Malignant hypertension

doc. Malignant hypertension

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By: Ala'a Fadhel Hassan
5
th
stage, Pharmacy dept.
Hospital Training


Supervised by: Dr.Anas

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Definition
Malignant hypertension is very high blood pressure that comes on suddenly
and quickly. The lower (diastolic) blood pressure reading, which is normally around
80 mmHg, is often above 130 mmHg (1)
It is a rare but very serious form of high blood pressure. Officially, defined as severe
hypertension that occurs along with internal bleeding of the retinas in both eyes
and swelling of optic nerves behind the retinas (2)
Alternative Names
Accelerated hypertension; arteriolar nephrosclerosis; Hypertension - malignant;
High blood pressure – malignant (1)
Causes, incidence & risk factors
Malignant hypertension is not a single disease entity but rather, a
syndrome in which the hypertension can be either primary (essential) or secondary
to any one of a number of different causes (3)

The disorder affects about 1% of people with high blood pressure, including both
children and adults. It is more common in younger adults,( which is the opposite
of the risk profile for essential hypertension), especially African-American men(1)
in which the underlying cause is almost always essential hypertension that has
entered a malignant phase (2)
Anyone with a history of kidney failure or a renal artery stenosis (narrowing of
arteries in the kidney) has a greatly increased risk(3) .History of primary renal
parenchymal disorders is The most common secondary causes of malignant
hypertension( Chronic glomerulonephritis is thought to be the cause of
malignant hypertension in up to 20% of cases)(2)
Pregnant women with gestational hypertension, or women experiencing certain
pregnancy related complications (toxemia of pregnancy) appear to have an
increased risk(3)
It also occurs in people with Collagen vascular disorders(1)
Drug Related Malignant Hypertension(MAO Inhibitors, Cold Preparations,
Withdrawal Antihypertensive Medicines as" Clonidine, -Blockers"&“Street
drugs" Cocaine, PCP)(4)

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Clinical presentation
Symptoms of Malignant Hypertension
Because malignant hypertension affects organ systems that are directly
sensitive to blood pressure (kidneys, eyes, brain, cardiovascular system), the
symptoms of the disease tend to be those associate with problems in these other
organ systems. For example, some symptoms include:
Blurry vision
Chest pain
Seizure
Decreased urine output
Weakness or strange tingling/numbness in the arms, legs, or face
Headache
Shortness of breath
These symptoms are not exclusive to malignant hypertension, but are
generally associated with a number of potentially serious medical conditions like
heart attack, stroke, or kidney problems (2)
Physical Examinations and Tests
Malignant hypertension is a medical emergency in which the physical exam
commonly shows:
Extremely high blood pressure
Swelling in the lower legs and feet
Abnormal heart sounds and fluid in the
lungs
Changes in thinking, sensation, muscle
ability, and reflexes
An eye examination will reveal changes that
indicate high blood pressure, including:
Bleeding of the retina
Narrowing of the blood vessels in
the eye area
Swelling of the optic nerve
Other problems with the retina

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Kidney failure, as well as other complications, may develop. (1)


Tests to determine damage to the kidneys may include:
Arterial blood gas analysis
BUN
Creatinine
Urinalysis
A chest x-ray may show congestion in the lung and an enlarged heart.
This disease may also affect the results of the following tests:
Aldosterone level
Cardiac enzymes (markers of heart damage)
CT scan of the brain
Electrocardiogram (EKG)
Renin level
Urinary sediment(1)

Principles of Therapy
Lower B.P. over hours, Initial goal B.P.  160’s/90’s
Too rapid lowering may cause dire consequences (CVA, MI)
May take several days to get to reasonable levels
Avoid medications that cannot be controlled (sublingual nifedipine)
For most patients the greatest risk of treating a hypertensive
emergency is the risk of accompanying hypotension.
Treat with short acting, easily titratable, I.V. drug(4)
Drug Dosage Onset Duration
Adverse
Effects
Indication(I)
Contraindication(C)
Vasodilators
Nitropru-
sside
0.3-10
mcg/kg/mi
n
1-2
min
1-2 min
N/V, muscle
twitching ,
cyanide,
I: CHF, aortic dissect,
Catechol.

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IV
infusion
Thiocyanide
tox. &
intracranial
pressure
C: hepatic, renal
insufficiency
Nitrogly-
cerin (IV)
5-100
mcg/kg/
min
2-5
min
3-5 min
Head ache,
dizziness,
vomiting,
methemgl-
obin
&tolerance
I: coronary dis., CHF
C: CVA, Intracranial
pressure
Diazoxide
( IV)
1-3
(mg/kg)
IV
bolus,
q5-15
/min;
repeat
every 4-
24 hr as
needed
2-4
min
3-12 hr
Nausea,
hypoten-
sion ,
flushing,
tachycardia
, hypergly-
cemia,
aggravat-
ion of
angina&
fluid
retention
C: Syndromes of
coronary insufficiency,
(unless used with beta-
blocking agent),
cerebrovascular
accident& hypersensi-
tivity to sulfonamides
Fenoldo-
pam
mesylate
0.1-1.7
mcg/kg/
min (IV
infusion)
5-15
min
1-4 hr
Headache,
dizziness,
flushing,
increased
intraocular
pressure,
Hypokal-
emia& dose
related
tachycardia
I: Severe hyperten-
sion with renal
insufficiency
C: Glaucoma
Hydrala-
zine HCl
10-20
mg IV
or IM
bolus,
(maxim
um
dose,
40 mg)
10-20
min
3-8 hr Tachy-
cardia,
flushing,
headache
,vomiting
&
aggravat-
ion of
angina
I: CHF
C: Coronary
insufficiency, aortic
dissection,
cerebrovascular
accident (may
increase intracranial
pressure)
Enalaprilat
(IV)
1.25-5
mg q6
15 min
6 hr Precipit-
ous drop
I: CHF
C: Use with caution in
patients with severe

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hr IV in blood
pressure
in high
renin st.
renal insufficiency (not
receiving dialysis)
Nicardi-
pine HCl
5-15
mg/hr
IV
infusion
5-20
min
1-2 hr Tachycar
dia,
headache
,flushing,
local
phlebitis
C: Greater than first-
degree heart block,
CHF
Adrenergic Inhibitors
Phentol-
amine
-
blocker
5-20 mg
IV,
repeat
as
necess-
ary
1-2
min
10-30 min
Tachycardia
, nausea,
flushing,
abdominal
pain& aggr-
avation of
angina
I: Catecholamine
excess
C: Syndromes of
coronary
insufficiency
Esmolol
HCl
200-500
mcg/kg/
min
over 1-4
min,
then 50-
300
mcg/kg/
min IV
infusion
1-2
min
10-20
min
Hypoten-
sion,
nausea,
bradycar-
dia or
heart
block&
dizziness
I: Syndromes of
coronary
insufficiency
C: Greater than first-
degree heart block,
CHF
Labetalol
HCl
- blocker
20-80
mg IV
bolus,
(maxim
um
dose,
300 mg
2-10
min
2-4 hr Hypoten-
sion,
nausea,
itching,
scalp
tingling&
dizziness
I: Syndromes of
coronary insuffi-
ciency, catechol-
amine excess
C: first-degree heart
block, CHF,
bronchial asthma

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References:
(1) Medline Plus-A service of the U.S. national library of
medicine
Malignant hypertension, causes, symp . &…
http://www.nlm.nih.gov/medlineplus/druginformation.html
(2) A.D.A.M. Medical Encyclopedia.
Malignant hypertension
http://www.ncbi.nlm.nih.gov/pubmedhealth/
(3) Hypertension & The Kidney
Chapter 8 (Hypertensive Crises) by Charles R. Nolan
(4) Hypertension Emergencies & Urgencies
By Stephen S. Levin, D.O.

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