What is accelerated hypertension?

Accelerated Hypertension

Accelerated hypertension is defined as severe elevation of blood pressure (typically with diastolic BP >120 mmHg) with vascular damage manifested as retinal hemorrhages and exudates but without papilledema, which distinguishes it from malignant hypertension. 1

Clinical Definition and Distinction

Accelerated hypertension is part of a spectrum of severe hypertensive states that includes:

• Accelerated hypertension: Severe BP elevation with retinal hemorrhages and exudates but no papilledema
• Malignant hypertension: Severe BP elevation (diastolic BP usually >140 mmHg) with vascular damage including retinal hemorrhages, exudates, AND papilledema 1, 2

Both conditions represent a breakdown of autoregulation due to arterial walls being continuously exposed to extremely high blood pressure levels. This leads to pathological changes including:

• Myointimal proliferation
• Fibrinoid necrosis of small arterioles
• Fluid leakage into extracellular space
• Small hemorrhages
• Target organ damage 1

Risk Factors and Demographics

• More common in economically deprived populations
• Higher prevalence among:
  • Current smokers
  • Black individuals (more frequently affected than Caucasians)
  • Patients with poorly treated essential hypertension
  • Patients with secondary causes of hypertension 1

Clinical Manifestations

Patients with accelerated hypertension may present with:

• Headache
• Visual disturbances
• Disturbed mental status
• Deterioration in renal function (prognostically important)
• Hematological abnormalities (hemolysis, red blood cell fragmentation)
• Evidence of disseminated intravascular coagulation 1, 2

Diagnostic Approach

1. Confirm elevated BP (typically >180/120 mmHg) with proper technique and appropriate cuff size
2. Perform fundoscopic examination to identify retinal hemorrhages and exudates (without papilledema)
3. Evaluate for target organ damage:
   • Neurological assessment
   • Basic metabolic panel
   • Urinalysis
   • Electrocardiogram
   • Consider chest X-ray if respiratory symptoms are present 2

Management

Accelerated hypertension requires prompt but controlled blood pressure reduction:

• Target: Reduce mean arterial pressure by 20-25% within the first 24 hours, not immediate normalization 2
• Setting: Typically requires hospitalization for close monitoring
• Approach: More gradual BP reduction compared to hypertensive emergencies with acute end-organ damage

Prognosis and Importance of Treatment

When untreated, accelerated/malignant hypertension has an extremely poor prognosis. The prevalence has diminished due to:

• Earlier treatment of hypertension
• More efficient therapeutic programs
• Decrease in predisposing causes 1

Important Distinctions in Hypertensive Crisis Classification

It's crucial to distinguish between:

1. Hypertensive emergency: Severe BP elevation (>180/120 mmHg) WITH evidence of acute target organ damage 1, 2
2. Hypertensive urgency: Severe BP elevation (>180/110 mmHg) WITHOUT evidence of acute target organ damage 1, 2
3. Accelerated/malignant hypertension: Specific forms of hypertensive emergency characterized by retinal findings and vascular damage 1

The clinical presentation and evidence of target organ damage, rather than absolute BP values, should guide management decisions and the urgency of intervention.