The pathogenesis of acute pulmonary edema associated with hypertension

N Engl J Med. 2001 Jan 4;344(1):17-22. doi: 10.1056/NEJM200101043440103.


Background: Patients with acute pulmonary edema often have marked hypertension but, after reduction of the blood pressure, have a normal left ventricular ejection fraction (> or =0.50). However, the pulmonary edema may not have resulted from isolated diastolic dysfunction but, instead, may be due to transient systolic dysfunction, acute mitral regurgitation, or both.

Methods: We studied 38 patients (14 men and 24 women; mean [+/-SD] age, 67+/-13 years) with acute pulmonary edema and systolic blood pressure greater than 160 mm Hg. We evaluated the ejection fraction and regional function by two-dimensional Doppler echocardiography, both during the acute episode and one to three days after treatment.

Results: The mean systolic blood pressure was 200+/-26 mm Hg during the initial echocardiographic examination and was reduced to 139+/-17 mm Hg (P< 0.01) at the time of the follow-up examination. Despite the marked difference in blood pressure, the ejection fraction was similar during the acute episode (0.50+/-0.15) and after treatment (0.50+/-0.13). The left ventricular regional wall-motion index (the mean value for 16 segments) was also the same during the acute episode (1.6+/-0.6) and after treatment (1.6+/-0.6). No patient had severe mitral regurgitation during the acute episode. Eighteen patients had a normal ejection fraction (at least 0.50) after treatment. In 16 of these 18 patients, the ejection fraction was at least 0.50 during the acute episode.

Conclusions: In patients with hypertensive pulmonary edema, a normal ejection fraction after treatment suggests that the edema was due to the exacerbation of diastolic dysfunction by hypertension--not to transient systolic dysfunction or mitral regurgitation.

Publication types

  • Clinical Trial
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Acute Disease
  • Aged
  • Antihypertensive Agents / therapeutic use
  • Diastole
  • Diuretics / therapeutic use
  • Echocardiography, Doppler
  • Female
  • Follow-Up Studies
  • Heart Failure / etiology
  • Humans
  • Hypertension / complications*
  • Hypertension / drug therapy
  • Hypertension / physiopathology
  • Male
  • Mitral Valve Insufficiency / complications
  • Pulmonary Edema / diagnostic imaging
  • Pulmonary Edema / drug therapy
  • Pulmonary Edema / etiology*
  • Radiography
  • Stroke Volume
  • Vasodilator Agents / therapeutic use
  • Ventricular Dysfunction, Left / complications*
  • Ventricular Function, Left


  • Antihypertensive Agents
  • Diuretics
  • Vasodilator Agents