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A long-term prognosis was studied in 69 patients with malignant hypertension, followed for an average of 56 months. Overall survival rate was 90% for a 5-year period, although the prognosis was different between two major underlying diseases, namely the 5-year survival was 79% for 33 essential hypertension (EHT) and 100% for 26 chronic glomerulonephritis (CGN); the difference is significant (p less than 0.01). In contrast, the 5-year rate for renal survival, defined as the probability of surviving without hemodialysis, was 37% in all cases. However, there was significant difference in the renal survival between EHT (60% for a 5-year period) and CGN (4% for a 18-month period). Multivariate analyses of the Cox's proportional hazards model revealed that the long-term change in renal function was different between the two groups, namely more rapid deterioration in the CGN group. These results indicate that a long-term prognosis of malignant hypertension is influenced by the underlying diseases and hemodialysis besides antihypertensive treatment may increase survival in malignant hypertension associated with severely damaged renal function.

Hypertension-induced morbidity and mortality can be positively affected by antihypertensive treatment. This was first shown in malignant phase hypertension and it is now clearly established that not only total mortality but also morbidity from stroke, left ventricular failure, and progressive renal failure can be positively affected by pharmacological lowering of arterial pressure. Benefits of treatment for coronary artery disease are less obvious. In spite of the positive effects of antihypertensive therapy briefly mentioned here, recent data from several centers show that hypertension-induced risks in treated hypertensive patients are not reduced down to the level seen in comparable normotensive subjects. There could be several reasons for this. Some of the hypertension-induced cardiovascular changes are irreversible, or that antihypertensive pharmacological agents may have some adverse effects that would partially offset the advantages obtained through a reduction in blood pressure, or that treated arterial blood pressure usually has not been brought down to strictly normotensive levels. Therefore, the risks associated with hypertension have not been lowered to those seen in normotensive subjects. This latter point assumes particular significance in view of some recent suggestions that a too drastic lowering of blood pressure in hypertensive subjects may be associated with an increased risk, particularly for coronary artery disease mortality.

The authors discuss the results of observation of 269 patients with adrenal arterial hypertension 247 of whom underwent operation. The malignant hypertension syndrome developed in 39% of the patients. It is presumed that its development was caused by the combination of adrenal and renal affections as well as by specific hormonal shifts: relative norepinephrine hyperproduction and reduced intensity of catecholamine metabolism. In all groups of the patients with the malignant hypertension syndrome, a higher daily excretion of aldosterone and increased blood renin activity were also found. The character of the drug therapy and the late results of surgical treatment are discussed. A new variant of hyperaldosteronism, dexamethasone-inhibited form of aldosteroma, is described.

A follow-up was made of 69 patients diagnosed as having malignant hypertension during 1969--76, essential in 26, secondary in 39 and unclassified in 4. A clear male dominance was seen (41 men, 28 women), particularly in the group with essential hypertension (18 men, 8 women). The mortality in this series was less than in previously published series. Thus, the 5-year survival rate was 75% in the patients with essential and 72% in those with secondary hypertension. In part this was due to haemodialysis and renal transplantation. The importance of renal function at the time of diagnosis was evident in this study. In most patients with essential hypertension and serum creatinine levels below 300 mumol/l, renal function could be maintained or improved when antihypertensive treatment was instituted, whereas progression of the renal damage was seen in those with serum creatinine levels above 300 mumol/l in spite of antihypertensive treatment with 3 or more drugs. The incidence of new cases of malignant hypertension tended to decrease during the observation period, particularly as regards essential hypertension.