Blood Pressure

Andrew S. Bomback MD, MPH, on Malignant Hypertension

Malignant hypertension is an acute onset of very high blood pressure that can cause damage to the eyes, kidneys, and brain if not managed quickly and appropriately. There are a few known causes of malignant hypertension, but challenges do arise when making a diagnosis.

These challenges were the topic of discussion during the 7th Annual Challenges in Hypertension conference at Columbia University.1

Speaker Andrew S. Bomback MD, MPH, who is an assistant professor of clinical medicine in the Division of Nephrology at Columbia University and director of clinical research in the Division of Nephrology at Columbia University Medical Center, answered our questions about his session.

CARDIOLOGY CONSULTANT: What clinical challenges do cardiologists face when diagnosing or managing malignant hypertension?

Andrew Bomback: The major challenge is not in diagnosing hypertensive emergencies—it should be clear when there is target organ damage—but rather in delineating whether the hypertension is secondary to a systemic cause (eg, scleroderma, complement-mediated thrombotic microangiopathy) or is accelerated essential hypertension. For management, the challenge is to find the best parenteral therapy to both reduce blood pressure at an appropriate rate and minimize adverse effects based on a patient’s comorbidities.

CARDIO CON: How can these challenges be overcome?

AB: A standard protocol to work up secondary causes is helpful, but utilization of our ophthalmology colleagues to perform a high-level fundoscopic examination can be very effective and cost effective. If there is grade III or IV hypertensive retinopathy, then this is highly indicative of accelerated essential hypertension.

CARDIO CON: What is the key take-home message from your session for cardiologists?

AB: Be comfortable with diagnosing hypertensive emergencies across an array of ages and comorbidities; for management, I recommend becoming an “expert” in 2 vasodilatory and 2 anti-sympathetic parenteral therapies.

Reference:

  1. Challenges in Hypertension - 7th Annual. Columbia Medicine. Accessed September 20, 2019. https://collectedmed.com/index.php/article/article/course_preview/article/85/7998/673.