malignant hypertension

Last edited 09/2019

This is a distinctive form of hypertension characterised by vascular fibrinoid necrosis and loss of precapillary arteriolar autoregulation. It is a medical emergency as blood pressure may rise acutely - to a diastolic level greater than 130 mm Hg.

Suggested indications for referral to secondary care include:

• if there is urgent treatment indicated
  • severe hypertension (e.g. 220/120 mmHg)
  • impending complications e.g. TIA
  • NICE suggest (1):
    
    

    • identifying who to refer for same-day specialist review

      • if a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral, carry out investigations for target organ damage as soon as possible:
        • if target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
        • If no target organ damage is identified, repeat clinic blood pressure measurement within 7 days
          
          
      • refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:
      • signs of retinal haemorrhage or papilloedema (accelerated hypertension) or
      • life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury
        
        
      • refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis)
        

Malignant hypertension may complicate the course of both essential and secondary hypertension. Occasionally, it may be the initial manifestation of high blood pressure.

Reference:

• NICE (August 2019). Hypertension - management of hypertension in adults in primary care.