Top Things to Know: Management of Hypertension in Patients With Ventricular Assist Devices
Published: April 18, 2022
Prepared by Paul St. Laurent, DNP, RN, Senior Science and Medicine Advisor
- Mechanical circulatory support with durable continuous-flow left ventricular assist devices (CF-LVADs) has become an important therapeutic management strategy for patients with advanced heart failure (HF).
- As more patients receive CF-LVADs and the duration of support has increased, post implantation complications have become more apparent and the need for approaches for management more compelling.
- Hypertension is a predictor of poor outcomes in patients with LVADs, contributing to device malfunction and device-associated complications including pump thrombosis, increased risk of stroke, right ventricular failure, aortic insufficiency, and ventricular arrhythmias.
- Stroke is a significant complication of long-term LVAD therapy, with nearly 1 in 5 patients having a clinical stroke during 2 years of device support. Risk factors for device related stroke include HTN, thromboembolic events, bleeding from anticoagulation, or some combination of these, with HTN the most readily identifiable and preventable cause.
- Reliable measurement of BP is critical but can be challenging using traditional auscultatory or automated oscillometric cuff measurements due to noise generation from CF-LVADs and a diminished to absent pulse pressure.
- An algorithm for the measurement of BP in patients with a CF-VAD depending on the presence of pulsatility is included in this statement. If the pulse is palpable, BP (systolic, diastolic, mean) can be measured using the manual or oscillometric method. If non-pulsatile, a Doppler device can be used to determine the mean arterial pressure (MAP).
- For patients with a CF-LVAD, current professional societies recommend an MAP of 80 mm Hg (International Society of Heart and Lung Transplantation) or MAP <85 mm Hg (European Association for Cardio-Thoracic Surgery).
- Although guidelines for HTN management after ventricular assist device implantation are based largely on expert consensus and conventional wisdom, the mainstay of treatment for includes guideline-directed medical therapy (GDMT) for HF with reduced ejection fraction because this may reduce adverse effects associated with HTN and increases the likelihood of favorable ventricular remodeling.
- Medications effective for treating HTN in patients with CF-VADs include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β- blockers, hydralazine, and nitrates.
- Appropriate treatment of HTN in patients with a CF-VAD is critically important issue given its effect on limiting VAD efficiency and as a risk factor for the developing stroke and other complications.
Citation
Eisen HJ, Flack JM, Atluri P, Bansal N, Breathett K, Brown AL, Hankins SR, Khazanie P, Masri C, Pirlamarla P, Rowe T; on behalf of the American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Hypertension; and Council on Lifelong Congenital Heart Disease and Heart Health in the Young. Management of hypertension in patients with ventricular assist devices: a scientific statement from the American Heart Association. Circ Heart Fail. 2022;15:e000074. doi: 10.1161/HHF.0000000000000074