Overview
Sudden and dramatic increase in blood pressure with significant retinopathy and kidney damage.
Dizziness, headache, blurred vision, palpitations, shortness of breath, even nausea and vomiting may occur.
Blood pressure rises dramatically over a short period of time.
Reduce blood pressure immediately to avoid target organ damage
Definition
Malignant hypertension is a sudden and significant increase in blood pressure, usually systolic blood pressure >200 mmHg and/or diastolic blood pressure >120 mmHg, accompanied by headache, blurred vision, and significant retinopathy in the fundus of the eye (bilateral flaming hemorrhages, cotton wool spots, or optic papillary edema).
It is often associated with severe renal impairment and may persist with proteinuria, hematuria and tubular urine.
Malignant hypertension has a high mortality and disability rate, and early, rational, safe, and controlled antihypertensive lowering is the basis for an improved prognosis.
Pathogenesis
Malignant hypertension is a type of hypertensive emergency, and there are no accurate epidemiologic data on malignant hypertension.
The prevalence of hypertension in China is about 27.9% in the adult population aged 18 years and older, and it is estimated that there are about 245 million people suffering from hypertension, and 1%-2% of hypertensive patients can develop hypertensive emergencies [2].
Secondary hypertension such as renal artery stenosis, pheochromocytoma, and Cushing’s syndrome are more likely to develop into malignant hypertension.
Etiology
Pathogenesis
Malignant hypertension is a type of hypertensive emergency, which usually occurs as a result of poor blood pressure control due to some specific reasons or other triggers that stimulate a sudden rise in blood pressure, and the common causes are listed below.
Discontinuation of antihypertensive drugs or failure to take antihypertensive drugs as prescribed.
Taking drugs that affect the metabolism of antihypertensive drugs (non-steroidal anti-inflammatory drugs, steroids, immunosuppressants, gastric mucous membrane protective agents, etc.).
Taking sympathomimetic toxic drugs (cocaine, lysergic acid diethylamide, amphetamines, etc.).
Severe trauma, surgery.
Acute and chronic pain.
Acute infections.
Acute urinary retention.
Emotional agitation, nervousness, panic attacks.
Poor control of concomitant risk factors (e.g., smoking, obesity, hyperlipidemia, and diabetes).
Symptoms
Main Symptoms
As blood pressure continues to rise or rises sharply, patients may experience dizziness, headache, blurred vision, palpitations, shortness of breath, and even nausea and vomiting.
Complications
Malignant hypertension without timely antihypertensive treatment may lead to complications of insufficiency of vital target organs such as the heart, brain and kidneys.
Acute renal failure: oliguria, edema, azotemia, and even uremia.
Heart failure: shortness of breath, palpitations, cough, cough pink foamy sputum, lower extremity edema, abdominal distension.
Hypertensive encephalopathy: acute onset of severe headache, nausea and vomiting, impaired consciousness (blurring of consciousness, drowsiness, or even coma), common progressive retinopathy.
Acute coronary syndrome: acute chest pain, chest tightness, radiating shoulder and back pain, pharyngeal constriction, irritability, sweating, palpitations.
Acute aortic coarctation: laceration-like chest pain, different ranges of blood vessels may have corresponding clinical manifestations, such as with the loss of peripheral pulse, oliguria, anuria.
Acute cerebral infarction: aphasia, facial paralysis, tongue paralysis, hemiplegia, hemiparesis, impaired consciousness, epileptic seizures.
Acute cerebral hemorrhage: headache, projectile vomiting, may be accompanied by different degrees of consciousness disorder, hemiparesis, aphasia, dynamic onset, often progressive aggravation.
Subarachnoid hemorrhage: severe headache, nausea, vomiting, neck and back pain, impaired consciousness, convulsions, hemiparesis, aphasia.
Pre-eclampsia and eclampsia: elevated blood pressure, proteinuria, or edema in pregnant women between the 20th week of gestation and the first week after delivery, which may be accompanied by headache, dizziness, blurred vision, epigastric discomfort, and nausea, and convulsions or even coma in patients with eclampsia [3-6].
Consultation
Department of Medicine
Emergency department
Regardless of whether there is a history of hypertension or not, sudden onset of emergency symptoms such as severe headache, dizziness, nausea, vomiting, blurred vision, chest pain, and respiratory distress is recommended to go to the Emergency Department or call 120 emergency immediately.
Cardiovascular Medicine
If the general population has elevated blood pressure during a doctor’s visit or physical examination, it is important to pay attention and go to the Cardiovascular Medicine Department for consultation and treatment.
Patients with high blood pressure should go to the Department of Cardiovascular Medicine for review if they find that their blood pressure is not well controlled during daily monitoring.
Preparation
Consultation: registration, preparation of information, common questions
Tips for Consultation: Registration, Preparation of Documents, Frequently Asked Questions
Seek medical attention as soon as possible, calm down and do not delay your condition.
Preparation List
Symptom list
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Is there dizziness, headache, nausea, vomiting?
Is there oliguria, edema?
Is there shortness of breath, palpitations, cough, pink frothy sputum, lower limb edema, abdominal distension?
Is there acute onset of severe headache, nausea and vomiting, impaired consciousness (confusion, drowsiness, or even coma), blurred vision?
Is there acute chest pain, chest tightness, radiating shoulder and back pain, pharyngeal constriction, irritability, sweating, palpitations?
Is there tearing chest pain, oliguria, anuria?
Is there severe headache, projectile vomiting, impaired consciousness, facial paralysis, tongue paralysis, limb hemiparesis, hemiplegia, aphasia, convulsions?
Does the pregnant patient have elevated blood pressure, proteinuria, edema, headache, dizziness, blurred vision, epigastric discomfort, nausea, convulsions, coma?
When did the symptoms appear and how long did they last? Are there fluctuations of relief, aggravation, etc.?
Medical History Checklist
Any previous history of hypertension, medication and usual blood pressure control?
Any history of cardiovascular disease such as diabetes, hyperlipidemia, coronary heart disease, etc.?
Any history of kidney disease such as chronic nephritis?
Any history of neurological diseases such as stroke?
Checklist
Test results in the last six months, which can be brought to the doctor’s office
Laboratory tests: electrolytes, blood gas analysis; urinalysis (urine routine, urine sediment, urine microalbumin), renal function; brain natriuretic peptide, troponin, etc.
Imaging tests: cranial CT/MRI, X-ray chest radiograph, electrocardiogram, echocardiogram, chest and abdominal CT angiography, adrenal CT/MRI, renal artery ultrasound.
Eye examination: funduscopic examination.
Medication List
Medication used in the last 3 months, if available in boxes or packages, carry with you to the doctor’s office
Antihypertensives: sodium nitroprusside, nicardipine, labetalol, uradil
Diagnosis
Diagnosis based on
Medical history
History of primary hypertension, renal disease, endocrine disease, cardiovascular lesions, cranial disease, sleep apnea syndrome, hypertension in pregnancy, etc.
or history of antihypertensive medication or failure to take antihypertensive medication as prescribed, medications that affect the metabolism of antihypertensive medication or sympathomimetic toxicity, severe trauma, surgery, acute and chronic pain, acute infection, and acute urinary retention.
Clinical symptoms
Symptoms
As the blood pressure continues to rise or rises sharply, and the diastolic blood pressure continues to be ≥130 mmHg, the patient may experience dizziness, headache, blurred vision, palpitations, shortness of breath, and even nausea and vomiting.
Physical signs
Blood pressure: diastolic blood pressure >200mmHg and/or diastolic blood pressure >120mmHg.
Neurological examination: acute cerebral infarction, acute cerebral hemorrhage, subarachnoid hemorrhage, hypertensive encephalopathy and other cranio-cerebral complications can be seen as altered state of consciousness (blurred consciousness, lethargy, or even coma), meningeal irritation signs (cervical ankylosis, Kirschner’s sign, Barthelson’s sign), changes in visual field and pathological signs (Babinski’s sign).
Funduscopic examination: malignant hypertension can be seen as retinopathy under funduscopy, including bilateral flame hemorrhage, cotton wool spots, or optic papilla edema.
Laboratory tests
Urine examination
Including urine routine, urine sediment, microalbuminuria.
Urine specific gravity decreases in impaired urinary concentrating function, and there may be microalbumin, red blood cells, and occasional tubular pattern; proteinuria is seen in preeclampsia and eclampsia.
It is mainly used to assess renal function.
Electrolytes
Purpose of examination: malignant hypertension with renal impairment and heart failure often has electrolyte disorders.
Significance: Significantly higher blood potassium concentration suggests poor prognosis.
Blood gas analysis
Purpose: To assess the degree of hypoxia in malignant hypertension with shortness of breath.
Significance of the examination: severe hypoxia can be seen in arterial partial pressure of oxygen, arterial oxygen saturation decreased, and blood pH value decreased and other signs of acidosis.
Renal Function
Purpose: To assess the degree of renal impairment.
Significance: If the blood creatinine is more than 300μmol/L or the blood urea nitrogen is more than 21.42mmol/L, it suggests severe renal impairment.
Brain natriuretic peptide
Purpose: To assess the cardiac function in malignant hypertension.
Significance: Brain natriuretic peptide level is significantly elevated in malignant hypertension complicated with heart failure.
Troponin
Aim: To evaluate the presence of myocardial damage in malignant hypertension.
Significance: malignant hypertension with acute coronary syndrome may have significantly elevated troponin levels.
Imaging
Chest X-ray
Purpose of examination: to assess the cardiac and large vessel disease in patients with malignant hypertension.
Significance: Aortic dilatation and enlargement of the left heart can be seen in hypertensive patients. In patients with heart failure, heart enlargement is more obvious, and there are signs of pulmonary hemorrhage. Complicated aortic coarctation can be seen mediastinal widening.
Precautions: Remove metal objects from the body before X-ray examination; take good protection of unchecked areas, such as the protection of the genital glands.
Cranial CT
Purpose of examination: To evaluate brain injury in malignant hypertension, including hypertensive encephalopathy and acute cerebral hemorrhage.
Significance of examination: hypertensive encephalopathy may show cerebral edema changes; cerebral hemorrhage can be seen as a well-defined high-density shadow on CT.
Precautions: Remove metal objects from the body; keep still during the examination, otherwise artifacts will be produced.
Echocardiography
Purpose of examination: to assess the cardiac function of patients with malignant hypertension, including systolic function, diastolic function and left ventricular ejection fraction.
Significance: Echocardiography is more sensitive and reliable in the diagnosis of left ventricular hypertrophy when compared with electrocardiogram and chest X-ray. In patients with concomitant heart failure, heart enlargement and decreased left heart ejection fraction are seen.
Chest and abdominal CT
Purpose of examination: to assess whether malignant hypertension is complicated by aortic coarctation.
Significance: Complicated aortic coarctation can be seen in the chest and abdomen of the aortic intima-media stripping, which is the gold standard for confirming the diagnosis of aortic coarctation.
Precautions: Remove metal objects from the body; keep still during the examination, otherwise artifacts will be produced.
Adrenal CT or MRI
Purpose of examination: To assess the presence of occupations and hyperplasia on the adrenal glands.
Significance of examination: patients with aldosteronism, malignant hypertension caused by pheochromocytoma can see nodules, tumors, thickening and other manifestations on the adrenal glands.
Precautions: Remove metal objects from the body; keep still during the examination, otherwise artifacts will be produced.
Electrocardiogram
Purpose of examination: to assess whether patients with malignant hypertension have complications of cardiovascular emergencies.
Significance: ST segment changes and T wave abnormalities can be seen in patients with malignant hypertension complicated by acute coronary syndrome or aortic dissection.
Precautions: Remain still during the ECG examination and keep the electrodes away from metal objects.
Differential Diagnosis
Hypertensive subacute
Similarity: Blood pressure can be significantly increased in a short period of time.
Difference: Hypertensive subacute disease does not present obvious clinical symptoms or target organ damage.
Treatment
Aim of treatment: lowering blood pressure gradually and controlling blood pressure rapidly.
Treatment principle: The first task is to lower the blood pressure, reduce the blood pressure by 20~25% within a few hours, or reduce the diastolic blood pressure to a safe level (100~110mmHg) rapidly. The speed of blood pressure reduction should not be too fast, otherwise it will lead to insufficient blood supply to important organs. After the blood pressure is stabilized, oral medication is chosen to maintain it, and the treatment is individualized according to the patient’s condition.
General treatment
Electrocardiographic monitoring.
Open intravenous access.
Oxygen intake, keep the airway open, mechanical ventilation if necessary.
Maintain water-electrolyte balance.
Medication
Vasodilator
Commonly used drugs: such as sodium nitroprusside.
Drug effects: direct dilation of arteries and veins, so that blood pressure can be reduced faster.
Precautions: Use with caution in patients with intracranial hypertension, glaucoma or renal insufficiency.
Calcium channel blockers
Commonly used drugs: such as Nicardipine.
Effects: Dilates peripheral blood vessels, coronary arteries, renal arteries and cerebral arteries by inhibiting vascular smooth muscle contraction.
Precautions: may cause reflex heart rate acceleration. Acute left heart failure, unstable angina, intracranial hypertension, cerebral hemorrhage is prohibited.
β-blockers
Commonly used drugs: such as labetalol.
Drug effects: reduce heart rate and systolic blood pressure.
Precautions: acute left heart failure, severe bronchial asthma, liver function abnormalities are prohibited.
Alpha-blockers
Commonly used drugs: such as uradil.
Effects: Reduce vascular resistance, exert antihypertensive effect without causing reflex acceleration of heart rate.
Precautions: contraindicated during pregnancy and lactation [7-8].
Prognosis
Cure
Untreated malignant hypertension is prone to cause damage to vital target organs such as heart, brain and kidney, and even lead to death.
Timely and safe antihypertensive treatment can alleviate the condition in a short time, prevent progressive or irreversible target organ damage, and reduce mortality.
Harmfulness
If malignant hypertension is not treated in time, the condition progresses rapidly and the blood pressure rises quickly.
It can easily lead to renal function damage and eventually cause uremia, as well as hypertensive encephalopathy, acute coronary syndrome, acute aortic coarctation and other serious complications.
Daily
Daily Management
Dietary management
Reasonable diet, obese people need to control the amount of food, reduce the daily intake of calories.
Limit sodium intake, daily sodium intake should be controlled below 5g.
Limit the intake of fat and cholesterol, and advocate a diet high in protein, low in animal fat and high in vitamins.
Life management
Reduce and control weight.
Exercise moderately every day, middle-aged and elderly patients can choose walking, jogging, going up the stairs, cycling and so on.
Quit smoking and drinking.
Maintain a good work routine and get enough sleep.
Avoid mental stress, maintain good mood and avoid great joy and sorrow.
Disease monitoring
Actively treat underlying diseases, such as primary hypertension, by taking antihypertensive drugs regularly and monitoring blood pressure to keep it within a reasonable range.
Long-term, smooth and effective control of blood pressure at a normal level is recommended, and the use of antihypertensive drugs under the guidance of a doctor is recommended.
Regularly measure and record your own blood pressure and seek medical advice if your blood pressure exceeds the control target.
Prevention
Regular Physical Examination
People without underlying diseases should have their blood pressure measured 2~3 times a year in order to detect elevated blood pressure in time.
People with primary diseases should regularly monitor various indicators, such as blood, blood pressure, blood glucose, heart rate and ultrasound, electrocardiogram, ambulatory blood pressure, etc., in order to detect abnormal changes in time.
Pay attention to dietary structure
Dietary structure is rich, and fresh vegetables and fruits should be consumed daily.
Eat a low-salt, low-fat diet and avoid barbecue and pickled products.
Adjust your daily routine
Stop smoking and drinking.
Ensure proper exercise.
Avoid overwork, staying up late, and regular work and rest [9-10].