This document discusses a 74-year-old female patient with severe hypertension, heart failure, and prior renal failure who was treated with CRRT and vasodilators. Measuring the patient's cardiac output, stroke volume, and systemic vascular resistance revealed that the vasodilator was actually raising her blood pressure by lowering her SVR and increasing her CO. Stopping the vasodilator and CRRT lowered her CO and SVR, reducing her blood pressure. The case demonstrates that identifying abnormalities in CO, SV, and SVR is important for determining the appropriate hypertension treatment, as the relationship between hypertension, heart failure, and renal disease can be complex.

1. Hypertension – Heart Failure
Presentation
74 year old female
Severe hypertension (187/85, MAP 115mmHg)
Prior renal failure and heart failure
8wks in ICU
Treatment
CRRT and controlled fluid
GTN 1.5ug/min/kg – vasodilator for HT
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2. Hypertension – Heart Failure
Effect of Vasodilator on SV
Frank Starling Curve
126cm3
SV Dilator
SV response to preload (filling pressure or LV volumes)
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3. Hypertension – Heart Failure
Hypertension treatments:
- Offload fluid – diuretics. (SVV)
- Reduce SV – Ca blockers and B Blockers (SV, CO, CPo, SW, II)
- Decrease SVR – dilate arteries with ACE inhibitors/GTN (SVR)
Is the abnormality in the heart or the vessels (CO/SV and SVR)?
Complex issues of cardiac and renal disease require
careful circulatory optimization.
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4. Hypertension – Heart Failure
Which treatment is right for this patient?
What is the cause of her hypertension?
CO/SV?
SVR?
What is her fluid status?
What is her best treatment?
Fluid – increase/decrease?
Inotropes – yes or no?
Vasoactives - yes or no?
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5. Hypertension – Heart Failure
USCOM exam
BP 185/85,
MAP 115mmHg
Can you treat this patient without knowing CO and SVR?
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6. Hypertension – Heart Failure
Result
High CO
Low SVR
The low SVR is raising the CO and increasing the MAP.
The vasodilator is actually raising the MAP!
Should the vasodilators and CRRT be stopped?
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7. Hypertension – Heart Failure
Treatment
The GTN and
CRRT was
stopped
Result
Increased SVR
Decreased CO
MAP 115 to 94
The vasodilator was actually raising the MAP!
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8. Hypertension – Heart Failure
SVR SV
1479 126
1600 140
1400 120
1200 1007
Dyne.s.cm-5
100 83 79
1000 866
697 80 66
cm3
800
60
600
400 40
200 20
0 0
Base Post Day2 Norm Base Post Day2 Norm
MAP CPo
115 3.2
120 102 3.5
94
100 3
82
2.5 2.1
80
mmHg
Watts 2 1.5
60
1.5 1
40
1
20 0.5
0 0
Base Post Day2 Norm Base Post Day2 Norm
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9. Hypertension – Heart Failure
Summary
Hypertension can be caused by excess fluid, high CO or high SVR.
Appropriate therapy requires identification of abnormality - need to
measure CO/SV and SVR.
Hypertension, heart failure and renal failure are closely related.
This relationship is complex and complicates fluid and circulatory
management.
Conclusion
Trend measures of objective hemodynamics provide unique insights into
renal and cardiac disease and may improve cardiovascular therapy
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