(167) Heart-to-Heart: Comparing Antihypertensive Strategies in Hypertensive Emergencies With Heart Failure

Introduction: 6.2 million Americans live with heart failure (HF) and are at risk for hospitalization due to hypertensive emergencies. Optimal treatment strategy for hypertensive emergency in decompensated heart failure remains unclear. Our study investigates what treatment modality is most effective in achieving guideline-directed blood pressure control.

Methods: Retrospective cohort study of hypertensive emergency with HF exacerbation from 2019-2021 at a single center. Patients with an initial blood pressure (BP) ≥180/120, HF exacerbation, and systolic or diastolic HF on echocardiogram were included. The primary outcome was length of time for a 25% decrease in systolic BP or BP of < 160/110 mmHg. Patients were categorized into 4 groups: only oral medications, IV bolus, continuous IV infusion (CIVI), or both CIVI and IV bolus. P-values for pairwise tests were adjusted using the Bonferroni method for multiple comparisons.

Results: 1041 patients had ICD codes of hypertensive emergency, and after excluding patients with missed dialysis, stroke, acute coronary syndrome or hypertension in pregnancy, a total of 120 admissions were analyzed. 28 received oral medications, 33 received IV bolus, 34 received CIVI, and 25 received both CIVI and IV bolus, with similar gender, race, ethnicity, and BMI. However HF phenotype, initial systolic BP, and age varied based on treatment modality, with younger and initially higher SBP patients more likely to receive CIVI or both CIVI and IV bolus treatment. There were no significant differences in achieving the target BP among groups (ANOVA p=0.662). CIVI had a nonsignificant trend towards achieving target BP fastest, followed by both CIVI and IV bolus, IV bolus, and followed by only oral (8.882 vs 10.720 vs 15.242 vs 15.429 hours; ANOVA p=0.068). However, IV bolus administration resulted in significantly fewer days in ICU compared to CIVI (0.182 [SD, 0.584] vs 0.765 [SD, 0.699] days, p = 0.003) without a significant change in total hospital length of stay (5.061 [SD, 4.899] vs 3.176 [SD, 2.007] days, p = 0.282).

Conclusions: IV bolus and CIVI appear equally efficacious strategies to achieve blood pressure goals in patients with heart failure exacerbation who have a hypertensive emergency. Use of IV bolus therapy in these patients was associated with shorter ICU length of stay.