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Malignant Hypertension

Alternate Names

  • malignant hypertensive arteriolar nephrosclerosis

Definition

Malignant hypertension refers to extremely high blood pressure that can cause injury to the eyes, heart, brain, and kidneys. This can result in permanent damage to these organs and even death.

What is going on in the body?

Uncontrolled severe hypertension, or high blood pressure, causes injury to both the small and large blood vessels within the kidney, brain, heart, and eyes. The blood vessel injury is, in turn, responsible for the symptoms in each organ.

Risks

What are the causes and risks of the disease?

Some individuals have high blood pressure that has never been discovered. Others have been found to have high blood pressure but because they have not stayed in care or have not taken their medications, the blood pressure is out of control. Left untreated, the high blood pressure can lead to malignant hypertension in a small percentage of these people. Malignant hypertension is very rare in a person who has never been found to have high blood pressure before.

Prevention

What can be done to prevent the disease?

Maintaining a healthy body weight, including physical activity in everyday life, and eating a diet designed to minimize heart disease can help avoid high blood pressure. However, even with these lifestyle guidelines, many cases of high blood pressure cannot be prevented. If there is a medical cause of high blood pressure, treatment of that condition can help prevent hypertension.

Diagnosed

How is the disease diagnosed?

Malignant hypertension is diagnosed first by measuring the blood pressure itself, and then by looking for signs that vessel damage has occurred.When blood pressure is measured, there are two numbers that are reported, for example, 140/90. The top number is the systolic blood pressure, and the bottom number is the diastolic blood pressure. An example of extremely high blood pressure is 220/140.
Other signs that a person has malignant hypertension include:
  • damage to the vessels in the eyeball seen on an optical exam
  • diastolic blood pressure that is always more than 120
  • signs of congestive heart failure or chronic renal failure
  • changes in mental status, such as confusion and memory loss
These signs indicate a medical emergency. Blood pressure must be controlled quickly to avoid permanent damage to internal organs and death.

Long Term Effects

What are the long-term effects of the disease?

There are many serious long-term effects of malignant hypertension, including:
  • damage to the brain, kidneys, and heart
  • blood vessel damage to the eye, with loss of vision
  • atherosclerosis, or narrowing of the arteries
  • stroke
  • heart attack
  • chronic renal failure, a form of kidney failure that requires dialysis to filter body fluids
  • enlargement of the heart, which weakens the heart muscle and leads to congestive heart failure
  • irregular heartbeats, or arrhythmias

Other Risks

What are the risks to others?

Malignant hypertension is not contagious and poses no risk to others.

Treatments

What are the treatments for the disease?

If the malignant hypertension is caused by another condition, treating the underlying condition may lower blood pressure. There are many medications used to treat high blood pressure, including:
  • diuretics, such as hydrochlorothiazide/triamterene (i.e., Dyazide) or furosemide (i.e., Lasix)
  • beta-blockers, such as propranolol (i.e., Inderal, InnoPran) or atenolol (i.e., Tenormin)
  • angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril (i.e., Prinivil, Zestril)
  • angiotensin II receptor blockers, such as losartan (i.e., Cozaar) or valsartan (i.e., Diovan)
  • vasodilators, such as hydralazine
  • centrally acting nervous system medications, such as clonidine (i.e., Catapres)
Calcium channel blockers, such as diltiazem (i.e., Cardizem, Cartia, Dilacor, Diltia, Taztia, Tiazac), nifedipine (i.e., Adalat, Procardia), or verapamil (i.e., Calan, Covera, Isoptin, Verlean), have been used for over 20 years to treat high blood pressure.
However, the findings of 2 recent studies show that people who take a calcium channel blocker have a much higher incidence of complications than people taking other medications for high blood pressure. The findings of one study, for example, showed that the risk of heart attack was 27% greater, and the risk of congestive heart failure was 26% higher.
The American Heart Association recommends discussing the risks and benefits of the medication with a healthcare provider. The choice of medication varies depending on the person's medical history.
Beta- blockers usually are not prescribed for someone who has breathing problems such as asthma or emphysema. ACE inhibitors and diuretics to reduce fluid buildup are especially useful for an individual with kidney disease or diabetes. A person with high blood pressure may be on multiple medications.
The goal of treatment is to keep the top number of the blood pressure below 140 and the bottom number below 90. In a person with diabetes, the goal is to keep the top number below 130 and the bottom number below 85. For an individual with heart disease or kidney disease, the goal is to get the blood pressure as low as can be tolerated.

Side Effects

What are the side effects of the treatments?

Side effects vary according to the medications used. Beta- blockers can worsen asthma. Diuretics can cause dehydration and salt imbalance. Calcium channel blockers can cause swelling of the legs, as well as a higher risk of heart attack and congestive heart failure. ACE inhibitors may lead to chronic dry cough.

After Treatment

What happens after treatment for the disease?

A person who has malignant hypertension needs to continue taking the prescribed medications every day. Blood pressure may return to normal with weight loss, increased physical activity, reduction of alcohol intake, and a diet low in sodium. In most cases a person will need to continue to take blood pressure medications for life.

Monitor

How is the disease monitored?

Malignant hypertension is monitored through frequent visits to a healthcare professional. A person with high blood pressure often records blood pressure readings in between office visits. Any new or worsening symptoms should be reported to the healthcare provider.

Sources

Merck Manual 1999

Current Medical Diagnosis and Treatment 1996

Harrison's Principles of Internal Medicine 1991

Heart Disease: A Textbook of Cardiovascular Medicine, Braunwald, E., 1980

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