CLINICAL THERAPEUTICS

 Case

A 30 year old man presents with recent-

onset headaches, blurred vision, and
dyspnea. On PE, he appears very ill and
difficulty concentrating and answering your
questions. You see cotton-wool spots on a
fundoscopic exam, a displaced forceful
heart beat and a BP of 190/130. You
immediately place the patient on IV
nicardipine for treatment and admit him to
ICU.
Salient features:
 A 30 year old
 male
 recent- onset symptoms
 Headaches
 blurred vision
 dyspnea
 Cotton-wool spots on fundoscopic exam
 Displaced forceful heart beat
 BP of 190/130
 difficulty concentrating and answering `
questions

Diagnosis: Malignant hypertension

DISCUSSION

 Malignant hypertension
 also called hypertensive emergency
 characterized by a sudden and very fast rise in
blood pressure in association with papilledema
and retinal hemorrhages and exudates, and with
acute impairment of one or more organ
systems(especially the CNS,CVS and/or the
renal system) that can result in irreversible
organ damage.
 The lower (diastolic) blood pressure
reading, which is normally around 80
mmHg, is often above 130 mmHg.
Causes:

 discontinuation of antihypertensive
medications
 autonomic hyperactivity
 collagen-vascular diseases
 drug use (particularly stimulants, especially
cocaineand [[amphetamines] and their
substituted analogues])
 glomerulonephritis
 head trauma
 Preeclampsia and eclampsia,
 renovascular hypertension
Risk factors:

 HPN
 Young adults
 African- American
 men are affected more often than women.
 Pregnant
 Family history
 Obesity
 Smoking and alcohol consumption
 Lack of exercise
CLINICAL MANIFESTATIONS

 Blurred vision
 Change in mental status
 anxiety
 confusion
 decreased ability to concentrate
 fatigue
 restlessness
 Sleepiness, lethargy, stupor
 Chest pain(feeling of crushing or pressure)
 cough
 headache
 Nausea and vomiting
 Numbness of the arms, legs, face, or other areas
 Reduced urine
 dyspnea
 weakness of the arms, legs, face, or other areas
A physical exam commonly shows:

 Extremely high blood pressure

 Swelling in the lower legs and feet
 Abnormal heart sounds and fluid in the
lungs
 Changes in thinking, sensation, muscle
ability, and reflexes
 An eye examination will reveal changes
that indicate high blood pressure,
including:
 Bleeding of the retina contributing to the
formation of “cotton wool spots”
 Narrowing of the blood vessels in the
eye area
 Swelling of the optic nerve
DIAGNOSTICS:
1. Ophthalmoscopy:

The Keith-Wagener-Barker classification of the retinal changes in hypertension

Alternative
Grade Description
description
minimal narrowing of the retinal arteries Non-malignant
I
narrowing of the retinal arteries in Non-malignant
II conjunction with regions of focal
narrowing and arterio-venous nipping
abnormalities seen in Grades I and II, as Malignant
III well as retinal haemorrhages, hard
exudation, and cotton-wool spots
abnormalities encountered in Grades I Malignant
IV through III, as well as swelling of the optic
nerve head and macular star
 2. Laboratory studies

 Initial laboratory studies: complete blood cell (CBC)

count and electrolytes (including calcium), blood urea
nitrogen (BUN), creatinine, glucose, coagulation profile,
and urinalysis.

 Expected findings include elevated BUN and creatinine,

hyperphosphatemia, hyperkalemia or hypokalemia,
glucose abnormalities, acidosis, hypernatremia, and
evidence of azotemic oliguric renal failure. Urinalysis
may reveal proteinuria, microscopic hematuria, and red
blood cell or hyaline casts.
3. Radiologic studies

 chest radiograph: useful for assessment of

cardiac enlargement, pulmonary edema, or
involvement of other thoracic structures
4. Electrocardiography
 In the earliest stages of malignant
hypertension, electrocardiogram and
echocardiogram reveal left atrial
enlargement and left ventricular hypertrophy.
MANAGEMENT:

 Patients with malignant hypertension are usually admitted

to an intensive care unit for continuous cardiac
monitoring, frequent assessment of neurologic status and
urine output, and administration of intravenous
antihypertensive medications and fluids.

 Pharmacotherapy:
 IV Nitroprusside
 IV calcium blockers (eg, nicardipine)
 IV Beta-blockers (eg. esmolol or metoprolol, diltiazem,
verapamil,enalapril)
 Hydralazine is reserved for use in pregnant patients

 Diet and Activity

Differential Diagnosis

 Acute renal failure

 Subarachnoid hemorrhage
 Renal artery stenosis