Paradoxical hypertension after reversal of heart failure in patients treated with intensive vasodilator therapy

Abstract

Hypertension is a major cause of heart failure, evolving from left ventricular hypertrophy to systolic and diastolic dysfunction. Although effective heart failure therapy has been associated with a lowering or no change in systemic arterial blood pressure in long-term follow-up, this study describes the symptomatic, clinical, and left ventricular functional response of a subgroup of heart failure patients with a prior history of hypertension who demonstrated a paradoxical hypertensive response despite high-dose vasodilator therapy. We prospectively identified 45 patients with a past history of hypertension who had become normotensive with symptomatic heart failure. Of these 45 heart failure patients, 12 became hypertensive while receiving therapy in follow-up, with systolic blood pressure ≥ 140 mm Hg (Group A). The remaining 33 patients did not have a hypertensive response to therapy (Group B). In the 12 Group A patients, 60 ± 10 years old, with symptomatic heart failure for 6.3 ± 4.3 years, vasodilator therapy was intensified in the 2.0 ± 0.5 years of follow-up, achieving final doses of enalapril 78 ± 19 mg and isosorbide dinitrate 293 ± 106 mg per day. New York Heart Association classification improved from 2.9 ± 0.8 to 1.3 ± 0.5 ( P ≤> .0001), with a reduction in heart-failure–related hospitalizations. Left ventricular ejection fraction increased from 17 ± 6% to 40 ± 10% ( P < .0001). Follow-up blood pressure at 1 to 3 months was unchanged. However, both systolic and diastolic blood pressure increased at final follow-up, rising from 116 ± 14 to 154 ± 13 mm Hg ( P = .0001) and from 71 ± 9 to 85 ± 14 mm Hg ( P = .004), respectively. Renal function remained unchanged. Although both groups had similar clinical responses, there were more blacks and women in the hypertensive Group A. Effectively, 12 of 45 (27%) heart failure patients with an antecedent history of hypertension demonstrated a paradoxical hypertensive response to vasodilator therapy. The recurrence of hypertension in a significant portion of patients successfully treated for heart failure has important clinical implications.