A CASE OF MALIGNANT
HYPERTENSION
DR ANN HOLMES GPST2
CASE
 Px, 56, c/o loss of central vision R eye,
blurred vision L +mild generalised headache.
 ∆hypertension 5yrs ago but had stopped
taking tablets entirely 12/12 ago due to £
issues. Previously on 3 meds but can’t recall
names. Feels well otherwise. PMH
unremarkable. Smokes 5/day; <14U ETOH
 GP refers: BP 200/130, ?papilloedema
 Ophthalmoscopy: frank papilloedemaGd IV hypertensive retinopathy
 ECG: LVH
 Urine dipstix: protein++++, trace blood
 Hb13; ur9,creat240,eGFR14 glucose N
LFTs N, neuro exam NAD
 Mild leg pitting oedema
 Moved to HDU, arterial line, catheterised,
labetolol+GTN infusions
 Further investigations: cortisol, TFTs,
nephritic screen, myeloma screen, urine
alb:creat ratio, urgent renal USS+CT head,
renin-angiotensinogen levels, urine 24hr
metanephrine+catecholamines, lipid profile
 Renal, endocrine+ophthalmology teams
informed
 Renal artery angiography
 HDU for 6/7 whilst BP slowly reduced.
 Antihypertensives recommenced with
omission of ACE inhibitors.
 ∆ Malignant hypertension secondary to
severe renal artery stenosis:
 R 100% occlusion; L 80%
 Candidate for possible
revascularization
 How common is it?
 In 1964, Holley et al data from 295 autopsies
performed in their institution during a 10month period. The mean age at death was 61
years. The prevalence rate of renal artery
stenosis was 27% of 256 cases identified as
having history of hypertension, while 56%
showed significant stenosis (>50% luminal
narrowing), and, among normotensive
patients, 17% had severe renal artery
stenosis (>80% luminal narrowing). Among
those older than 70 years, 62% had severe
renal artery stenosis. Similar results with
other studies.
Causes of Renovascular
hypoperfusion
 Atheroma>90%
 Takayasu’s arteritis>60% in Indian
subcontinent+Far East
 Fibromuscualar hyperplasia
 Rarely:PAN,AVM,neurofibramatosis
 NB Renal artery stenosis prevalence
cauc:black 2:1
 Numerous referrals with high BP >180
systolic and headache…
 Definition of malignant hypertension?
 Severe hypertension with WITH papilloedema
+ end organ damage
 Primary care: Urine dipstix key
?proteinuria+/-blood; ophthalmoscopy. ECG
 NOT diagnosed on numbers alone
 <1% hypertensives develop: rare
 Cause: Essential hypertension in 80%
Blacks, 2-30% Caucasians; renal disease the
rest
 High BPloss of autoregulation; endothelial
injury, vascular smooth muscle
hypertrophy+collagen depositionluminal
narrowing with ischaemia+infarction of end
organs
 Concurrent pressure triggered
natriuresis+SNS stimulationfurther BP
 Mortality 90% at 1yr if untreated
NICE hypertension 2011
 Severe hypertension (syst>180 or
diastol>110) at diagnosis:
 Same day referral if accelerated
hypertension with papilloedema/retinal
haems + BP>180/110 or suspect
phaeochromocytoma
 Otherwise assess for end organ damage,
don’t wait for ambulatory BP/serial BD home
recordings+consider starting treatment with
A/C +review
 A/C if <55 +C+D;stepwise addition of therapy
 Review 1/52ly or sooner post med change for
progress aiming for <140/90 if <80 (<150/90
if >80; 130/80 if DM
 Then further diuretic/low dose
spironolactone dep on K/-blocker if not
tolerated
 Monitor U+Es within 1/12
 Refer if not controlled on 4 meds
 Check compliance
 Px education-address lifestyle issues
 CVD risk factor assess+manage
references
 http://www.patient.co.uk/doctor/Ren
al-Vascular-Disease.htm
 http://emedicine.medscape.com/artic
le/245023-overview
 Clinical opthalmology 3rd edn:Kanski
p369
 NICE guidelines 2011 hypertension