MALIGNANT HTN Definition Hypertension Hypertensive emergency acute lifethreatening

• Hypertensive emergency - acute, life-threatening, and usually associated with marked increases in

• Hypertensive urgency - Marked increases in blood pressure (BP) with no acute

Etiology • Most common (80~95%) - rapid unexplained rise in BP in pt with

End organ damage - Hypertensive encephalopathy - Intracerebral hemorrhage - Stroke - Ischemic heart

Hypertensive encephalopathy • Clinical manifestation of cerebral edema and microhemorrhages seen with dysfunction of

Hypertensive encephalopathy • Not adequately treated –> cerebral hemorrhage, coma and death • BUT

Hypertensive retinopathy • Fundoscopy used to be considered a definitive tool in diagnosing HTN

Plasma & urine catecholamines, metabolites • Plasma catecholamines & metabolites - metanephrine, catecholamine(epi, NE),

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MALIGNANT HTN

Definition • Hypertension

• Hypertensive emergency - acute, life-threatening, and usually associated with marked increases in blood pressure (BP), generally ≥ 180/120 mm. Hg & end organ damage (hypertensive encephalopathy, retinal hemorrhages, papilledema, acute renal failure) ü Accelerated HTN : marked hypertension with retinal hemorrhages, exudates ü Malignant HTN : marked hypertension with papilledema

• Hypertensive urgency - Marked increases in blood pressure (BP) with no acute signs of end-organ damage

Etiology • Most common (80~95%) - rapid unexplained rise in BP in pt with chronic essential HTN - most have history of poor treatment/compliance or an abrupt discontinue of their meds • Other causes (5– 20%) - Renal parenchymal disease (80% of sec. causes) - Systemic disorders with renal involvement (SLE) - Renovascular disease (Atheroscleroses/fibromuscular dysplasia) - Endocrine ( phaeochromocytoma/cushing syndrome) - Drugs (cocaine/amphetam/clonidine withdrawal/diet pills) - CNS (trauma or spinal cord disorders – Guillain-Barre) - Coarctation of the aorta - Preeclampsia/Eclampsia - Postop. hypertension

End organ damage - Hypertensive encephalopathy - Intracerebral hemorrhage - Stroke - Ischemic heart disease (most common) - AMI - Acute LVF with P/oedema - Unstable angina - Aortic dissection - Acute glomerulonephritis - Renal crises from collagen vascular diseases - Eclampsia - Life threatening arterial bleeding

Hypertensive encephalopathy • Clinical manifestation of cerebral edema and microhemorrhages seen with dysfunction of cerebral autoregulation • Defined as an acute organic brain syndrome or delirium in the setting of severe hypertension • Symptom • Severe headache, Nausea and vomiting, Visual disturbances • Confusion, focal or generalized weakness • Sign • Disorientation, Focal neurologic defects • Focal or generalized seizures, nystagmus

Hypertensive encephalopathy • Not adequately treated –> cerebral hemorrhage, coma and death • BUT with proper treatment – completely reversible

Hypertensive retinopathy • Fundoscopy used to be considered a definitive tool in diagnosing HTN encephalopathy

HYPOKALEMIA WITH MALIGNANT HTN

Plasma renin activity/aldosterone

Adrenal dynamic CT

Renal angio CT

Plasma & urine catecholamines, metabolites • Plasma catecholamines & metabolites - metanephrine, catecholamine(epi, NE), normetanephrine - Metanephrine 검사가 가장 sensitive 함 • Urine catecholamines & metabolites - 24 hrs urine metanephrine, catecholamine(epi, NE), VMA(vanilyl mandelic acid) -> plasma & urine catecholamines, metabolites 증가시 “ Pheochromocytoma”

Cortisol 증가시