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Management of patients with myocardial infarction and hypertension.

A patient presenting with acute myocardial infarction and severe or uncontrolled hypertension represents an emergency situation requiring prompt and accurate evaluation of both conditions, and treatment should be neither inadequate nor overzealous. The acute coronary event may be accompanied by raised blood pressure either due to acute stress or secondary to long-standing but possibly undiagnosed hypertension. Very rarely, such a presentation may be part of a true hypertensive emergency, such as malignant phase hypertension, hypertensive encephalopathy or dissection of the aorta. Whilst both myocardial infarction and uncontrolled hypertension require treatment, the question is not only ‘what should I use to lower the pressure’ but also ‘how much time do I have in order to obtain the potential benefit from thrombolytic treatment’; indeed immediate and rapid normalization of blood pressure is not the goal of initial therapy in most cases. Treating one condition but not the other also creates potential problems. For example, giving thrombolytic therapy to a patient with severe hypertension may increase the risk of cerebral bleeding. By contrast, treating the hypertension alone and ignoring the heart attack may result in complications secondary to myocardial infarction, including severe cardiac dysfunction, arrhythmias and valve dysfunction. This has led to some debate and confusion over the management of such patients, leading to suboptimal care and different treatment policies in different coronary care units. Some of the treatments that are being employed have even been shown to be dangerous.