensive medication may lead to malignant hypertension.

Other factors that can lead to this complication include glomerulonephritis, renovascular hypertension, pre-eclampsia and eclampsia, autonomic hyperactivity, head trauma, collagen-vascular diseases, neoplasias, and using stimulant drugs such as amphetamines and cocaine.

Signs and symptoms

The following are signs and symptoms of malignant hypertension:

  • Headaches
  • Nosebleeds (epistaxis)
  • Faint spells
  • Shortness of breath
  • Heart palpitations
  • Chest pain
  • Vomiting
  • Agitation
  • Severe anxiety
  • Sensation of numbness in parts of the body
  • Formation of exudates or hemorrhage of the retina on examination of the back of the eyes
  • Papilledema
  • Protein and/or blood being present in the urine


The diagnosis of malignant hypertension is done based on the combination of symptoms as mentioned above. This would include a systolic blood pressure of over 180 or a diastolic pressure of over 120 together with papilledema.

The cause of malignant hypertension would need to be investigated further by performing the appropriate blood tests and imaging investigations.


The management of malignant hypertension will depend on the condition, how severe the increase in blood pressure is, and what the usual blood pressure of the patient was before the problem developed.

The most important aspect regarding the management of malignant hypertension is that reduction in blood pressure needs to be performed smoothly. The goal is to decrease the pressure by 25 percent over a few minutes to one or two hours, and then get it to around 160/100 within a time period of about two to six hours. If the blood pressure is reduced very quickly, then there’s an increased chance of reducing blood flow to important areas such as the heart and brain resulting in a possible myocardial infarct (heart attack) or cerebrovascular incident (stroke), respectively.

Intravenous administration of sodium nitroprusside has an almost immediate effect on high blood pressure and may be suitable to be used in this situation. This medication may not be readily available though and it also has a risk of resulting in cyanide poisoning. Other medications such as nicardipine, nitroglycerine, phentolamine, fenoldopam, or labetalol can also be used although their effect is delayed by a few minutes compared to sodium nitroprusside.

Surgical procedures may have to be performed where these medications are not effective enough to reduce the blood pressure in patients with end-stage kidney failure. These include surgeries such as laparoscopic nephrectomy (removal of a kidney), open nephrectomy, and renal artery embolization in cases where patients are considered to be an anesthetic risk.