Malignant Hypertension Treatment & Management

Updated: Jan 13, 2017
  • Author: John D Bisognano, MD, PhD, FACP, FACC; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Treatment

Approach Considerations

Patients with malignant hypertension are usually admitted to an intensive care unit for continuous cardiac monitoring, frequent assessment of neurologic status and urine output, and administration of intravenous antihypertensive medications and fluids. Patients typically have altered blood pressure (BP) autoregulation, and overzealous reduction of BP to reference range levels may result in organ hypoperfusion.

Hypertensive urgencies do not mandate admission to a hospital. The goal of therapy is with these cases is to reduce BP within 24 hours, which can be achieved on an outpatient basis.

For more information, see Hypertension.

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Pharmacologic Therapy

The initial goal of therapy is to reduce the mean arterial pressure by approximately 25% over the first 24-48 hours. An intra-arterial line is helpful for continuous monitoring of BP. Sodium and volume depletion may be severe, and volume expansion with isotonic sodium chloride solution must be considered. [3]  Secondary causes of hypertension should be investigated.

No trials exist comparing the efficacy of various agents in the treatment of malignant hypertension. Drugs are chosen on the basis of their rapidity of action, ease of use, special situations, and convention.

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 intravenous to oral dosing. However, a trial by Peacock et al demonstrated that intravenous calcium blockers (eg, nicardipine) could be useful in quickly and safely reducing BP to target levels and seemed more effective than intravenous labetalol. [13]

Beta-blockade can be accomplished intravenously with esmolol or metoprolol. Also available parenterally are diltiazemverapamil, and enalapril. Hydralazine is reserved for use in pregnant patients, whereas phentolamine is the drug of choice for a pheochromocytoma crisis. Oral medications should be initiated as soon as possible in order to ease transition to an outpatient setting.

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Surgical Care

An approach that is being clinically investigated involves implantation of a carotid baroreflex stimulator. Early phase III results from the Rheos Pivotal Trial on continuous carotid baroreceptor pacing for resistant hypertesion with a first-generation device were equivocal on safety and efficacy, but initial results with a miniaturized second-generation device appeared promising in patients with heart failure. [14]  A phase III trial with the second-generation device for resistant hypertension has been registered. [14]

For more information, see Hypertension.

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Complications

Properly diagnosing hypertensive emergency and urgency is essential to proper triage and treatment; however, reducing BP too rapidly can result in patient harm. Specifically, overzealous reduction of BP can result in organ hypoperfusion, and target organ damage can be missed without a thorough evaluation. Note that enalapril has an unpredictable response in hypovolemic patients, with a possible uncontrolled drop in BP.

In addition, all patients should be carefully assessed for secondary causes of hypertension, and upon discharge, patients should have close follow-up care. They should know the signs and symptoms that necessitate immediate notification of a physician.

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Diet

Initially, patients treated for malignant hypertension are instructed to fast until stable. Once stable, all patients should obtain good long-term care of their hypertension, including a diet that is low in salt. If indicated, the patient should follow a diet that can induce weight loss.

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Activity

Activity is limited to bedrest until the patient is stable. Patients should be able to resume normal activity as outpatients once their BP has been controlled.

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Prevention

The best way to prevent further episodes of hypertensive emergencies is to ensure that the patient has close outpatient follow-up for hypertension treatment. This can usually be accomplished by a general medicine or family practice physician, but referral to a hypertension specialist should also be considered for patients who require complex drug therapy or additional secondary workup.

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Consultations

In patients with stroke, cardiac compromise, or renal failure, appropriate consultation should be considered. In institutions with specialists in hypertension, prompt consultation may improve the overall control of BP.

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