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| {{SK}} Accelerated hypertension; hypertension - malignant; high blood pressure - malignant. | | {{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== |
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| == Overview == | | [[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== |
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| 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.
| | [[Malignant hypertension medical therapy|Medical Therapy]] |
| | | ==Case Studies== |
| == Causes ==
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| * [[Cocaine]]
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| * [[Monoamine oxidase inhibitors]] (MAOIs)
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| * [[Oral contraceptives]]
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| * Withdrawal of [[beta-blockers ]]
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| * Alpha-stimulants (such as [[clonidine]])
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| * [[Alcohol]]
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| * [[Steroids]]
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| * [[Renal]] disease
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| == Natural history , Complications and Prognosis ==
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| 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.
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| == Diagnosis ==
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| === Symptoms ===
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| The most common presentations of hypertensive emergencies at an emergency department are
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| * [[Chest pain]] (27%)
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| * [[Dyspnea]] (22%)
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| * Neurologic deficit (21%)
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| The primary cardiac symptoms are
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| * [[Angina pectoris|angina]]
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| * [[Myocardial infarction]]
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| * [[Pulmonary edema]]
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| * [[Orthostatis]]
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| * [[Headache]]
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| * [[Visual disturbance]]
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| * [[Nausea]] and [[Vomiting]]
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| === Physical examination ===
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| ==== Vital Signs ====
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| * Blood pressure must be checked in both arms to screen for [[aortic dissection]] or [[coarctation]].
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| * Orthostatic vital signs
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| ==== Eyes ====
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| * 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)
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| ==== Head and Neck ====
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| * Examination of jugular veins
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| * Carotid bruits
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| ==== Heart ====
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| * Third or fourth heart sound or murmurs.
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| ==== Lungs ====
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| * [[Pulmonary rales]]
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| ==== Abdomen ====
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| * Renal bruits
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| * Assessment of liver size
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| ==== Extremities ====
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| * [[Pedal edema]]
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| ==== Neurologic ====
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| * Focal neurologic signs
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| * Focal signs of [[subarachnoid hemorrhage]], [[infarct]], or the presence of a mass.
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| ===Laboratory Findings===
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| * [[Complete blood count]]
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| * [[Electrolyte]]s
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| * [[Coagulation]] profile
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| * [[Urinalysis]]
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| * [[Cardiac enzymes]]
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| * urinary [[catecholamines]]
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| * [[Thyroid-stimulating hormone]] (TSH)
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| * 24-hour urine collection for [[vanillylmandelic acid]] (VMA) and catecholamines.
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| * [[BUN]], [[creatinine]]
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| Urinalysis may reveal
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| * [[Proteinuria]]
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| * Microscopic [[hematuria]]
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| * RBC or [[hyaline cast]]s.
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| In patients with [[hyperaldosteronism]] (a secondary cause of hypertension), aldosterone promotes renal potassium wasting, resulting in low serum potassium.
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| === Electrocardiogram ===
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| The ECG is necessary to screen for ischemia, infarct, or evidence of electrolyte abnormalities or drug overdose.
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| === Chest X ray ===
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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.
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| == Treatment ==
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| 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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| == References ==
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| {{reflist|2}}
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| == Related Chapters == | | == Related Chapters == |