Initial Emergency Department Blood Pressure and Acute Congestive Heart Failure Outcomes

Congestive heart failure (CHF) may affect eight million Americans by 2030. These patients present to the Emergency Department (ED) with a wide range of initial blood pressure (BP), and the mainstay of therapy is diuretics. Our objective is to assess if presenting BP affects outcomes for CHF patients who receive diuretics in the ED.

We conducted a retrospective cohort study of a large health system from 2016 to 2022. We included ED-admitted CHF exacerbations with history of CHF and received ED diuretics. We excluded patients with history of aortic stenosis, SBP < 90, need for inotropes/vasopressors, creatinine (Cr) > 3, on dialysis, and missing data. Patients were divided based on triage BP. The Normal group included patients with systolic (SBP) of <120 or a diastolic BP of <80, Stage 1 included SBP ≥ 120 or DBP ≥ 80, Stage 2 included SBP ≥ 140-179 or DBP ≥ 90-119, and Hypertensive Crisis included SBP ≥ 180 or DBP ≥ 120. Primary outcome was hospital LOS and additional outcomes include readmission, mortality, ICU, BIPAP and AKI. Multivariable regression analysis was performed adjusting for age, sex, race, BMI, initial Cr, and Elixhauser Comorbidity Index and ED diuretic dosing.

There were 10,129 patients identified of which 5,515 were excluded, leaving 4,614 for analysis. Patients fell into the following BP cohorts: Normal (N=1236), Stage 1 (N=784), Stage 2 (N=2055), Hypertensive Crisis (N=539); the median age was 76.0, 37.1% Black and 52.0% female. The LOS for both Stage 1 and Hypertensive Crisis patients was significantly decreased compared to Normal patients, with 8.5% reduction (p=0.012) and 9.2% reduction (p=0.016) respectively. Stage 2 had a 4.9% reduction in LOS that was not significant. Hypertensive Crisis patients saw a 24.9% reduction in readmission (p=0.025), while other groups were reduced but not significant. Higher stages of HTN saw a large decrease in mortality. Stage 2 had 48.2% decreased mortality (p=<0.001), and Hypertensive Crisis had 64.5% decreased mortality (p=0.003). ICU admission and AKI were not significantly different, however BIPAP usage was significantly higher in Stage 2 and Hypertensive Crisis categories.

In our cohort of ED CHF patients receiving diuretics, higher stages of presenting BP were associated with decreased LOS, readmission, and mortality. This may reflect clinicians' more aggressive treatment of CHF patients with elevated BP.