Causes and Risk Factors of Malignant Hypertension

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The most common cause of malignant hypertension (MHT) is uncontrolled hypertension (high blood pressure). But kidney failure, the use of drugs such as cocaine or amphetamines, pregnancy, and certain medical conditions may also lead to this condition.

This article will take a look at the most common causes and risk factors of malignant hypertension. 

Person taking their blood pressure reading with a home blood pressure monitor

Grace Cary / Getty Images

Common Causes

MHT is a medical emergency requiring immediate medical attention. The condition is relatively rare. It occurs in less than 1% of people with hypertension.

The presence of hypertensive heart disease or coronary heart disease is a major risk factor for MHT. Uncontrolled hypertension is the single biggest risk factor for MHT.

The most common causes of MHT are:

  • Uncontrolled hypertension (often as a result of medication noncompliance)
  • High blood pressure in pregnancy (preeclampsia)
  • Kidney failure or some other type of renal disorder, such as narrowing of the renal arteries (renal artery stenosis) or inflammation of the kidney tissue (glomerulonephritis)
  • Collagen vascular diseases (conditions that cause chronic inflammation in your connective tissues), such as systemic lupus erythematosus and systemic sclerosis
  • Drug use, especially cocaine and amphetamines
  • Use or withdrawal from certain prescribed medications, including birth control pills, some antidepressants, and some immunosuppressant medications (cyclosporine)
  • Nervous system disorders such as bleeding in the brain, stroke, spinal cord injury, or traumatic brain injury
  • Tumors of the adrenal gland, such as a tumor causing Cushing’s syndrome or a pheochromocytoma
  • Coarctation (narrowing present at birth) of the aorta

The following groups are at the highest risk of MHT:

  • Anyone who is not compliant with hypertension medication or unable to keep blood pressure levels within healthy ranges
  • History of moderate or severe high blood pressure that requires the need for multiple antihypertensive medications
  • Older adults
  • Prior history of cardiovascular diseases, such as heart failure or coronary heart disease
  • Current or former smoker
  • Family history of high blood pressure
  • Members of lower socioeconomic status (SES) groups (that is, less educational achievement, income, savings, and occupational opportunities)

Black Americans are diagnosed with malignant hypertension nearly four times more often than White Americans. The exact reasons for this disparity remain a mystery, although a complex set of social, environmental, and genetic factors are likely at play.

Poor access to health care also increases the risk of malignant hypertension. 


The pathophysiology (the bodily processes associated with the condition) of MHT is not fully understood. But, it seems as if an exaggerated activation of the renin-angiotensin system plays a major role (this system of hormones regulates blood pressure).

An extreme elevation of blood pressure results in vasoconstriction (narrowing of blood vessels due to the action of muscles in blood vessel walls). Systemic vasoconstriction may lead to low blood flow (hypoperfusion) and ischemia (low oxygen) to your organs. This can occur in the eyes, kidneys, and blood vessels to other organs, resulting in organ damage.

However, in some spots, the blood vessels dilate (widen) when there is severely high blood pressure, which can cause damage to the blood vessels, a leakage of fluids, and the setting off the clotting mechanism.

Unregulated blood pressure can lead to brain swelling (encephalopathy), damage to the light-sensing retina of the eye, damage to the kidneys, and more. The effects progressively worsen the longer treatment is delayed.

Lifestyle Risk Factors

Lifestyle risk factors greatly contribute to the development of hypertension. Lifestyle modifications are the first-line treatment for hypertension.

The following lifestyle modifications can prevent hypertension or prevent your chronic hypertension from worsening, greatly lowering your MHT risk:

  • Eat a heart-healthy diet that is low in salt, sugar, and saturated fats. Avoiding sugary sodas, processed or junk food, and drinking water regularly also can help.
  • Take your medication as prescribed by your healthcare provider.
  • Quit smoking or never start smoking.
  • Have frequent contact with a healthcare provider to report and discuss the progress of your blood pressure goals.
  • Check your blood pressure three to four times per week.
  • Stick with a routine exercise program, ideally a minimum of 30 minutes of sweat-breaking cardiovascular exercise per day.
  • Maintain a healthy weight. A healthy weight is different for everyone, so check with a healthcare provider to determine the best weight for you.


The most common cause of malignant hypertension is uncontrolled hypertension. But many health conditions and unhealthy behaviors can increase the risk of malignant hypertension. These include kidney failure, use of cocaine or amphetamines, and smoking,

A Word From Verywell

Malignant hypertension is relatively rare. But it can be fatal without emergency medical care to promptly lower your blood pressure and prevent further organ damage. Prevention is therefore key.

Some great strategies to prevent MHT include taking your antihypertensive medications as prescribed by your healthcare provider, quitting smoking, and engaging in a heart-healthy lifestyle centered on eating a low-sodium diet and engaging in routine exercise. 

10 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Brokmann JC, Rossaint R, Müller M, et al. Blood pressure management and guideline adherence in hypertensive emergencies and urgencies: A comparison between telemedically supported and conventional out-of-hospital careJ Clin Hypertens (Greenwich). 2017;19(7):704-712. doi:10.1111/jch.13026

  2. Tulman DB, Stawicki SP, Papadimos TJ, Murphy CV, Bergese SD. Advances in management of acute hypertension: a concise review. Discov Med. 2012;13(72):375-83

  3. Unger T, Borghi C, Charchar F, et al. 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension. 2020;75(6):1334-1357. doi:10.1161/HYPERTENSIONAHA.120.15026

  4. Mishra P, Dash N, Sahu SK, Kanaujia V, Sharma K. Malignant hypertension and the role of ophthalmologists: a review article. Cureus. 2022;14(7):e27140. doi:10.7759/cureus.27140

  5. Riemekasten G. Progress in systemic sclerosis - early, targeted and intensive therapy is the key to success. Dtsch Med Wochenschr. 2019;144(3):189-193. doi:10.1055/a-0652-2488

  6. Mir D, Ardabilygazir A, Afshariyamchlou S, Sachmechi I. Malignant hypertension in association with low estrogen dose oral contraceptives: case report and review of literature. Cureus. 2018;10(7):e2978. doi:10.7759/cureus.2978

  7. Naranjo M, Chauhan S, Paul M. Malignant hypertension. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. 2022.

  8. MedlinePlus. Coarctation of the aorta.

  9. Boulestreau R, van den Born BH, Lip GYH, Gupta A. Malignant hypertension: current perspectives and challenges. JAHA. 2022;11(7):e023397. doi:10.1161/JAHA.121.023397

  10. Saito T, Hasebe N. Malignant hypertension and multiorgan damage: mechanisms to be elucidated and countermeasures. Hypertens Res. 2021;44(1):122-123. doi:10.1038/s41440-020-00555-4

By Shamard Charles, MD, MPH
Shamard Charles, MD, MPH is a public health physician and journalist. He has held positions with major news networks like NBC reporting on health policy, public health initiatives, diversity in medicine, and new developments in health care research and medical treatments.