Pharmacological management of malignant hypertension

ABSTRACT

Introduction

According to current guidelines, malignant hypertension is one of the emergencies in hypertension. The definition requires the presence of bilateral retinal hemorrhages or exudates, with or without papilledema, acute heart failure and acute deterioration in renal function in severe hypertension. Patients with malignant hypertension are characterized by pronounced target organ damage, including structural and functional cardiac abnormalities and renal insufficiency.

Areas covered

Knowledge of the available treatment options is extremely important as we know that we only have a limited time to reduce blood pressure. There are only four drugs dedicated to immediate blood pressure lowering in patients with malignant hypertension, including ‘first-line’ and alternative drugs. Our review aims to discuss all those drugs and gives practical suggestions on how to properly use them.

Expert commentary

The decision of which drug to use depends on numerous factors including the clinical indications, pharmacokinetics, toxicity and drug interactions. Furthermore, frequently, more than one of the recommended drugs is required for the successful lowering of the patient’s blood pressure.

KEYWORDS:

• Labetalol
• malignant hypertension
• nicardipine
• nitroprusside
• pharmacotherapy
• urapidil

Article highlights

• In malignant hypertension, there is only a limited time to reduce blood pressure

• Drugs dedicated to immediate BP lowering can be divided into first-line (Labetalol and Nicardipine) and alternative (Nitroprusside and Urapidil)

• Various studies have been conducted over new drugs using animal models: examples include fenofibrate and the 20-HETE receptor antagonist (AAA) with new mechanisms of action

• Combination therapy seems to be crucial in effective blood pressure lowering

• There is a general lack of studies on the treatment of malignant hypertension due to its rare prevalence and sudden characterization

This box summarizes key points contained in the article.

Declaration of Interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.