Hypertensive heart failure: patient characteristics, treatment, and outcomes

Abstract

Background

Acute heart failure (AHF) is a common, poorly characterized manifestation of hypertensive emergency. We sought to describe characteristics, treatment, and outcomes of patients with severe hypertension complicated by AHF.

Methods and Results

The observational retrospective Studying the Treatment of Acute hypertension (STAT) registry records data on emergency department and hospitalized patients receiving intravenous therapy for blood pressure (BP) greater than 180/110 mm Hg in 25 US hospitals. A subset of patients with HF was defined as pulmonary edema on chest x-ray (CXR) or an elevated B-type natriuretic peptide level (BNP > 500 or NTproBNP > 900 pg/mL) in patients with creatinine level 2.5 mg/dL or less. Remaining STAT patients, after excluding those with a primary neurologic diagnosis, constitute the non-HF cohort. An adverse composite outcome was defined as mechanical ventilation, intensive care unit (ICU) admission, hospital length of stay more than 1 week, or death within 30 days. Of 1199 patients, 302 (25.2%) had AHF. Acute HF patients and non-AHF patients were similar in age, sex, and overall mortality, but AHF patients were more commonly African American, with a history of HF, diabetes or chronic obstructive pulmonary disease, and prior hypertension admissions. Heart failure patients had higher creatinine and natriuretic peptide levels but lower ejection fraction. They were more likely admitted to the ICU; receive electrocardiograms, bilevel positive airway pressure ventilation, and CXRs; and be readmitted within 90 days. Finally, BP decreases lower than 120 mm Hg within 12 hours were associated with an increased rate of the composite adverse outcome.

Conclusions

Acute HF as a manifestation of hypertensive emergency is common, more likely in African Americans, and requires more clinical resources than patients with non–HF-related severe hypertension. Accurate BP control is critical, as declines less than 120 mm Hg were associated with increased adverse event rates.

Introduction

Hypertensive crises, consisting of urgencies (without end-organ damage) and emergencies (with end-organ damage), are reported to account for 25% or greater of all emergency department (ED) medical emergencies [1] and may result in 3% of all ED visits. Overall, approximately 1% of patients who have long-term hypertension will experience a crisis in their lifetime [2]. If untreated, the 1-year mortality of uncontrolled hypertension is high [3], and in patients presenting with crises, the 5-year death rate is 26% [4].

Heart failure is a significant public health challenge. It is estimated that there are approximately 1.1 million annual US ED visits for HF [5], [6], of which 80% require hospitalization. Once hospitalized, the in-hospital HF mortality rate is 2% to 20% [7], [8]. After discharge, 11% die within 30 days, 44% require rehospitalization within 6 months, and 33% do not survive 1 year [7]. As an index event, ED HF presentations are associated with increased short-term mortality risk [9]. If admitted from the ED to the intensive care unit (ICU) for acute HF (AHF), in-hospital mortality exceeds 10% [8]. Finally, an ED presentation for acute pulmonary edema has a particularly poor prognosis; 12% die during their admission and greater than 40% within 1 year [10].

ED investigations report that 53% to 73% of all patients presenting with AHF have a history of hypertension [7], [10], with hypertension somewhat more prevalent in preserved (vs reduced) systolic function (76% vs 66%; P < .0001) [11]. More than 60% of patients with AHF have normal or elevated blood pressure (BP), and some report they have a lower mortality than patients with lower BP [12].

Hypertensive emergencies presenting as AHF have been poorly described. Our purpose was to describe the characteristics, treatment, and outcomes of patients presenting with severe hypertension complicated by AHF and compare them to the population presenting with severe hypertension without HF.