Malignant Hypertension Assessment and Management

Definition and Diagnostic Criteria

The European Society of Cardiology recommends that malignant hypertension is characterized by severe blood pressure elevation (usually >200/120 mmHg) and advanced retinopathy with bilateral retinal hemorrhages, exudates, with or without papilledema 1, 2
Advanced retinopathy with bilateral flame-shaped hemorrhages, cotton wool spots, and papilledema is a key diagnostic criterion for malignant hypertension, as stated by the European Heart Journal 3, 4

The European Heart Journal states that the breakdown of autoregulation due to arterial walls being continuously exposed to extremely high blood pressure is a key pathophysiological mechanism in malignant hypertension 3
Myointimal proliferation and fibrinoid necrosis in vascular walls, as well as spasm and forced dilatation of small arterioles, contribute to the development of malignant hypertension 3

Bilateral flame-shaped hemorrhages and cotton wool spots (Grade III retinopathy) are common findings in patients with malignant hypertension, according to the European Heart Journal 1, 2
Papilledema (Grade IV retinopathy) may be present in some patients with malignant hypertension 1
Hypertensive encephalopathy, characterized by reversible neurological alterations, is a dangerous condition associated with malignant hypertension, as reported by the European Heart Journal 3, 4

The European Society of Hypertension recommends that fundoscopy is essential and should be performed in all patients with suspected malignant hypertension 5
Basic laboratory tests, such as serum creatinine, eGFR, and urinalysis, should be used to assess for target organ damage in patients with malignant hypertension 5

The European Heart Journal states that malignant hypertension must be regarded as a hypertensive emergency, requiring prompt treatment to bring diastolic blood pressure down to 100-110 mmHg over 24 hours 3
Care should be taken to avoid extremely rapid falls in blood pressure, which may cause complications such as underperfusion of the brain, cerebral infarction, or damage to the myocardium and kidneys, as warned by the European Heart Journal 3