The Effectiveness of Long-Term Treatment of Malignant Hypertension

A survey is reported of the courses of 84 patients who presented the syndrome of malignant hypertension and who have been under treatment with potent antihypertensive drugs. Among these, 70 per cent survived 1 year of observation, 50 per cent 3 years, 33 per cent 5 years, and 26 per cent 6 years. These survival rates represent substantial therapeutic gains over survival rates in the untreated series of Keith, Wagener, and Barker. The reported first-year survival rate is weighted by the untoward complication of hexamethonium pneumonitis, and current survival is greater than in the estimate presented. Other causes of death are (1) rapidly or (2) delayed or slowly progressive renal failure and (3) complications of atherosclerosis. The first is usually associated with poor control of blood pressure. It seems merely an attenuation of the usual course of malignant hypertension. The syndrome of delayed or slowly progressive renal failure is associated with diffuse occlusive fibrous intimal hyperplasia of major renal arteries. Among the complications of atherosclerosis, cerebral hemorrhage was the most common and was associated with poor control of blood pressure level, while myocardial infarction, the next most common, was not. It may be that the coronary arteries, like the renal, are subject to progressive occlusive disease in some patients with treated malignant hypertension. It is not clear whether this process represents a continuation in vessels larger than arterioles, of a basic vascular disease or a delayed response on the part of the arteries to preexisting severe hypertension. Survival is improved in patients who undertake treatment before malignant hypertension has caused extensive vascular damage. Patients who present themselves for treatment with evidences of severe renal damage generally do not survive for long periods. However, several such have maintained active lives for many months and years. Hence treatment should be withheld only in the most desperate circumstances.