Comparison of the Effects of Nitroglycerin and Nitroprusside on Transmitral Doppler Flow Parameters in Patients with Hypertensive Urgency

Clinical and Research Considerations for Patients With Hypertensive Acute Heart Failure: A Consensus Statement from the Society for Academic Emergency Medicine and the Heart Failure Society of America Acute Heart Failure Working Group

Management approaches for patients in the emergency department (ED) who present with acute heart failure (AHF) have largely focused on intravenous diuretics. Yet, the primary pathophysiologic derangement underlying AHF in many patients is not solely volume overload. Patients with hypertensive AHF (H-AHF) represent a clinical phenotype with distinct pathophysiologic mechanisms that result in elevated ventricular filling pressures. To optimize treatment response and minimize adverse events in this subgroup, we propose that clinical management be tailored to a conceptual model of disease that is based on these mechanisms. This consensus statement reviews the relevant pathophysiology, clinical characteristics, approach to therapy, and considerations for clinical trials in ED patients with H-AHF.

Usefulness of speckle tracking echocardiography in hypertensive crisis and the effect of medical treatment

The acute impact of hypertensive crisis, and changes after treatment, on left ventricular (LV) systolic and diastolic function using comprehensive echocardiography, including speckle tracking, has not been well characterized. Thirty consecutive patients admitted to the hospital from the emergency room with hypertensive crisis underwent Doppler echocardiography at baseline and after blood pressure optimization. The mean age of the patients was 54 ± 13 years, with 19 men (63%). The most common presenting symptoms included dyspnea (70%), chest pain (43%), and altered mental status (13%). Mean systolic and diastolic blood pressures at presentation were 198 ± 12 and 122 ± 12 mm Hg, decreasing to 143 ± 15 and 77 ± 12 mm Hg (p <0.001 for both) after treatment. There was no significant change in LV ejection fraction between baseline and follow-up (48 ± 18% vs 46 ± 18%, p = 0.50); however, global longitudinal LV systolic strain (-10 ± 4% to -12 ± 4%, p = 0.01) and global systolic strain rate (-1.0 ± 0.4 vs -1.4 ± 0.6 s(-1), p = 0.01) significantly improved. Mean global early diastolic strain (-7.2 ± 4.0% to -9.4 ± 2.9%, p = 0.004) and early diastolic strain rate (0.3 ± 0.2 to 0.5 ± 0.4 s(-1), p = 0.05) also improved after treatment. On multivariate analysis, the independent predictors of LV longitudinal strain at follow-up were LV ejection fraction (p <0.001), heart rate (p = 0.005), systolic blood pressure (p = 0.04), and left atrial volume index (p = 0.05). In conclusion, as opposed to LV ejection fraction, LV systolic strain and strain rate were depressed during hypertensive crisis and significantly improved after medical treatment. LV diastolic function, assessed using conventional and speckle-tracking parameters, was also depressed and significantly improved after treatment.

Acute Heart Failure Treatment

Dyspnea is the predominant symptom for patients with acute heart failure and initial treatment is largely directed towards the alleviation of this. Contrary to conventional belief, not all patients present with fluid overload and the approach to management is rapidly evolving from a solitary focus on diuresis to one that more accurately reflects the complex interplay of underlying cardiac dysfunction and acute precipitant. Effective treatment thus requires an understanding of divergent patient profiles and an appreciation of various therapeutic options for targeted patient stabilization. The key principle within this paradigm is directed management that aims to diminish the work of breathing through situation appropriate ventillatory support, volume reduction and hemodynamic improvement. With such an approach, clinicians can more efficiently address respiratory discomfort while reducing the likelihood of avoidable harm.