Treatment of Acute Heart Failure in Hypertensive Crisis
Hypertensive crisis can trigger the onset of an acute heart failure (AHF) episode through the steep increase in afterload that occurs as a result of the increase in blood pressure (BP) levels per se, through acute dissection of the ascending aorta, which
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Oana Gheorghe-Fronea
22.1 Introduction Hypertensive emergencies and hypertensive urgencies are what we call hypertensive crisis (HC). From a clinical perspective it is very useful to distinguish between urgencies and emergencies because the treatment approaches are different. The definition of a hypertensive emergency is a situation (usually systolic blood pressure [SBP] >180 mmHg or diastolic BP [DBP] >120 mmHg) that requires immediate reduction in BP because of acute or progressive target organ damage, while the same increase in BP values in an otherwise stable and asymptomatic patient, without any signs of target organ damage, is considered a hypertensive urgency [1–9]. Hypertensive emergencies constitute a collection of heterogeneous conditions. A useful classification of hypertensive emergencies is based on organ damage, although two or more target organs can be affected simultaneously (Table 22.1). The emergency is not determined by the BP level but rather by the clinical status of the patient. The degree of target organ damage determines the speed of the required BP lowering [1–9]. Acute heart failure (AHF) is defined by the new onset or acute worsening of signs and symptoms of heart failure, which requires urgent treatment [10, 11]. Since the persistence of uncontrolled BP values will affect mainly the functionality of the left ventricle (LV), the acute heart failure episodes triggered by HC will
O. Gheorghe-Fronea (*) Department of Cardiology, Carol Davila University of Medicine and Pharmacy, Clinical Emergency Hospital, Bucharest, Romania © Springer Nature Switzerland AG 2019 M. Dorobantu et al. (eds.), Hypertension and Heart Failure, Updates in Hypertension and Cardiovascular Protection, https://doi.org/10.1007/978-3-319-93320-7_22
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Table 22.1 Hypertensive emergencies: classification based on organ damage Target organ Brain
Eyes Heart Aorta Kidney Placenta/maternal circulation
Complications Hypertensive encephalopathy Cerebral infarction Intracerebral hemorrhage Subarachnoid hemorrhage Advanced retinopathy Acute coronary syndromes Acute congestive heart failure Dissection Acute renal failure Severe (pre) eclampsia
present as acute onset of dyspnea with or without chest pain, with acute pulmonary edema being the most severe clinical manifestation [10, 11].
22.2 F rom Hypertensive Crisis (HC) to Acute Heart Failure (AHF) Acute heart failure in HC occurs in the setting of hypertensive cardiopathy with diastolic dysfunction with or without systolic dysfunction [11–15]. Myocardial factors rather than the pressure factor play the main role in AHF, but decrease of BP is a major treatment objective. Hypertensive patients with a history of uncontrolled BP values and LV hypertrophy are more frequent subjects of AHF episodes such as pulmonary edema because of the presence of the following factors [11–15]: • small coronary occlusive disease owing to the specific structural lesions of hypertensive vascular disease (predominantly muscular hypertrophy), • inadequate developm
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