Cardiac Adaptation in Acute Hypertensive Pulmonary Edema

      The aim of this study was to evaluate the role of left ventricular (LV) dysfunction (global and regional, systolic and diastolic) acute dyssynchrony, ischemic mitral regurgitation (MR), and afterload changes in acute hypertensive pulmonary edema (AHPE). Forty-four consecutive patients were evaluated by comprehensive echocardiography during clinical and radiologic pulmonary edema (63 ± 29 minutes after first dose of treatment) and after 48 to 92 hours. Twenty age- and gender-matched asymptomatic hypertensive and diabetic subjects served as controls. AHPE was associated with increased afterload (estimated arterial elastance 3.0 vs 2.3 mm Hg/ml, p = 0.024) and subsequent decreased longitudinal LV systolic function (mean strain of 6 basal segments −11.0% vs −15.4%; p = 0.015) compared to the stable follow-up state. However, global LV systolic function was maintained (estimated ventricular elastance 1.7 vs 1.6 mm Hg/ml, stroke work 76.7 vs 84.5 cJ, ejection fraction 0.33 vs 0.37, all nonsignificant). Except for diastolic filling time (ratio to cardiac cycle 0.41 vs 0.49, p <0.001), other indexes of diastolic function, dyssynchrony, and MR severity were similar between evaluations. Patients with AHPE had worse ventricular–arterial coupling, systolic function, estimated diastolic stiffness, and filling pressures compared to asymptomatic controls, suggesting a decreased capacity to adapt to changes in loading. In conclusion, acute alterations of systolic and diastolic LV function, myocardial synchrony, and ischemic MR are unlikely mechanisms of AHPE. Rather, AHPE is likely to develop in patients with decreased systolic and diastolic capacity to adapt to acute changes in loading.
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        • Nieminen M.S.
        • Brutsaert D.
        • Dickstein K.
        • Drexler H.
        • Follath F.
        • Harjola V.P.
        • Hochadel M.
        • Komajda M.
        • Lassus J.
        • Lopez-Sendon J.L.
        • Ponikowski P.
        • Tavazzi L.
        • EuroHeart Survey Investigators
        • Heart Failure Association, European Society of Cardiology
        EuroHeart, Heart Failure Association, European Society of Cardiology Failure Survey II (EHFS II): a survey on hospitalized acute heart failure patients: description of population.
        Eur Heart J. 2006; 27: 2725-2736
        • Adams Jr., K.F.
        • Fonarow G.C.
        • Emerman C.L.
        • LeJemtel T.H.
        • Costanzo M.R.
        • Abraham W.T.
        • Berkowitz R.L.
        • Galvao M.
        • Horton D.P.
        • ADHERE Scientific Advisory Committee and Investigators
        Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE).
        Am Heart J. 2005; 149: 209-216
        • Lee D.S.
        • Mamdani M.M.
        • Austin P.C.
        • Gong Y.
        • Liu P.P.
        • Rouleau J.L.
        • Tu J.V.
        Trends in heart failure outcomes and pharmacotherapy: 1992 to 2000.
        Am J Med. 2004; 116: 581-589
        • Gandhi S.K.
        • Powers J.C.
        • Nomeir A.M.
        • Fowle K.
        • Kitzman D.W.
        • Rankin K.M.
        • Little W.C.
        The pathogenesis of acute pulmonary edema associated with hypertension.
        N Engl J Med. 2001; 344: 17-22
        • Uriel N.
        • Torre-Amione G.
        • Milo O.
        • Kaluski E.
        • Perchenet L.
        • Blatt A.
        • Kobrin I.
        • Turnovski A.
        • Kaplan S.
        • Rainisio M.
        • Frey A.
        • Vered Z.
        • Cotter G.
        Echocardiographic ejection fraction in patients with acute heart failure: correlations with hemodynamic, clinical, and neurohormonal measures and short-term outcome.
        Eur J Heart Fail. 2005; 7: 815-819
        • Zile M.R.
        • Baicu C.F.
        • Gaasch W.H.
        Diastolic heart failure—abnormalities in active relaxation and passive stiffness of the left ventricle.
        N Engl J Med. 2004; 350: 1953-1959
        • Baicu C.F.
        • Zile M.R.
        • Aurigemma G.P.
        • Gaasch W.H.
        Left ventricular systolic performance, function, and contractility in patients with diastolic heart failure.
        Circulation. 2005; 111: 2306-2312
        • Ware L.B.
        • Matthay M.A.
        Clinical practice.
        N Engl J Med. 2005; 353: 2788-2796
        • Piérard L.A.
        • Lancellotti P.
        The role of ischemic mitral regurgitation in the pathogenesis of acute pulmonary edema.
        N Engl J Med. 2004; 351: 1627-1634
        • Borlaug B.A.
        • Kass D.A.
        Ventricular–vascular interaction in heart failure.
        Heart Fail Clin. 2008; 4: 23-36
        • Cotter G.
        • Felker G.M.
        • Adams K.F.
        • Milo-Cotter O.
        • O'Connor C.M.
        The pathophysiology of acute heart failure—is it all about fluid accumulation?.
        Am Heart J. 2008; 155: 9-18
        • Vinereanu D.
        • Khokhar A.
        • Fraser A.G.
        Reproducibility of pulsed wave tissue Doppler echocardiography.
        J Am Soc Echocardiogr. 1999; 12: 492-499
        • Margulescu A.D.
        • Thomas D.E.
        • Ingram T.E.
        • Vintila V.D.
        • Egan M.A.
        • Vinereanu D.
        • Fraser A.G.
        Can isovolumic acceleration be used in clinical practice to estimate ventricular contractile function?.
        J Am Soc Echocardiogr. 2010; 23: 423-431
        • Bland J.M.
        • Altman D.G.
        Statistical methods for assessing agreement between two methods of clinical measurement.
        Lancet. 1986; 8476: 307-310
        • Leite-Moreira A.F.
        • Correia-Pinto J.
        Load as an acute determinant of end-diastolic pressure-volume relation.
        Am J Physiol Heart Circ Physiol. 2001; 280: H51-H59
        • Ross J.
        • Braunwald E.
        The study of left ventricular function in man by increasing resistance to ventricular ejection with angiotensin.
        Circulation. 1964; 29: 739-749
        • Franciosa J.A.
        • Limas C.J.
        • Guiha N.H.
        • Rodriguera E.
        • Cohn J.N.
        Improved left ventricular function during nitroprusside infusion in acute myocardial infarction.
        Lancet. 1972; 7752: 650-654
        • Vinereanu D.
        • Nicolaides E.
        • Tweddel A.C.
        • Fraser A.G.
        “Pure” diastolic dysfunction is associated with long-axis systolic dysfunction.
        Eur J Heart Fail. 2005; 7: 820-828
        • Westermann D.
        • Kasner M.
        • Steendijk P.
        • Spillmann F.
        • Riad A.
        • Weitmann K.
        • Hoffmann W.
        • Poller W.
        • Pauschinger M.
        • Schultheiss H.P.
        • Tschöpe C.
        Role of left ventricular stiffness in heart failure with normal ejection fraction.
        Circulation. 2008; 117: 2051-2060
        • Sengupta P.P.
        • Tajik A.J.
        • Chandrasekaran K.
        • Khandheria B.K.
        Twist mechanics of the left ventricle: principles and application.
        JACC Cardiovasc Imaging. 2008; 1: 366-376
        • Dong S.J.
        • Hees P.S.
        • Siu C.O.
        • Weiss J.L.
        • Shapiro E.P.
        MRI assessment of LV relaxation by untwisting rate: a new isovolumic phase measure of tau.
        Am J Physiol Heart Circ Physiol. 2001; 281: H2002-H2009
        • Takeuchi M.
        • Borden W.B.
        • Nakai H.
        • Nishikage T.
        • Kokumai M.
        • Nagakura T.
        • Otani S.
        • Lang R.M.
        Reduced and delayed untwisting of the left ventricle in patients with hypertension and left ventricular hypertrophy: a study using two-dimensional speckle tracking imaging.
        Eur Heart J. 2007; 28: 2756-2762
        • Tan Y.T.
        • Wenzelburger F.
        • Lee E.
        • Heatlie G.
        • Leyva F.
        • Patel K.
        • Frenneaux M.
        • Sanderson J.E.
        The pathophysiology of heart failure with normal ejection fraction: exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion.
        J Am Coll Cardiol. 2009; 54: 36-46
        • Charoenpanichkit C.
        • Little W.C.
        • Mandapaka S.
        • Dall'armellina E.
        • Morgan T.M.
        • Hamilton C.A.
        • Hundley W.G.
        Impaired left ventricular stroke volume reserve during clinical dobutamine stress predicts future episodes of pulmonary edema.
        J Am Coll Cardiol. 2011; 57: 839-848
        • Popović Z.B.
        • Richards K.E.
        • Greenberg N.L.
        • Rovner A.
        • Drinko J.
        • Cheng Y.
        • Penn M.S.
        • Fukamachi K.
        • Mal N.
        • Levine B.D.
        • Garcia M.J.
        • Thomas J.D.
        Scaling of diastolic intraventricular pressure gradients is related to filling time duration.
        Am J Physiol Heart Circ Physiol. 2006; 291: H762-H769
        • Borlaug B.A.
        • Paulus W.J.
        Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment.
        Eur Heart J. 2011; 32: 670-679
        • James T.N.
        A cardiogenic hypertensive chemoreflex.
        Anesth Analg. 1989; 69: 633-646
        • Levine R.A.
        • Schwammenthal E.
        Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts.
        Circulation. 2005; 112: 745-758
        • van Belle G.
        • Martin D.C.
        Sample size as a function of coefficient of variation and ratio of means.
        Am Stat. 1993; 47: 165-167