How Malignant Hypertension Is Treated

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Malignant hypertension (MHT) requires emergency medical attention to limit organ damage and other complications of severely high blood pressure. The first-line treatment is the administration of intravenous medications to lower blood pressure in a hospital setting.

Treatment will depend on your health status, the cause of your MHT, and what symptoms, organ damage, or complications you developed during your malignant hypertension episode.

This article will discuss the most common forms of medical treatment used to treat malignant hypertension, plus prescription and lifestyle modifications that may be used after stabilization and discharge from the hospital.

Person in hospital bed in intensive care unit with healthcare provider checking monitors

Ariel Skelley / Getty Images

Medical Management

Medical management to gradually reduce blood pressure is the gold standard treatment for malignant hypertension.

According to the 2017 clinical guidelines from the American College of Cardiology and the American Heart Association, anyone with suspicion of MHT should be admitted to the intensive care unit (ICU) for continuous monitoring of blood pressure and target organ damage.

Antihypertensive medications are administered via an intravenous (IV) line for quick onset of action.

IV beta-blockers or calcium channel blockers are administered to reduce systolic blood pressure (SBP) levels by no more than 25% within the first hour. They will aim to avoid low blood flow (hypoperfusion) to the organs, which may worsen organ damage.

Over the next two to six hours, if severe organ damage has been identified, the goal is to lower the systolic blood pressure (the top number) to 140 millimeters of mercury (mmHg). If there is no severe organ dysfunction, a higher level of blood pressure (systolic of 160 mmHg) is allowed. A further reduction to normal blood pressure is made gradually in a couple of days.

Hypertension reduction and treatment of symptoms are often initiated nearly simultaneously. For example, if you are experiencing severe organ dysfunction, like kidney failure, IV blood pressure medications are initiated first, and dialysis soon after that. 

Treating Organ Complications

By definition, malignant hypertension displays symptoms of damage to organs in addition to severely high blood pressure. Treatment will depend on which organs are affected, most commonly the eye, kidney, heart, and brain.

Ultimately the best hypertensive treatment for you will be based on symptoms, medical history,  and the cause of your MHT. The following treatment protocols may be used based on your specific circumstance:

  • IV beta-blockers (labetalol and esmolol) and calcium channel blockers Cardene (nicardipine) and Cleviprex (clevidipine) are first-line treatments for uncomplicated MHT cases detected in its early stages. 
  • IV nitroglycerin, a nitric oxide vasodilator, is only used in people with acute coronary syndrome or acute pulmonary edema due to its rapid onset of action. 
  • Nitropress (sodium nitroprusside), a nitric oxide vasodilator, may be used in cases of MHT that present with intracranial bleeding, swelling of the brain (encephalopathy), heart attack, or aortic dissection (a tear in the aorta) with the goal of achieving a systolic blood pressure of less than 140 mmHg during the first hour (and to less than 120 mmHg in the case of aortic dissection). 
  • Hydralazine is most often used in hypertensive cases in pregnancy (preeclampsia). 
  • Phentolamine, an alpha blocker, is most often used in MHT cases induced by increases in systemic catecholamines (hormones produced by the adrenal glands) by the following conditions: pheochromocytoma (a type of adrenal tumor), cocaine or amphetamine overdose, drug interactions with monoamine oxidase inhibitors (MAOIs), and Catapres (clonidine) withdrawal. 
  • Vasotec (enalapril), an angiotensin-converting enzyme (ACE) inhibitor, may be used in MHT cases caused by high levels of plasma renin (a hormone that influences blood pressure). This drug should be avoided in pregnant people.

Prescriptions

After stabilizing your blood pressure in the hospital, your blood pressure will be further managed by prescription medications.

If you have hypertension, managing your blood pressure by never missing or skipping doses of your blood pressure medications is the most important way to lower your MHT risk. Untreated hypertension increases your MHT risk and can lead to other potentially fatal medical complications like heart attack, stroke, and brain aneurysm.

Always take your blood pressure meds as prescribed by your healthcare provider and pharmacist. Your blood pressure medication is likely to fall into one of the following drug categories:

Surgeries and Specialist-Driven Procedures

Malignant hypertension includes symptoms of organ damage, often to the blood vessels, heart, eyes, kidneys, and brain. Depending on which organs are affected, your care team will include specialists in those areas for primary treatment and follow-up.

These can include an ophthalmologist (for eye care), a cardiologist (for heart and blood vessel issues), a nephrologist (for kidney issues), a surgeon, a neurologist (for stroke), a speech therapist, an occupational therapist, a physical therapist, dietitian, and more.

Renal (kidney) complications may involve surgery, dialysis, and even a kidney transplant. In cases where MHT has an identified underlying cause (such as an adrenal tumor), this will also be treated or managed by a specialist.

Lifestyle

After an episode of malignant hypertension, lifestyle modifications are essential to reduce hypertension and lower the risk of a repeat episode of MHT. They include:

  • Eat a heart-healthy diet. It should be low in salt, sugar, and saturated fats. Avoid junk food and sugar-sweetened drinks.
  • If you smoke, quit smoking.
  • Find a cardiovascular exercise you enjoy (one where you can break a sweat) for 30 minutes daily.
  • Maintain a healthy weight.
  • Adhere to the medications and dosing schedule prescribed by your healthcare provider.
  • Check your blood pressure three to four times per week.
  • Check in with your healthcare provider frequently to report on your blood pressure goals.

Summary

Malignant hypertension is a medical emergency. The administration of intravenous medications under the guidance of a medical professional in a hospital setting is the first-line treatment for most cases of MHT.

Other treatments, such as surgery or dialysis, will be initiated based on which organs were damaged by severely high blood pressure. Once stabilized, blood pressure medication and lifestyle modifications will be used to manage blood pressure and prevent a recurrence.

The best treatment for you will ultimately depend on your health status, the cause of MHT, and any resulting organ damage or complications.

A Word From Verywell

The importance of prevention cannot be understated in the management of MHT. Not only do lifestyle modifications go a long way in lowering your heart disease risk, but taking your medications as prescribed can help lower the chances of experiencing a life-threatening event.

Still, some people do everything right and still get MHT. If you experience any MHT symptoms, such as headache, confusion, blurry vision, shortness of breath, or back or chest pain, seek immediate medical attention so that you may get the lifesaving emergency care you need.

4 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.