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

Abstract

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. ACADEMIC EMERGENCY MEDICINE 2016;23:922-931 © 2016 by the Society for Academic Emergency Medicine PATHOPHYSIOLOGY OF HYPERTENSION IN ACUTE HEART FAILUREH ypertensive acute heart failure (H-AHF) is defined as the rapid onset of pulmonary congestion in the setting of a systolic blood pressure over 140 mm Hg and often times over 160 mm Hg. 1Many patients with H-AHF have a history of poorly controlled hypertension.2 The consequences of longstanding hypertension include changes to both the vasculature and the left ventricle (LV), resulting in increased stiffness and reduced compliance across the cardiovascular system.3,4 Such stiffening increases systolic load on the LV

Congestion in heart failure: a contemporary look at physiology, diagnosis and treatment

“…Pulmonary ultrasonography. Ultrasonography of the lungs is becoming a generally accepted tool for the evalu ation of pulmonary oedema 6,85 . The quantity of water in the lungs corresponds to the degree of echogeni city found on ultrasonography 86 .…”

Organ dysfunction, injury and failure in acute heart failure: from pathophysiology to diagnosis and management. A review on behalf of the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

“…The therapeutic approach to congestion depends on whether vascular‐type fluid redistribution or cardiac‐type fluid accumulation is the primary cause of the elevated cardiac filling pressures ( Figure ). More than 80% of patients are initially treated homogeneously with i.v.…”

Current U.S. Guideline-Based Management Strategies for Special Clinical Situations Involving Hypertensive Crises

“…32 Hunter et al 33 suggest that aggressive therapy with vasodilators be initiated for hypertensive AHF patients. Collins et al 34 also recommend the use of vasodilators for treatment but list signs of hypoperfusion, hypotension, or altered mental status as contraindications. Collins and Storrow et al 35 recommend administering intravenous nitroprusside or nitroglycerin if the BP is greater than 150/100 mm Hg after the administration of sublingual nitroglycerin.…”