Malignant hypertension (MHT) is a very serious, potentially lethal form of hypertension. However, there are currently no specific guidelines for therapeutic management.

Our study based on the MHT prospective cohort of the Bordeaux University Hospital included 74 patients treated in the acute phase of the disease between 2009 and 2019. When no life-threatening organ damage was observed (“uncomplicated MHT”), patients received an oral titration of Angiotensin converting enzyme inhibitors (ACEI) up to twice the full-recommended dose. Our objective was to describe the results of this protocol in terms of feasibility, efficiency and safety.

Of the 74 patients, 66% were men and 15% were of Afro-Caribbean origin. The patients treated averaged 47.1 years of age with an entry blood pressure of 219 (±29)/125 (±22) mmHg, an average organ damage of 3.2±0.9 (including brain, eye, heart, hemolysis, and kidneys) and 11% of MOD-HTA. The protocol was completed on all 74 patients. Saline infusion was used in 34% of patients. No serious adverse event such as acute renal failure, hyperkalaemia or hypotension requiring the transfer to an intensive care unit occurred. Substantial reduction of blood pressure was observed in 97%of patients, and one-month average blood pressure was ≤140/90mmHg in 84% of patients. This remains true in the subgroups of patients with renal failure or renal artery stenosis.

Management of uncomplicated MHT by titration of ACE inhibitors makes it possible to achieve effective blood pressure control with a very good tolerance profile. The comparatively low cost of this protocol, its wide availability in developing countries and its focus on MHT pathophysiology cornerstone seem to make it a robust alternative to the IV approach.