THE FAILURE OF MALIGNANT HYPERTENSION TO DECLINE - A SURVEY OF 24 YEARS EXPERIENCE IN A MULTIRACIAL POPULATION IN ENGLAND

Introduction: The widespread use of antihypertensive medication and th e increasing frequency of diagnosis of mild-to-moderate hypertension s hould mean that malignant-phase hypertension should be becoming less c ommon, and this trend has been reported elsewhere. Na decline in the i ncidence of malignant hypertension has been apparent in our practice i n a district general hospital in a city centre. Objective and methods: To investigate the incidence and mode of clinical presentation of pat ients presenting with malignant hypertension, we performed a retrospec tive survey of the number of patients presenting with malignant hypert ension to our hospital, over the 24-year period from 1970 to 1993. We identified a total of 242 patients (155 male, 87 female; mean+/-SD age 50.1+/-13.3 years) with malignant hypertension. Results: There were n o significant differences in the number of patients presenting each ye ar, the mean age or the presenting systolic and diastolic blood pressu res over the period surveyed. At presentation, 131 patients (54.1%) ha d no previous history of hypertension; 161 (66.5%) were receiving no a ntihypertensive therapy and only 70 (28.9%) were receiving antihyperte nsive treatment (with no record of therapy in 11 patients). The most c ommon presenting symptoms included visual disturbance in 62 (25.6%), h eadaches in 29 (12.0%), headaches and visual disturbance in 24 (9.9%), heart failure in 19 (7.9%), stroke or transient ischaemic attack in 1 7 (7.0%) and dyspnoea in 13 (5.4%), although 23 patients (9.5%) were a symptomatic. The most common presenting complications were heart failu re [27 patients (11.1%)], stroke [23 patients (9.5%)], angina [10 pati ents (4.1%)], myocardial infarction [nine patients (3.7%)] and chronic renal failure [77 patients (31.7%)]. in the whole group the majority (147 patients, 60.5%) had no complicating clinical features. Primary o r essential hypertension was the most common underlying cause in 137 p atients (56.4%). Secondary causes of hypertension (mainly renal diseas e) were identified in 97 patients (39.9%). Conclusion: Our experience suggests that malignant hypertension is still common, with a small pro portion of hypertensives presenting each year. in particular, the inci dence has failed to decline in Birmingham. The incidence rate in the p opulation served by our hospital is approximately 1-2 cases per 100 00 0 per year. An awareness of the different presenting clinical features is required to allow better recognition and management of this life-t hreatening condition.