| Malignant high blood pressure occurs because of a narrowing of blood vessels (vasoconstriction) that lead to acute and severe increase in blood pressure beyond the control of the body's autoregulation system. The result is an acute increase in vascular resistance with reduced blood flow throughout the body. The condition is characterized by swelling of the optic disc (papilledema), destruction of arteries and arterioles, and related organ damage. The level of cardiac, renal, and cerebral function at the time of the emergency is as critical as the acceleration of blood pressure itself. Systolic pressure is usually greater than 180 mm Hg. Diastolic blood pressure is in the range of 120 to 140 mm Hg. Serious organ damage due to insufficient local blood flow to the organs may occur if therapy is not begun promptly to reduce blood pressure. Organ failure can lead to death.
Any hypertensive condition can progress to a hypertensive emergency, especially untreated essential hypertension. Essential hypertension is the underlying diagnosis in 50% of hypertensive crises (Schwartz). Other risk factors associated with this condition include renovascular hypertension, acute kidney disease (glomerulonephritis), chronic kidney failure (renal failure), inflammation of vessels in the kidney (renal vasculitis), collagen vascular disease (e.g., scleroderma), a type of tumor called pheochromocytoma, sudden discontinuance of drug therapy, or a condition in pregnancy characterized by hypertension (eclampsia or pre-eclampsia). Often the underlying cause for the hypertensive emergency is unknown.Risk: Malignant high blood pressure is more common in individuals who are young, black, or male. Incidence and Prevalence: Malignant hypertension occurs in 1% to 5% of individuals with high blood pressure. |
Source: Medical Disability Advisor
| History: Symptoms may include headache, irritability, restlessness, confusion, prolonged drowsiness, blurred vision, nausea, vomiting, malaise, dizziness, chest pain, palpitations, or shortness of breath. Blood pressure will be elevated to an extreme and often occurs suddenly. Individuals may report previously diagnosed essential hypertension or hypertension related to renal disease, diabetes, or cardiovascular disease. A history of anti-hypertensive drug therapy may be revealed or the individual may report discontinuing a drug regimen recently, or adding a drug that actually elevates blood pressure. Surprisingly, in some individuals the condition is discovered without their awareness of any symptoms. Physical exam: An exam shows both systolic blood pressure and diastolic blood pressure readings accelerating rapidly (usually to 180 and 130 mm Hg or higher respectively). Symptomatic evidence of damage to organ systems may be noted. Retinal examination may reveal damage to the retina at back of the eye (retinopathy) and swelling of the head of the optic nerve (papilledema). Tests: The diagnosis of malignant hypertension is based on accelerated hypertension and the involvement of or damage to other organ systems as a result of vasoconstriction. Cerebral, renal, cardiac, and vascular function will be evaluated generally, beginning with a chest x-ray, an electrocardiogram, and laboratory tests to evaluate the impact severe hypertension may be having on blood flow to the heart, kidneys and brain. Blood tests may reveal signs of anemia, coagulation disorders, or elevated levels of renin (a vasoconstrictive kidney enzyme elevated in some forms of hypertension), and aldosterone (hormone elevated in hypertension); abnormalities such as these are indicative of acute organ system dysfunction. A complete blood count (CBC) will determine red and white blood cell counts and hemoglobin level, possibly indicating anemia; red blood cell volume (hematocrit), which may show more fluid than cells, indicative of edema and fluid imbalance; and a platelet count, which may reveal coagulation problems. A differential blood smear will be done to look for red blood cell fragments indicative of red blood cell destruction (hemolysis or hemolytic anemia), which severely affects the oxygen carrying capacity of the blood and causes widespread organ damage. Blood chemistries, including measurements of blood urea nitrogen, blood glucose, creatinine, renin, aldosterone, and electrolytes, will help evaluate organ system response to the acute rise in blood pressure. Urinalysis may show gross hematuria and the presence of abnormal protein (albumin) levels; blood and protein in the urine indicate progressive kidney involvement (hypertensive nephropathy). Microscopic analysis of urine sediment may reveal red cells and red cell casts, indicating kidney dysfunction. |
Source: Medical Disability Advisor
| Malignant hypertension requires immediate hospitalization, often in an intensive care unit. The goal of treatment is to lower the blood pressure and to stabilize and reverse the damage to target organs. Antihypertensive drugs are given promptly to gradually reduce systolic and diastolic pressure to levels somewhat above normal, usually reducing pressure by 10% to 20% in the first hour and thereafter another 10% to 15% (Elliot). Although intravenous antihypertensive drug therapy is usually indicated, oral drugs can also be used successfully in some individuals. The type of antihypertensive drug administered will depend on its mode of action and the nature of specific organ dysfunction. Therapy may also include a diuretic to remove excess fluid from the body. If acute renal failure is involved, dialysis may be needed to remove fluid and wastes from the body until kidney function can be restored. When the underlying cause for the hypertensive emergency is known, it can be treated appropriately. |
Source: Medical Disability Advisor
| The prognosis varies between individuals and depends primarily on the degree of renal damage. Without prompt and aggressive treatment, malignant hypertension will be fatal. Death is typically due to brain damage, renal damage, or myocardial infarction (heart attack). The availability of more effective antihypertensive drug therapies has improved the prognosis for hypertensive crises significantly. With antihypertensive treatment, individuals have a 1-year survival rate of 90% and a 5-year survival rate of 75% to 80%. |
Source: Medical Disability Advisor
| Because malignant high blood pressure is typically an emergency requiring immediate treatment in the hospital, rehabilitation for this form of high blood pressure begins after the underlying cause has been identified and treated. As with rehabilitation for other forms of high blood pressure, an exercise program developed by a healthcare professional is important and focuses on aerobic exercise designed to reduce blood pressure.
Rhythmic forms of moderate exercise are used in the rehabilitation of most forms of high blood pressure. These exercises include jogging, bicycling, and swimming. The benefits come from the expansion of the blood vessels in the working muscles, decreasing total resistance in blood vessels throughout the body and enhancing blood flow. In the hospital setting, an electrocardiograph will be used to record the continuous electrical activity of the heart muscle during these exercises. A physical therapist experienced in cardiac rehabilitation keeps a daily log of the individual's blood pressure, heart rate, and cardiac rhythm.
Throughout the course of rehabilitation for high blood pressure, patient and family education is necessary to establish a program the individual can continue once discharged from the care of the rehabilitation professional. If the individual enjoys exercising with machines, the more common units that may be recommended are the treadmill, NordicTrack, rowing machine, stair stepper and the bicycle. Studies have shown that the treadmill burns 40% more calories than the bicycle.
A 6-month exercise program contributes to a decrease in the resistance of blood flow within the body. This results in a subsequent decrease in blood pressure. Because most individuals who have survived malignant high blood pressure are managed with medication, it is important that the therapist has a medication history for each individual to help understand the individual's acute and chronic response to exercise, which may be altered by a specific drug. |
Source: Medical Disability Advisor
| Possible complications include acute brain dysfunction, fluid accumulation in the lungs (pulmonary edema), kidney damage (nephropathy), renal failure, damage to the retina at the back of the eye (retinopathy), insufficient blood supply to the heart muscle, and heart failure or heart attack (myocardial infarction). |
Source: Medical Disability Advisor
| Work restrictions or special accommodations need to be determined on an individual basis. They depend on the degree of organ damage or impairment resulting from the hypertension. Employability may be affected if the patient is a commercial driver, pilot or works in another situation where blood pressure must be controlled. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Has diagnosis of malignant hypertension been confirmed?
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Have other conditions with similar symptoms been ruled out?
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Has the underlying cause of malignant hypertension been identified?
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Has individual experienced any complications related to the malignant hypertension?
Regarding treatment:
- Has blood pressure been stabilized? Was blood pressure successfully sustained at acceptable levels?
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Has individual sustained organ damage? Is damage reversible?
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If renal failure was involved, was dialysis necessary? Are kidneys again functional?
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If the underlying cause for the condition is known, has it responded favorably to treatment?
Regarding prognosis:
- Does individual's condition continue to be monitored by a physician?
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Has individual responded favorably to antihypertensive treatment?
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Has blood pressure remained within acceptable limits?
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Did individual sustain permanent organ damage?
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Does individual have a coexisting condition, such as coronary artery disease or renovascular disease that may complicate treatment or impact recovery?
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Is the individual participating in a comprehensive rehabilitation program?
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Source: Medical Disability Advisor
| Elliot, W. "Hypertensive Emergencies." Critical Care Clinics 17 2 (2001): 435-451.Schwartz, Gary L., and Sheldon G. Sheps. "Hypertension." Medscape. 6 May. 2004. WebMD Inc. 17 Dec. 2004 <http://www.medscape.com/viewarticle/474790>. |
Source: Medical Disability Advisor
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