Signs and symptoms
The eyes may show retinal hemorrhage or an exudate. Papilledema must be present before a diagnosis of malignant hypertension can be made.
The brain shows manifestations of increased intracranial pressure, such as headache, vomiting, and/or subarachnoid or cerebral hemorrhage.
Patients will usually suffer from left ventricular dysfunction.
The kidneys will be affected, resulting in hematuria, proteinuria, and acute renal failure.
It differs from other complications of hypertension in that it is accompanied by papilledema. This can be associated with hypertensive retinopathy.
Other signs and symptoms can include:
- Chest pain
- Arrhythmias
- Headache
- Epistaxis
- Dyspnea
- Faintness or vertigo
- Severe anxiety
- Agitation
- Altered mental status
- Paresthesias
- Vomiting
Treatment
Several classes of antihypertensive agents are recommended, with the choice depending on the etiology of the hypertensive crisis, the severity of the elevation in blood pressure, and the usual blood pressure of the patient before the hypertensive crisis. In most cases, the administration of an intravenous sodium nitroprusside injection, which has an almost immediate antihypertensive effect, is suitable (but in many cases not readily available). In less urgent cases, oral agents like captopril, clonidine, labetalol, or prazosin can be used, but all have a delayed onset of action (by several minutes) compared to sodium nitroprusside. Controlled bloodletting is an effective salvage therapy in the interim when nitroprusside is unavailable, and aggressive oral therapy has not yet taken effect.
In addition, non-pharmacological treatment could be considered in cases of resistant malignant hypertension due to end stage renal failure, such as: surgical nephrectomy, laparoscopic nephrectomy and renal artery embolization in cases of anesthesia risk.
It is also important that the blood pressure be lowered smoothly, not too abruptly. The initial goal in hypertensive emergencies is to reduce the pressure by no more than 25% (within minutes to 1 or 2 hours), and then toward a level of 160/100 mm Hg within a total of 2–6 hours. Excessive reduction in blood pressure can precipitate coronary, cerebral, or renal ischemia and, possibly, infarction.
The diagnosis of a hypertensive emergency is not based solely on an absolute level of blood pressure, but also on the typical blood pressure level of the patient before the hypertensive crisis occurs. Individuals with a history of chronic hypertension may not tolerate a "normal" blood pressure.
