Malignant Hypertension and accelerated high blood pressure are two emergency conditions which should be treated promptly. Both conditions have same outcome and therapy. However Malignant hypertension is really a complication of hypertension characterized by very elevated high blood pressure, and organ damage in the eyes, brain, lung and/or kidneys. It differs from other complications of hypertension for the reason that it is combined with papilledema. (Edema of optic disc of eye) Systolic and diastolic blood pressures are usually greater than 240 and 120, respectively. While Accelerated hypertension is condition rich in blood pressure level, target organ damage, on fundoscopy we have flame shaped hemorrhages, or soft exudates, but without papilledema.

There’s two things. Hypertensive Urgency and Hypertensive emergency. In hypertensive urgency we don’t see any target organ damage while in emergency we have seen target organ damage together with hypertension greater than systolic >220. Now based upon target organ damage you’ll decide whether you have hypertensive emergency or urgency. It is essential to reduce hypertension in hypertensive emergency immediately, while in urgency, bring down blood pressure level quickly is not needed.

Pathogenesis of malignant hypertension is fibrinoid necrosis of arterioles and small arteries. Red blood cells are damaged because they flow through vessels obstructed by fibrin deposition, resulting in microangiopathic hemolytic anemia. Another pathologic process is the dilatation of cerebral arteries resulting in increased blood circulation to brain which results in clinical manifestations of hypertensive encephalopathy. Common age is above 40 years which is more frequent in man instead of women. Black people are at greater risk of developing hypertensive emergencies than the general population.

Target organs mostly are Kidney, CNS and Heart. So the signs of Malignant hypertension are oligurea, Headache, vomiting, nausea, heart problems, breathlessness, paralysis, blurred vision. Most commonly heart and CNS are involved in malignant hypertension. The pathogenesis is not fully understood. Up to 1% of patients with essential hypertension develop malignant hypertension, and also the reason some patients develop malignant hypertension while others don’t is unknown. Other causes include any form of secondary hypertension; utilization of cocaine, MAOIs, or oral contraceptives; , beta-blockers, or alpha-stimulants. Renal artery stenosis, withdrawal of alcohol, pheochromocytoma most pheochromocytomas can be localized using CT scan of the adrenals, aortic coarctation, complications of being pregnant and hyperaldosteronism are secondary reasons for hypertension. Main Investigations to access target organ damage are complete renal profile, BSR, Chest Xray, ECG, Echocardiography, CBC, Thyroid function tests.

Management:

Patient is admitted in Intensive Care Unit. An intravenous lines are taken for fluids and medicines. The first goal of treatments are to reduce the mean arterial pressure by approximately 25% over the first 24-48 hours. However Hypertensive urgencies do not mandate admittance to a hospital. The goal of therapy is to lessen blood pressure within 24 hours, which can be achieved being an outpatient department. Initially, patients treated for malignant hypertension are expected to fast until stable. Once stable, all patients with malignant hypertension should take low salt diet, and really should concentrate on weight lowering diet. Activity is limited to bed rest until the patient is stable. Patients should be able to resume normal activity as outpatients once their blood pressure has been controlled.

Hospitalization is important until the severe hypertension is under control. Medications delivered with an IV line, for example nitroglycerin, nitroprusside, varieties, may lower your blood pressure level. An alternate for patients with renal insufficiency is IV fenoldopam. Beta-blockade can be accomplished intravenously with esmolol or metoprolol. Labetalol is another common alternative, providing easy transition from IV to oral (PO) dosing. Also available parenterally are enalapril, diltiazem, verapamil, Hydralazine is restricted to use in pregnant patients because it also increases uterine profusion, while phentolamine may be the drug of preference for any pheochromocytoma crisis. Following the severe high blood pressure is brought in check, regular anti-hypertensive medications taken by mouth can control your blood pressure. The medication may need to be adjusted occasionally.

Pulmonary hypertension is a condition in that the pressure within the pulmonary circulation, mainly the pulmonary arteries, becomes elevated. This problem can be either primary (idiopathic), which is not caused by any disease or condition, or secondary, which results from some other underlying cause such as left-sided heart disease, chronic lung disease, pulmonary embolism and auto-immune disorders. The idiopathic or primary kind of this condition commonly affects young adults and it is unusually aggressive and often fatal. Common symptoms include breathlessness, cough, fatigue, heart problems and the signs of left or right ventricular failure.

The Ayurvedic treatment of pulmonary hypertension is targeted at treating the suspected pathology from the idiopathic variety, or treating the known cause of the secondary kind of this problem. Left-sided heart failure may be treated using medicines like Arjunarishta, Dashmoolarishta, Laxmi-Vilas-Ras, Shrung-Bhasma, Maha-Laxmi-Vilas-Ras, Punarnavadi-Qadha, Panch-Tikta-Ghrut-Guggulu, Punarnavadi-Guggulu, Gomutra-Haritaki, Drakshasav, Arjun (Terminalia arjuna), Punarnava (Boerhaavia diffusa), Draksha (Vitis vinifera), Amalaki (Emblica officinalis), Gokshur (Tribulus terrestris), Haritaki (Terminalia chebula), Nimba (Azadirachta indica), Musta (Cyperus rotundus), Kutaj (Holarrhina antidysentrica), Patol (Tricosanthe dioica) and Saariva (Hemidesmus indicus). Chronic lung disease may be treatable using medicines like Ras-Sindur, Malla-Sindur, Sameer-Pannag-Ras, Pippali (Piper longum), Kantakari (Solanum xanthocarpum), Kushtha (Saussurea lappa), Pushkarmool (Inula racemosa) and Vasa (Adhatoda vasaka).

Modern anti-coagulation treatments are indicated where recurrent pulmonary embolism is suspected to become the cause of this problem. Ayurvedic medicines like Triphala (Three fruits), Trikatu (Three pungent herbs), Chavya (Piper retrofractrum), Chitrak (Plumbago zeylanica) and Lashuna (Allium sativum) might be put into the modern therapy to avoid recurrent embolism. Auto-immune disorders like scleroderma and systemic lupus erythematosus need to be treated based on the individual presentation of the disease. However, medicines have to be provided to correct the dysfunctional immune-system from the body. These medicines include Tulsi (Ocimum sanctum), Bhrungraj (Eclipta alba), Ashwagandha (Withania somnifera), Shatavari (Asparagus racemosus), Bala (Sida cordifolia), Naagbala (Grewia hirsuta), Suvarna-Bhasma, Abhrak-Bhasma and Suvarna-Malini-Vasant.

The primary or idiopathic type is believed to be brought on by constriction from the pulmonary arteries or biochemical alterations in the arterial smooth muscle cells due to a familial genetic abnormality. This problem may be treated using medicines which act about the arterial walls and reduce the constriction or obstruction. These medicines include Kutki (Picrorrhiza kurroa), Patol, Saariva, Patha (Cissampelos pareira), Musta, Kutaj, Amalaki, Haritaki, Nimba, Kuchla (Strychnos nuxvomica) and Behada (Terminalia bellerica). Medicines like Tapyadi-Loh, Ekang-Veer-Ras, Trayodashang-Guggulu and Bruhat-Vat-Chintamani can also be used for this function.

The prognosis of pulmonary hypertension usually is determined by the seriousness of the underlying cause. An earlier diagnosis and initiation of treatment is important in order to enhance the entire prognosis. Ayurvedic medicines can be given as additional therapy to modern medicines in order to enhance the quality of life and long-term survival.