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Malignant hypertension: diagnosis, treatment and prognosis with experience from the Bordeaux cohort
Sébastien Rubin1, Antoine Cremer2, Romain Boulestreau2
1Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Hôpital Pellegrin.
Insights
Malignant hypertension causes severe organ damage, particularly to the brain and heart. Treatment with renin-angiotensin system blockers shows promising results in preserving kidney function.
Area of Science:
- Nephrology
- Cardiology
- Neurology
Background:
- Malignant hypertension is a severe form of hypertension characterized by high blood pressure and acute ischemic organ damage.
- It has a worse prognosis than other hypertensive forms, particularly in Black patients.
- Advanced diagnostic tools for heart and brain organ damage can improve patient evaluation.
Purpose of the Study:
- To enhance understanding of organ damage characteristics in malignant hypertension.
- To facilitate diagnosis and evaluate treatment effectiveness for malignant hypertension.
Main Methods:
- A registry of 168 malignant hypertension patients was analyzed.
- Systematic cardiac (ECG, echocardiography) and brain (MRI) evaluations were performed.
- Treatment involved a protocol of renin-angiotensin system blockers with forced oral titration.
Main Results:
- Significant brain damage was detected in 93% of patients via MRI.
- High prevalence of heart involvement (82% left ventricular mass, 56% systolic dysfunction).
- Renal involvement (55%) and thrombotic microangiopathy (15%) were noted; 5-year renal survival was 90.8%.
Conclusions:
- Malignant hypertension is a systemic disease affecting brain, heart, kidneys, and eyes, often asymptomatically.
- Renin-angiotensin system blockers are crucial for managing malignant hypertension and preserving renal function.
Background:
Malignant hypertension, the most severe form of hypertension, is defined by high blood pressure and acute ischemic organ damage. It has a worse prognosis than other forms of hypertension, especially in black patients. New tools to assess organ damage, especially that of the heart and brain, are now available and may contribute to a better evaluation of these patients. This report improves knowledge of the characteristics of involved organs to facilitate diagnosis and to evaluate the effectiveness of our treatment protocol.
Method:
The Bordeaux registry, started in 1995, recruited 168 patients. In addition to evaluations of their eyes and kidneys, these patients had a systematic evaluation of their hearts with ECG and echocardiography and, since 2007, a systematic brain MRI. Blood pressure was lowered with a protocol based on blockers of the renin-angiotensin system started at a very low-dose with forced titration over 48 h. Only an oral route was used for antihypertensive medication.
Results:
Systematic MRIs found significant brain damage in 93% of patients. Heart involvement was highly prevalent: 82% had left ventricular mass more than 60 g/m, and 56% had systolic dysfunction (estimated by global longitudinal strain). Renal involvement and thrombotic microangiopathy were respectively present in 55 and 15% of patients. Median follow-up was 48 months. Renal survival at 5 years was 90.8%, similar to other studies.
Conclusion:
Malignant hypertension is a systemic disease causing severe damage to the brain, heart, kidneys and eyes, even in absence of symptoms. Renin-angiotensin system blockers seem to be the cornerstone of treatment.
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