Objective: To investigate the factors affecting survival in patients with malignant hypertension by analysing the prognosis of all of the patients referred to the City Hospital, Birmingham, with malignant hypertension since 1965. Results: We identified 315 patients with malignant hypertension (211 men, 104 women; mean age +/- SD 49.4 +/- 12.7 years). Of those patients, 219 were Caucasian, 55 were black and 41 were Asian. Black patients had greater renal impairment and higher blood pressures at presentation. After a median follow-up period of 33 months (range 1-389), 126 patients (40.0%) were still alive, 126 patients (40.0%) were dead, 10 patients (3.2%) were receiving chronic haemodialysis and 53 patients (16.8%) were lost to follow-up. Mean follow-up blood pressures in the patients who died were significantly higher than in those who lived. Median survival times for Caucasian, black and Asian patients were 121.0, 30.4 and 107.5 months, respectively, with the lowest survival time being that of black patients. There was a lower median survival time among patients with proteinuria and high serum urea (>10 mmol/l) and creatinine (> 200 mu mol/l) levels at presentation and if left ventricular hypertrophy was detected on the electrocardiogram, but there was no difference in median survival time between those with and without haematuria, nor between non-smokers and current or former smokers. The most common causes of death were renal failure (39.7%), stroke (23.8%), myocardial infarction (11.1%) and heart failure (10.3%). Median survival times for the patients who presented before 1970, during 1970-1979 and during 1980-1989 were 39.2, 68.6 and 144.0+ months, respectively, demonstrating an improved survival time for the patients who were diagnosed after 1980. Using multivariate Cox's proportional hazards analyses, the duration of known hypertension and serum urea level at presentation were found to be the main predictors of survival. Conclusion: Malignant hypertension remains a disease with a poor overall prognosis, namely progression to death or chronic renal haemodialysis. The prognosis has improved with recent advances in therapy, with a 5-year survival of 74% of patients. The poor outlook for black patients could be explained by their late presentation with severe hypertension and the higher prevalence of renal impairment in this group.
