I read with interest Harinstein et al's review of clinical assessment in acute heart failure syndromes (AHFS) . Initial assessment of AHFS included evaluation of important prognostic factors which influence treatment such as the presence of atrial fibrillation, acute pulmonary oedema and renal function. This is in accordance with the 6 axis model described by Professor Gheorghiade. An important factor in the 6 axis model which has been neglected is the role of blood pressure in the presentation and evaluation of AHFS. Blood pressure plays a critical role in the prognosis of acute heart failure and should be a central consideration in management decisions. Previous work by Prof Gheorghiade describes the central role of blood pressure in acute heart failure. Blood pressure is an independent predictor of mortality and morbidity in heart failure. AHFS can present with low, normal and high blood pressure and each of these groups have different pathophysiology and respond differently to treatment. It is important to distinguish between them in the evaluation of AHFS. High blood pressure in AHFS tends to be due to a reactive hypertension caused by high sympathetic tone whereas low blood pressure reflects poor cardiac output . Studies have shown that elevated systolic blood pressure (SBP) is common in patients hospitalized with AHFS. These patients have a lower post-discharge mortality, lower rates of rehospitalisation and shorter duration of stay that those with low systolic blood pressure. However they also have a increased risk of morbid events. It is hypothetised that blood pressure may distinguish those with early or mid stage disease (high SBP) from those with advanced disease (low SBP) . Congestive symptoms were more likely in high blood pressure at admission however during discharge low SBP had more congestive symptoms. Patients with high blood pressure may respond to heart failure treatment differently to low SBP however high blood pressure in AHFS is underrepresented in clinical trials of heart failure drugs. Use of ACE inhibitors and Beta blockers in these patients may have beneficial anti- hypertensive effect whereas they are less used in heart failure with hypotension. Hypotension may represent low cardiac output and maintaining adequate blood pressure is a treatment priority in the management of these types of AHFS. High SBP had better response to treatment however the re- hospitalisation rates and risk of morbid events were similar to low SBP. Better treatment response in high SBP gave physician a false sense of security that these patients were not as ill as hypotensive AHFS. This may have resulted in less aggressive management. There were lower rates of left ventricular function assessment and aldosterone use in high SBP. Acute heart failure is often inadequately managed in hospitals resulting in poor prognosis and re-hospitalisation. One of the factors influencing good management is careful evaluation of blood pressure. The role of this important factor is often poorly understood and underestimated. Yet it is a clinical feature which makes a substantial difference to treatment response.

Harinstein M E, Flaherty J D, Fonarow G C, Mehra M R, Lang R M, Raymond K J, Cleland J G, Knight B P, Pang P S, Bonow R O, GHEORGHIADE M Clinical assessment of acute heart failure syndromes: emergency department through the early post-discharge period Heart 2011 97:1607-1618; doi:10.1136/hrt.2011.222331

Gheorghiade M, Abraham W T, Albert N M, Greenberg B H, O'Connor C, Yancy C W, Young J B, Fonorow G C, Systolic Blood Pressure at Admission, Clinical Characteristics, and Outcomes in Patients Hospitalized With Acute Heart Failure JAMA. 2006;296(18):2217-2226. doi: 10.1001/jama.296.18.2217

Gheorghiade M, Abraham WT, Albert NM, et al., OPTIMIZE-HF Investigators and Coordinators. Systolic blood pressure at admission, clinical characteristics, and outcomes in patients hospitalized with acute heart failure. JAMA. 2006;296(18):2217-2226.

Flaherty JD, Bax JJ, De Luca L, et al., Acute Heart Failure Syndromes International Working Group. Acute heart failure syndromes in patients with coronary artery disease early assessment and treatment. J Am Coll Cardiol. 2009;53(3):254-263

Gheorghiade M, Zannad F, Sopko G, et al. Acute heart failure syndromes: current state and framework for future research. Circulation.2005;112:3958

Conflict of Interest:

None declared