You may have heard of high blood pressure or hypertension. But, have you ever heard of malignant (malignant) hypertension? Malignant hypertension is an attack of high blood pressure that has an acute impact and damages one or several organ systems in the body. This condition is so serious that it is considered an emergency. If you think you or someone else has malignant hypertension, visit the nearest hospital immediately.
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Part 1 of 3: Recognizing the Symptoms of Malignant Hypertension
Step 1. Distinguish between normal and malignant hypertension
In ordinary hypertension, blood pressure can be lowered gradually over several weeks or months with strict medical care. In malignant hypertension, the condition must be controlled immediately with intravenous blood pressure lowering drugs. If not controlled, blood pressure will damage the blood vessels in the brain, eyes, kidneys, and heart. If you have malignant hypertension, your doctor will assess and treat certain symptoms you are experiencing.
- Malignant hypertension is an archaic term from the 1920s. Today, this condition is more commonly referred to as a hypertensive emergency. A hypertensive emergency is when your systolic blood pressure is above 180 and your diastolic blood pressure is above 120
- About 1/3 of Americans have hypertension, but only 1% have malignant hypertension or hypertensive crisis. The rest just had normal hypertension.
Step 2. Determine if there is brain damage
If you have very high blood pressure, your doctor will also check for symptoms of damage to your body's central nervous system:
- Severe headache, especially when you wake up. This is the most common symptom seen, even if you are the visible symptom.
- Vomiting, without other gastrointestinal symptoms (eg diarrhea).
- Blurred vision
- stroke
- convulsions
- Head trauma.
- Swelling of the optic disc in the eye. The doctor will dilate the pupil to see the disc, which usually has neat edges. If you have malignant hypertension, your doctor will see a disc that is blurry with irregular edges.
- Slight bleeding in the eye. Usually this is caused by the rupture of small blood vessels in the eye due to high blood pressure.
Step 3. Determine if there is any damage to the heart
Symptoms of malignant hypertension rarely affect the heart of the sufferer. Symptoms may appear as shortness of breath when inactive, active, or lying down. This is because fluid can collect in the lungs when the heart tries to pump against it. You may also feel pain in your chest as your heart tries to force blood out against the high blood pressure supplying your heart. Your doctor will perform a physical exam to look for symptoms consistent with congestive heart failure, such as:
- The jugular vessels are prominent in the neck.
- Blood rises up the jugular vessels in the neck when your heart is pushed (hepatojugular reflux)
- We swell (pedal edema)
- A third or fourth heart sound called a “gallop” due to the condensation of the ventricles of the heart with blood (can be seen on the EKG)
- Chest X-ray evidence of congestive heart failure, fluid in the lungs, or an enlarged heart.
- Chemicals produced by congestive heart ventricles (type B Natriuretic Peptides and Troponins). These chemicals can be found with laboratory tests and some additional tests if the doctor thinks the damage is caused by something else.
Step 4. Determine if there is damage to the kidneys
Your doctor will run laboratory tests on your kidneys to determine your kidney function. Renal and nerve test findings are usually found together in malignant hypertension. Your doctor will check:
- Swelling of the legs (pedal edema).
- A rustling sound in your renal arteries (renal bruit) which indicates an obstruction to blood flow.
- Protein in your urine analysis. Since the kidneys are supposed to filter protein, this indicates that the kidney's filtering unit is damaged by a strong increase in blood pressure.
- Ratio of Blood Urea Nitrogen (Blood Urea Nitrogen or BUN) and Creatinine (Creatinine or Cr) in the blood. The normal BUN/Cr ratio is 1, and increases by 1 daily due to kidney damage. For example, a BUN/Cr ratio of 3 indicates kidney damage has occurred for 3 days.
Step 5. Distinguish between primary and secondary malignant hypertension
Primary malignant hypertension means normal hypertension that runs suddenly increases and damages the body's organs. Secondary malignant hypertension is caused by another disease. The doctor will order additional lab tests or imaging studies to diagnose the cause. Treating hypertension by lowering blood pressure is important, but curing the disease that causes it is equally important. Here are some secondary causes of malignant hypertension (and their treatments):
- Pregnancy (eg preeclampsia): The best treatment is delivery of the baby, but the symptoms can be temporarily treated with medication if the baby's lungs are not fully developed and the mother shows neurological symptoms. During pregnancy, hypertensive emergencies should be treated with magnesium sulfate, methyldopa, hydralazine, and/or labetalol.
- Cocaine use/overdose, treated as primary malignant hypertension.
- Alcohol withdrawal: Medications (benzodiazepines) are used to treat malignant hypertension due to alcohol withdrawal.
- Discontinue beta blockers: Stopping beta blockers or hypertension medications suddenly may cause a reverse effect so beta blockers will be prescribed to treat this hypertension
- Breaking alpha blockers (clonidine)
- Renal artery stenosis, or narrowing of the renal arteries leading to the kidneys. The treatment is surgery (angioplasty) to widen the arteries.
- Pheochromocytoma: Tumor of the adrenal gland that is usually treated by removing the tumor.
- Coactarition of the aorta, which is a shortening of the aorta which is a congenital defect. Treatment is carried out by surgery.
- Hypothyroidism: Treatment is with drugs, surgery, or beta blockers.
- Aortic dissection, which is a tear in the aorta. The treatment is carried out with surgery within a few hours because this condition is very life-threatening.
Part 2 of 3: Using Drugs
Step 1. Talk to your doctor about medications for malignant hypertension
Because there are many factors to consider when diagnosing hypertension, there are no standard guidelines in pharmacology or medical therapy that can be recommended. Your doctor will evaluate your medical history and current condition before starting treatment right away.
Your doctor will need to know the use of the medication (especially if there is an underlying cause of malignant hypertension), the resources available at the medical facility, and the level of medical expertise available
Step 2. Prepare for medical treatment
The doctor will immediately try to reduce the blood pressure level to a safe level within 1 hour (usually a decrease of 10-15%). Your blood pressure should continue to drop in the next 24-48 hours, while you are in intensive care. Your doctor will then stop using the intravenous or oral agent to prepare you for discharge.
Treatment for malignant hypertension is always intravenous drugs/agents. When the use is ended, you will be given medication in the same class in smaller amounts
Step 3. Start with labetalol
Labetalol is a beta blocker that counteracts the effects of epinephrine and adrenaline. You will be given this medicine if you have a heart attack (myocardial infarction or angina) due to malignant hypertension. This drug works quickly to reduce blood pressure and is an easy-to-adjust intravenous drug.
Because the lungs also have beta-receptors, labetalol is not administered directly to patients with pulmonary edema from malignant hypertension
Step 4. Use nitroprusside to dilate blood vessels and improve blood flow
Nitroprusside is a vasodilator, a drug used to widen or open blood vessels so that blood pressure is quickly reduced. Because the drug pumps intravenous (IV) infusions constantly, the dose can be changed in the range of 0.25-8.0 g/kg/min. A sensor line is required to be inserted into the femoral artery so that it can be continuously monitored.
- You will continue to be monitored while receiving nitroprusside. Because this drug acts quickly, the drop in blood pressure may occur too quickly. This condition can endanger the amount of blood that enters the brain. Fortunately, the dosage of this drug is easy to adjust.
- Fenoldopam is another fast acting vasodilator agent and is recommended for patients with renal failure.
Step 5. Dilate blood vessels using Nicardipine
Nicardipine is a calcium-channel blocker that works with calcium channel cells in smooth muscle in blood vessels.
Nicardipine is easily adjusted for optimal blood pressure control. This drug is also easily diverted to eating medications, eg Verapamil
Step 6. Use drugs that are rarely used
Depending on your medical needs, your doctor may treat you with one of the following intravenous medications:
- Hydralazine: Used to control malignant hypertension in pregnant women for the safety of the fetus.
- Phentolamine: Used specifically if you are confirmed to have malignant hypertension due to a tumor of the adrenal glands (pheochromocytoma).
- Lasix: Used to complement the treatment of malignant hypertension. This drug is a diuretic, so it causes a lot of urination. This drug is useful if you have pulmonary edema or congestive kidney failure as a symptom of hypertension.
- Enalapril: an ACE inhibitor that works by blocking the dilation of blood vessels, but it can also be used for kidney failure.
Part 3 of 3: Controlling Blood Pressure
Step 1. Work closely with your doctor
You must comply with the treatment advice of the doctor. Don't delay and be consistent about visiting your doctor. You need to work together to meet the goal for your blood pressure, usually, the target blood pressure goal is less than 140/90.
Step 2. Maintain a low sodium diet
Make sure you consume a maximum of 2,000 mg of sodium each day. Too much sodium will increase blood pressure and make you vulnerable to the risk of heart attack and stroke. Make sure you eat fresh fruits and vegetables and stay away from processed foods. These foods can be high in sodium.
Resist the temptation to buy canned food, because it usually contains salt to preserve the color and freshness of the food. If you buy canned food, look for canned foods that are low in sodium and without salt
Step 3. Exercise to improve heart function
Although your activities will be limited until you are discharged from the hospital, you can resume normal activities and exercise once your blood pressure has stabilized. You can do aerobics (cardio), weight or resistance training, and isometric resistance training. All these exercises will reduce diastolic and systolic blood pressure. Systolic blood pressure measures the pressure when the heart contracts while diastolic blood pressure measures the pressure when the heart is at rest between beats.
Adults should exercise for a total of 2 hours 30 minutes a week, according to the Surgeon General. Try doing moderate-intensity exercise, such as walking, cycling, or swimming
Step 4. Lose weight, if you are obese
If you are obese, your arteries have to work harder to supply the body with blood, increasing blood pressure. Determine your Body Mass Index (BMI) using an online calculator. According to the Center of Disease Control, you are obese if you have a BMI of 30 or more. Strive to lose weight and BMI to between 25-30.
Reduce calorie intake and exercise regularly. This is the safest way to lose weight
Step 5. Quit smoking
Smoking decreases the amount of oxygen that gets to the heart, raises blood pressure, increases blood clotting, and damages cells that line the coronary arteries and other blood vessels. If you are a smoker, you are more susceptible to developing hypertension, which can progress to malignant hypertension.
