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Malignant hypertension

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doc. Malignant hypertension

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Malignant hypertension

  1. 1. 1 By: Ala'a Fadhel Hassan 5th stage, Pharmacy dept. Hospital Training Supervised by: Dr.Anas
  2. 2. 2 Definition Malignant hypertension isvery high bloodpressure thatcomes on suddenly and quickly.The lower (diastolic)bloodpressure reading, which is normally around 80 mmHg, is often above130 mmHg (1) It is a rare but very serious form of high bloodpressure. Officially, definedas severe hypertension thatoccursalong with internalbleedingof the retinasin both eyes and swelling of opticnervesbehindtheretinas (2) Alternative Names Acceleratedhypertension; arteriolarnephrosclerosis;Hypertension -malignant; High bloodpressure – malignant (1) Causes, incidence & risk factors Malignant hypertension isnota single disease entity but rather, a syndromein which thehypertension can beeitherprimary (essential)or secondary to any oneof a number of different causes (3) The disorderaffects about 1% of peoplewith high bloodpressure, including both children andadults. It is more common in youngeradults,( which is the opposite of the risk profile for essential hypertension),especially African-American men(1) in which the underlyingcause is almost always essential hypertension thathas entereda malignant phase (2) Anyonewith a history of kidney failure or a renal artery stenosis (narrowingof arteries in the kidney)has a greatly increasedrisk(3) .History of primary renal parenchymaldisordersis The most common secondary causes of malignant hypertension(Chronicglomerulonephritisisthought to be thecause of malignant hypertension in upto 20% of cases)(2) Pregnantwomen with gestationalhypertension,orwomen experiencingcertain pregnancy relatedcomplications(toxemiaof pregnancy)appearto havean increasedrisk(3) It also occurs in people with Collagen vascular disorders(1) Drug Related Malignant Hypertension(MAOInhibitors,ColdPreparations, WithdrawalAntihypertensive Medicinesas" Clonidine,-Blockers"&“Street drugs" Cocaine, PCP)(4)
  3. 3. 3 Clinical presentation Symptoms of Malignant Hypertension Because malignant hypertension affectsorgan systems that are directly sensitiveto bloodpressure (kidneys,eyes, brain,cardiovascular system), the symptoms of the disease tendto bethose associate with problems in theseother organ systems. For example, some symptomsinclude: Blurry vision Chest pain Seizure Decreasedurine output Weakness orstrange tingling/numbnessin the arms, legs, or face Headache Shortnessof breath These symptoms are notexclusive to malignant hypertension,butare generally associated with a number of potentially serious medical conditionslike heartattack, stroke, or kidney problems(2) Physical Examinations and Tests Malignant hypertension isa medicalemergency in which the physicalexam commonlyshows: Extremelyhigh bloodpressure Swelling in the lowerlegs and feet Abnormalheartsounds andfluid in the lungs Changes in thinking,sensation,muscle ability,and reflexes An eye examination will revealchanges that indicatehigh bloodpressure, including: Bleedingof theretina Narrowing of thebloodvessels in theeye area Swelling of theopticnerve Other problemswith the retina
  4. 4. 4 Kidney failure, as well as othercomplications,may develop.(1) Tests to determinedamageto the kidneysmay include: Arterialbloodgas analysis BUN Creatinine Urinalysis A chestx-ray may show congestion in thelung and an enlargedheart. This disease may also affect the results of the following tests: Aldosterone level Cardiac enzymes(markers of heart damage) CT scan of the brain Electrocardiogram(EKG) Renin level Urinary sediment(1) Principles of Therapy LowerB.P. overhours, Initial goal B.P.  160’s/90’s Too rapidlowering may cause dire consequences(CVA, MI) May take several days to get to reasonablelevels Avoidmedicationsthatcannotbecontrolled(sublingual nifedipine) For most patientsthegreatest risk of treating a hypertensive emergency is the risk of accompanyinghypotension. Treat with short acting,easily titratable, I.V. drug(4) Drug Dosage Onset Duration Adverse Effects Indication(I) Contraindication(C) Vasodilators Nitropru- sside 0.3-10 mcg/kg/mi n 1-2 min 1-2 min N/V, muscle twitching, cyanide, I: CHF, aortic dissect, Catechol.
  5. 5. 5 IV infusion Thiocyanide tox. & intracranial pressure C: hepatic,renal insufficiency Nitrogly- cerin (IV) 5-100 mcg/kg/ min 2-5 min 3-5 min Head ache, dizziness, vomiting, methemgl- obin &tolerance I: coronary dis.,CHF C: CVA, Intracranial pressure Diazoxide ( IV) 1-3 (mg/kg) IV bolus, q5-15 /min; repeat every 4- 24 hr as needed 2-4 min 3-12 hr Nausea, hypoten- sion , flushing, tachycardia , hypergly- cemia, aggravat- ion of angina& fluid retention C: Syndromesof coronary insufficiency, (unless used with beta- blockingagent), cerebrovascular accident& hypersensi- tivity to sulfonamides Fenoldo- pam mesylate 0.1-1.7 mcg/kg/ min (IV infusion) 5-15 min 1-4 hr Headache, dizziness, flushing, increased intraocular pressure, Hypokal- emia& dose related tachycardia I: Severehyperten- sion with renal insufficiency C: Glaucoma Hydrala- zineHCl 10-20 mg IV or IM bolus, (maxim um dose, 40 mg) 10-20 min 3-8 hr Tachy- cardia, flushing, headache ,vomiting & aggravat- ion of angina I: CHF C: Coronary insufficiency,aortic dissection, cerebrovascular accident(may increaseintracranial pressure) Enalaprilat (IV) 1.25-5 mg q6 15 min 6 hr Precipit- ous drop I: CHF C: Use with caution in patientswith severe
  6. 6. 6 hr IV in blood pressure in high renin st. renal insufficiency (not receivingdialysis) Nicardi- pine HCl 5-15 mg/hr IV infusion 5-20 min 1-2 hr Tachycar dia, headache ,flushing, local phlebitis C: Greater than first- degree heartblock, CHF AdrenergicInhibitors Phentol- amine - blocker 5-20 mg IV, repeat as necess- ary 1-2 min 10-30 min Tachycardia , nausea, flushing, abdominal pain&aggr- avation of angina I: Catecholamine excess C: Syndromesof coronary insufficiency Esmolol HCl 200-500 mcg/kg/ min over1-4 min, then 50- 300 mcg/kg/ min IV infusion 1-2 min 10-20 min Hypoten- sion, nausea, bradycar- dia or heart block& dizziness I: Syndromesof coronary insufficiency C: Greater than first- degree heartblock, CHF Labetalol HCl - blocker 20-80 mg IV bolus, (maxim um dose, 300 mg 2-10 min 2-4 hr Hypoten- sion, nausea, itching, scalp tingling& dizziness I: Syndromesof coronary insuffi- ciency,catechol- amine excess C: first-degree heart block,CHF, bronchialasthma
  7. 7. 7 References: (1) Medline Plus-A service of the U.S. national library of medicine Malignant hypertension, causes, symp . &… http://www.nlm.nih.gov/medlineplus/druginformation.html (2) A.D.A.M. Medical Encyclopedia. Malignant hypertension http://www.ncbi.nlm.nih.gov/pubmedhealth/ (3) Hypertension& The Kidney Chapter8 (Hypertensive Crises) byCharles R. Nolan (4) HypertensionEmergencies & Urgencies By StephenS. Levin, D.O.
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