2020 Vision? A case of malignant hypertension

In keeping with European Society of Cardiology (ESC) 2018 arterial hypertension guidelines and uptodate recommendations on hypertensive emergency, we targeted a reduction in MAP of 10%–20% in the first hour and a further 10% over the following 24 hours.1 A controlled reduction in blood pressure (BP) was planned as there was no indication to rapidly reduce his BP (aortic dissection, intracranial haemorrhage, acute heart failure, acute coronary event, encephalopathy) and to avoid cerebral watershed infarcts. Hypertensive retinopathy has a prevalence of 3%–14% in non-diabetic adults aged ≥40 years with focal arteriolar narrowing (7%) and arteriovenous nicking (12%) being the most common finding and cotton wool spots being uncommon (0.3%).2 3 The presence of hypertensive retinopathy correlates with an increased risk of ischaemic stroke (adjusted relative risk 2.58, 95% CI (1.59–4.2)) and predicts long-term risk of stroke independent of BP control.4 5 Moreover, an adjusted analysis found retinopathy to predict a doubling of coronary artery disease events irrespective of BP control.6 Similarly, retinopathy was found to be an independent predictor of congestive heart failure (RR 1.96, 95% CI (1.51–2.54)).7 These finding in addition to the ESC recommendation of funduscopy for all patients with grade II or III hypertension (all with diabetes) support funduscopy as an essential component in assessing a patient with hypertension. Learning points Funduscopy is a fundamental part of assessing hypertensive patients for end-organ damage and offers a unique opportunity to visualise the microvasculature affected by hypertension The presence of hypertensive retinopathy can help risk-stratify a patient when assessing future risk of stroke, coronary artery disease and heart failure, even if hypertension is well controlled On admission, patients need a clearly documented plan as to how the patient’s blood pressure will be managed to avoid complications due to rapid blood pressure correction.