Orthostatic Hypertensive Emergency in Obesity-Related Heart Failure With Preserved Ejection Fraction (HFpEF): A Single-Center Retrospective Observational Study.

backgroundOrthostatic hypertension is an under-recognized abnormal blood pressure phenotype defined by a paradoxical increase in systolic blood pressure after standing. Consensus definitions describe an exaggerated orthostatic pressor response as a systolic blood pressure increase of at least 20 mmHg after standing, with orthostatic hypertension present when standing systolic blood pressure reaches at least 140 mmHg. Although orthostatic hypertension has been associated with adverse cardiovascular and cerebrovascular outcomes, acute symptomatic presentations resembling a hypertensive emergency remain poorly characterized.

objectiveThis study describes the clinical characteristics, hemodynamic profile, management, and follow-up outcomes of hospitalized patients with symptomatic orthostatic hypertensive emergency in the setting of severe obesity and obesity-related heart failure with preserved ejection fraction (HFpEF).

methodsWe conducted a single-center retrospective observational study of hospitalized adult patients evaluated by cardiology who had orthostatic blood pressure measurements obtained during routine clinical care. Patients were included if they had an orthostatic systolic blood pressure increase of at least 20 mmHg from supine to standing, a standing systolic blood pressure of at least 140 mmHg, and associated neurological or cardiac symptoms. Patients were excluded if they were critically ill, unable to stand, or receiving vasopressor therapy or lacked complete orthostatic blood pressure documentation. Demographics, comorbidities, symptoms, blood pressure values, echocardiographic findings, cardiac catheterization results when available, treatment strategies, lifestyle adherence, weight change, and follow-up outcomes were abstracted from the medical record.

resultsSeven patients met the inclusion criteria. The median age was 56 years, and body mass index ranged from 44.1 to 78.2 kg/m². Initial orthostatic systolic blood pressure increases ranged from 21 to 44 mmHg, with a peak standing systolic blood pressure ranging from 148 to 194 mmHg at index presentation. One patient later developed recurrent severe orthostatic hypertension, with systolic blood pressure increasing from 109 mmHg supine to 188 mmHg standing. Presenting symptoms included dyspnea, chest pain, pulmonary edema, syncope or near-syncope, confusion, and stroke-like symptoms. All patients had severe obesity and clinical features consistent with obesity-related cardiometabolic disease and HFpEF. Patients who adhered to structured cardiometabolic lifestyle and medical therapy demonstrated weight loss and improvement or resolution of orthostatic symptoms and blood pressure abnormalities. Patients who were non-adherent experienced persistent symptoms, recurrent hospitalization, or loss to follow-up.

conclusionOrthostatic hypertensive emergency may represent an under-recognized acute phenotype of postural blood pressure dysregulation in patients with severe obesity, cardiometabolic disease, and HFpEF. Routine orthostatic blood pressure assessment in hospitalized patients with obesity-related heart failure symptoms may improve the recognition of clinically significant blood pressure variability. The very small sample size of our experience serves as a hypothesis-generating report. Larger prospective studies are needed to define prevalence, prognosis, mechanisms, and optimal treatment strategies.