How Is Malignant Hypertension Diagnosed

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Malignant hypertension is often diagnosed in the emergency room when a person seeks care for symptoms produced by severely high blood pressure causing damage to organ systems. The eyes, kidneys, and blood vessels are the organs most commonly affected.

The clinical diagnosis of malignant hypertension (or hypertensive crisis) is based on the presence of high blood pressure (measured in both arms) at or above 180/120 millimeters of mercury (mmHg) and evidence of organ damage from a urinalysis, achest X-ray, a fundoscopic eye exam, and blood tests.

This article will discuss how malignant hypertension is diagnosed, including physical examination, tests, and imaging. It will also discuss what other conditions will be considered.

A healthcare provider takes a person's blood pressure in the hospital

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Self Checks/At-Home Testing

If you have chronic high blood pressure, you may use a blood pressure monitor at home to track your readings.

If you have a reading of 180/120 mmHg or higher, you should take a second reading after sitting quietly for five minutes. If the second reading is also in this severely high range, seek medical attention right away.

Symptoms of organ damage include blurred or double vision, chest or back pain, shortness of breath, trouble speaking, or numbness or weakness. If you experience any of these, call 911 for emergency medical care.

If you have no concerning symptoms, you should urgently call a healthcare provider for advice on blood pressure medications. This may include starting a new medication or changing the dosage of medications you are already taking for high blood pressure.

When to Call 911

Call 911 if two blood pressure readings are 180/120 mmHg or higher and you have any symptoms that could indicate organ damage, such as changes in vision, chest pain, difficulty breathing, numbness or paralysis, or difficulty speaking.

Physical Examination

Your medical history, a report of symptoms, and a physical examination help in diagnosing malignant hypertension. A healthcare provider will ask questions about your prior medical history, the medications you take (and whether you have been taking them as prescribed), and recreational drug use, such as amphetamines, cocaine, and phencyclidine (PCP).

They will perform a focused physical examination that begins with taking your blood pressure in both arms, listening to your heart and lungs with a stethoscope, assessing the function of your central nervous system via a cranial nerve exam, and performing an eye test (fundoscopic examination) looking for evidence of vascular eye damage.

Labs and Tests 

Malignant hypertension often affects the eyes, kidneys, and cardiovascular system. Therefore, an electrocardiogram (ECG or EKG), urinalysis, and a fundoscopic (eye) exam are performed with or immediately after the physical exam. 


An electrocardiogram is a relatively quick and highly accessible tool used to detect the presence of heart arrhythmias (abnormal heartbeat) and evidence of myocardial ischemia (lack of blood flow to the heart muscle causing damage) or myocardial infarction (heart attack). 

Fundoscopic Exam

A fundoscopic examination is an eye test performed by a healthcare provider to look for evidence of vascular eye damage. It is performed using an ophthalmoscope—a specialized instrument that uses a light and various lenses.

Papilledema (swelling of the optic nerve), flame-shaped hemorrhages, or soft exudates on your eye exam indicates damage to your eye.


The main laboratory studies in the initial evaluation of MHT are:

  • Urinalysis: A urinalysis is performed on a urine sample. It may reveal the presence of protein (proteinuria), blood (hematuria), and red blood cell or hyaline casts, evidence of microscopic or gross kidney damage.
  • Complete blood cell count (CBC): Malignant hypertension may cause changes in blood cell counts.
  • Basic metabolic panel (BMP): This blood test includes estimated glomerular filtration rate (GFR), creatinine, blood glucose, sodium, calcium, blood urea nitrogen (BUN), and creatinine. This helps assess whether there is kidney damage.

The following labs may be ordered as needed based on the values obtained from the aforementioned tests: 


Chest X-ray imaging is performed in the workup of MHT, looking for signs of heart and lung problems such as pulmonary edema (fluid in the lungs) and enlargement of the heart.

If there are symptoms of heart problems, such as chest pain or shortness of breath, your provider may order an echocardiogram plus a chest computed tomography (CT) or magnetic resonance imaging (MRI) to assess your heart function and check for other conditions that may have developed, like aortic dissection (a tear in the wall of the aorta).

Brain imaging (CT or MRI) may be done if signs of neurological damage are present, CT or MRI may also be used to visualize the kidneys if there are signs of kidney damage, such as microscopic hematuria (blood in urine) on urine analysis or high levels of BUN and creatinine. A kidney ultrasound may be used if CT or MRI is unavailable.

Differential Diagnoses

Malignant hypertension is characterized by damage in one or more organs. Other conditions that cause cardiovascular, renal, and nervous system damage may mimic malignant hypertension.

MHT is sometimes referred to as a retrospective diagnosis—one that is made after significant organ damage has occurred. Healthcare providers must have a high degree of suspicion for this condition and be aware of a person's medical history.

Oftentimes, when people present with symptoms of organ damage from MHT, prompt treatment of their chief complaint is started (for example, dialysis for severe kidney damage). While this is necessary and often lifesaving, lowering blood pressure is the key to preventing organ damage and complications.

Below are the diagnoses that most commonly mimic MHT:


Malignant hypertension is diagnosed when there is severely high blood pressure and symptoms of damage to organ systems, especially the eyes, kidneys, and blood vessels.

You may detect high blood pressure via a blood pressure monitor at home, along with other symptoms, and get emergency medical care. Or, you may seek emergency care for the symptoms without knowing your blood pressure is high.

A healthcare provider will take a medical history, perform a physical exam, and use imaging and lab tests to make a diagnosis. They will need to determine whether MHT is present and that organ damage is not due to other causes without severely high blood pressure.

A Word From Verywell

The diagnosis of MHT can be difficult and complex, as it depends on evidence of organ damage. In some cases, much attention is paid to treating the symptoms and not the root cause.

MHT is a medical emergency that can become fatal if left untreated. Knowing the signs and symptoms and getting urgent help is paramount to preserving your quality of life and limiting your risk of developing permanent medical complications.

5 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.
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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.