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| {{Infobox_Disease |
| | '''For patient information, click [[Malignant hypertension (patient information)|here]]''' |
| Name = {{PAGENAME}} |
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| Image = |
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| Caption = |
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| DiseasesDB = 7788 |
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| ICD10 = {{ICD10|I|10||i|10}} |
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| ICD9 = {{ICD9|401.0}}<ref>http://medaphase.net/Newsletter/ViewArticle.asp?ArticleID=20</ref> |
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| ICDO = |
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| OMIM = |
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| MeshID = D006974 |
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| {{SI}}
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| {{CMG}}
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| ==Overview==
| | {{Malignant hypertension}} |
| '''Malignant hypertension''' is a complication of [[hypertension]] characterized by very elevated [[blood pressure]], and organ damage in the [[eye]]s, [[brain]], [[lung]] and/or [[kidney]]s. It differs from other complications of hypertension in that it is accompanied by [[papilledema]]. [[Systolic]] and [[diastolic]] [[blood pressure]]s are usually greater than 200 and 140, respectively.
| | {{CMG}} ; {{AE}} {{ADI}} |
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| ==Diagnosis
| | {{SK}} Accelerated hypertension; hypertension - malignant; high blood pressure - malignant. |
| ===Symptoms=== | | ==[[Malignant hypertension overview|Overview]]== |
| The most common presentations of hypertensive emergencies at an emergency department are chest pain (27%), [[dyspnea]] (22%), and neurologic deficit (21%). The primary cardiac symptoms are [[Angina pectoris|angina]], [[myocardial infarction]], and [[pulmonary edema]]. Orthostatic symptoms may be prominent. Neurologic presentations are occipital [[headache]], cerebral infarction or hemorrhage, visual disturbance, or hypertensive [[encephalopathy]] (a symptom complex of severe hypertension, headache, vomiting, visual disturbance, mental status changes, seizure, and retinopathy with papilledema). Medications or drugs that may cause a hypertensive emergency include [[cocaine]], monoamine oxidase inhibitors (MAOIs), and oral contraceptives; the withdrawal of beta-blockers, alpha-stimulants (such as [[clonidine]]), or [[alcohol]], steroids also may cause hypertensive emergency. [[Renal]] disease may present as oliguria ([[renal failure]]) or any of the typical features of renal failure. Gastrointestinal symptoms are nausea and vomiting.
| | ==[[Malignant hypertension historical perspective|Historical Perspective]]== |
| | | ==[[Malignant hypertension pathophysiology|Pathophysiology]]== |
| ===Physical===
| | ==[[Malignant hypertension causes|Causes]]== |
| ====Cardiovascular system==== | | ==[[Malignant hypertension differential diagnosis|Differentiating Malignant hypertension from other Diseases]]== |
| Blood pressure must be checked in both arms to screen for [[aortic dissection]] or [[coarctation]]. If coarctation is suspected, blood pressure also should be measured in the legs. Screen for carotid or renal bruits. Listen for a third or fourth heart sound or murmurs. Volume status should be assessed, with orthostatic vital signs, examination of jugular veins, assessment of liver size, and investigation for peripheral edema and pulmonary rales.
| | ==[[Malignant hypertension epidemiology and demographics|Epidemiology and Demographics]]== |
| | | ==[[Malignant hypertension risk factors|Risk Factors]]== |
| ====Central nervous system====
| | ==[[Malignant hypertension natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| A complete neurologic examination is needed to screen for localizing signs. Focal neurologic signs might not be attributable to encephalopathy. Focal signs mandate screening for subarachnoid hemorrhage, infarct, or the presence of a mass. A funduscopic examination may reveal silver wiring (Grade I retinopathy), AV nipping (Grade II) flame-shaped retinal hemorrhages, soft exudates (Grade III), or papilledema (Grade IV).
| | ==Diagnosis== |
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| ==Lab tests==
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| Lab studies include a [[complete blood count]] and [[electrolyte]]s, [[coagulation]] profile, and [[urinalysis]], [[cardiac enzymes]], urinary [[catecholamines]], [[thyroid-stimulating hormone]] (TSH), and 24-hour urine collection for [[vanillylmandelic acid]] (VMA) and catecholamines.
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| Renal function should be evaluated through a [[urinalysis]], complete chemistry profile, and [[complete blood count]]. Expected findings include elevated [[BUN]] and [[creatinine]], [[hyperphosphatemia]], [[hyperkalemia]] or [[hypokalemia]], glucose abnormalities, [[acidosis]], [[hypernatremia]], and evidence of [[microangiopathic hemolytic anemia]]. Urinalysis may reveal [[proteinuria]], microscopic [[hematuria]], and RBC or [[hyaline cast]]s. In patients with [[hyperaldosteronism]] (a secondary cause of hypertension), aldosterone promotes renal potassium wasting, resulting in low serum potassium.
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| The chest radiograph is useful for assessment of cardiac enlargement, [[pulmonary edema]], or involvement of other thoracic structures, such as rib notching with aortic coarctation or a widened [[mediastinum]] with [[aortic dissection]]. Other tests, such as head CT scan, transesophageal echocardiogram, and renal angiography, are indicated only as directed by the initial workup. The ECG is necessary to screen for ischemia, infarct, or evidence of electrolyte abnormalities or drug overdose.
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| | [[Malignant hypertension history and symptoms|History and Symptoms]] | [[Malignant hypertension physical examination|Physical Examination]] | [[Malignant hypertension laboratory findings|Laboratory Findings]] | [[Malignant hypertension electrocardiogram|Electrocardiogram]] | [[Malignant hypertension x ray|X Ray]] | [[Malignant hypertension CT|CT]] | [[Malignant hypertension MRI|MRI]] | [[Malignant hypertension echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Malignant hypertension other imaging findings|Other Imaging Findings]] | [[Malignant hypertension other diagnostic studies|Other Diagnostic Studies]] |
| ==Treatment== | | ==Treatment== |
| The most commonly used intravenous drug is [[nitroprusside]]. An alternative for patients with renal insufficiency is intravenous [[fenoldopam]]. [[Labetalol]] is another common alternative, providing easy transition from IV to oral (PO) dosing. Beta-blockade can be accomplished intravenously with [[esmolol]] or [[metoprolol]]. [[Hydralazine]] is reserved for use in pregnant patients, while [[phentolamine]] is the drug of choice for a [[pheochromocytoma]] crisis. iv sodium nitroprusside should be used with caution as it can cause a rapid uncontrollable drop in blood pressure.
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| ==Natural history , Complications and Prognosis==
| | [[Malignant hypertension medical therapy|Medical Therapy]] | [[Malignant hypertension surgery|Surgery]] | [[Malignant hypertension primary prevention|Primary Prevention]] | [[Malignant hypertension secondary prevention|Secondary Prevention]] | [[Malignant hypertension cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Malignant hypertension future or investigational therapies|Future or Investigational Therapies]] |
| Prior to effective therapy, life expectancy was less than 2 years, with most deaths resulting from [[stroke]], renal failure, or [[heart]] failure. The survival rate at 1 year was less than 25% and at 5 years was less than 1%. With current therapy, including dialysis, the survival rate at 1 year is greater than 90% and at 5 years is 80%. The most common cause of death is cardiac, with stroke and renal failure also common. The single greatest prognostic factor in malignant hypertension is renal function, with renal insufficiency secondary to malignant nephrosclerosis being strongly associated with poorer outcomes.
| | ==Case Studies== |
| | [[Malignant hypertension case study one|Case #1]] |
| | == Related Chapters == |
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| ==References==
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| {{reflist|2}}
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| ==See also==
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| * [[Hypertensive emergency]] | | * [[Hypertensive emergency]] |
| * [[Hypertension]] | | * [[Hypertension]] |
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| | [[Category:Disease]] |
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