From the Guidelines
Malignant hypertension is defined as a severe BP elevation (usually >200/120 mmHg) and advanced retinopathy, characterized by the bilateral presence of flame-shaped haemorrhages, cotton wool spots, or papilloedema, as outlined in the 2019 esc council on hypertension position document 1.
Definition and Characteristics
Malignant hypertension is a hypertensive emergency that requires immediate attention to prevent further organ damage. The condition is marked by extremely high blood pressure readings, often exceeding 200/120 mmHg, accompanied by signs of advanced retinopathy, including flame-shaped haemorrhages, cotton wool spots, or papilloedema. This definition is supported by the most recent guidelines, including the 2024 esc guidelines for the management of elevated blood pressure and hypertension 1.
Key Features
The key features of malignant hypertension include:
- Severe BP elevation (usually >200/120 mmHg)
- Advanced retinopathy, characterized by:
- Flame-shaped haemorrhages
- Cotton wool spots
- Papilloedema
- Potential for acute end-organ damage, including:
- Encephalopathy
- Acute kidney injury
- Heart failure
- Retinal hemorrhages and exudates
Management
The management of malignant hypertension involves immediate hospitalization and intravenous antihypertensive therapy to gradually lower blood pressure. The goal is to reduce blood pressure by no more than 25% within the first hour, then to 160/100-110 mmHg within the next 2-6 hours, and to normal levels over the following days. This careful approach prevents complications from too-rapid blood pressure reduction, as recommended by the 2024 esc guidelines 1.
From the Research
Definition of Malignant Hypertension
- Malignant hypertension is defined as a severe form of hypertension characterized by extreme blood pressure elevation and acute microvascular damage affecting various organs, particularly the retinas, brain, and kidneys 2.
- It requires the presence of bilateral retinal hemorrhages or exudates, with or without papilledema, acute heart failure, and acute deterioration in renal function in severe hypertension 3.
- The condition is also defined by high blood pressure and acute ischemic organ damage, with a worse prognosis than other forms of hypertension, especially in black patients 4.
Diagnostic Criteria
- The diagnosis of malignant hypertension is usually based on the association of severely elevated blood pressure with a Keith and Wagener stage III or IV retinopathy 5.
- However, it has been proposed that the definition of malignant hypertension should be reconsidered to include acute hypertension with multi-organ damage (hypertension-MOD), which is characterized by acute elevation of blood pressure associated with impairment of at least three different target organs 5.
- The diagnostic criteria may also include the presence of target organ damage, such as pulmonary edema/heart failure, acute coronary syndrome, ischemic and hemorrhagic stroke 6.
Characteristics
- Malignant hypertension is a systemic disease that causes severe damage to the brain, heart, kidneys, and eyes, even in the absence of symptoms 4.
- Patients with malignant hypertension are characterized by pronounced target organ damage, including structural and functional cardiac abnormalities and renal insufficiency 3.
- The condition has a high prevalence of left ventricular mass, systolic dysfunction, renal involvement, and thrombotic microangiopathy 4.