Malignant hypertension: Difference between revisions

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{{Infobox_Disease |
'''For patient information, click [[Malignant hypertension (patient information)|here]]'''
  Name          = {{PAGENAME}} |
  Image          = |
  Caption        = |
  DiseasesDB    = 7788 |
  ICD10          = {{ICD10|I|10||i|10}} |
  ICD9          = {{ICD9|401.0}}<ref>http://medaphase.net/Newsletter/ViewArticle.asp?ArticleID=20</ref> |
  ICDO          = |
  OMIM          = |
  MedlinePlus    = |
  MeshID        = D006974 |
}}
{{SI}}
{{CMG}}


==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}}
 
==Causes==
* [[Cocaine]]
* [[Monoamine oxidase inhibitors]] (MAOIs)
 
* Oral contraceptives
 
* Withdrawal of beta-blockers,
 
* Alpha-stimulants (such as [[clonidine]])
 
* [[Alcohol]]
 
* Steroids
 
* [[Renal]] disease
 
 
 
==Natural history , Complications and Prognosis==
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.


{{SK}} Accelerated hypertension; hypertension - malignant; high blood pressure - malignant.
==[[Malignant hypertension overview|Overview]]==
==[[Malignant hypertension historical perspective|Historical Perspective]]==
==[[Malignant hypertension pathophysiology|Pathophysiology]]==
==[[Malignant hypertension causes|Causes]]==
==[[Malignant hypertension differential diagnosis|Differentiating Malignant hypertension from other Diseases]]==
==[[Malignant hypertension epidemiology and demographics|Epidemiology and Demographics]]==
==[[Malignant hypertension risk factors|Risk Factors]]==
==[[Malignant hypertension natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
==Diagnosis==
==Diagnosis==
===Symptoms===
The most common presentations of hypertensive emergencies at an emergency department are
* [[Chest pain]] (27%)
* [[Dyspnea]] (22%)
*  Neurologic deficit (21%)
The primary cardiac symptoms are
* [[Angina pectoris|angina]]
* [[Myocardial infarction]]
* [[Pulmonary edema]]
* [[Orthostatis]]
* [[Headache]]
* [[Visual disturbance]]
* [[Nausea]] and [[Vomiting]]
===Physical examination===
====Cardiovascular system====
* Blood pressure must be checked in both arms to screen for [[aortic dissection]] or [[coarctation]].
* Carotid or renal bruits.
* Third or fourth heart sound or murmurs.
* Orthostatic vital signs
* Examination of jugular veins
* Assessment of liver size
* Pedal edema and pulmonary rales.
====Central nervous system====
* Hypertensive [[encephalopathy]] (a symptom complex of severe hypertension, headache, vomiting, visual disturbance, mental status changes, seizure, and retinopathy with papilledema)
* Focal neurologic signs
* Focal signs of 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).
==Lab tests==
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.
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.
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.


[[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.


==References==
[[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]]
{{reflist|2}}
==Case Studies==
[[Malignant hypertension case study one|Case #1]]
== Related Chapters ==


==See also==
* [[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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Latest revision as of 20:08, 22 February 2013

For patient information, click here

Malignant hypertension Microchapters

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Patient Information

Overview

Historical Perspective

Pathophysiology

Causes

Differentiating Malignant hypertension from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X Ray

CT

MRI

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]

Synonyms and keywords: Accelerated hypertension; hypertension - malignant; high blood pressure - malignant.

Overview

Historical Perspective

Pathophysiology

Causes

Differentiating Malignant hypertension from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | X Ray | CT | MRI | Echocardiography or Ultrasound | Other Imaging Findings | Other Diagnostic Studies

Treatment

Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Case Studies

Case #1

Related Chapters


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