Can a patient with hydrostatic pulmonary edema due to severe hypertension (hypertension) and acute agitation have a normal B-type natriuretic peptide (BNP) level?

From the Guidelines

Yes, it is possible to have normal BNP levels with hydrostatic pulmonary edema in this case. The patient's pulmonary edema is likely due to a combination of acute hypertensive crisis (SBP 200-220) and sympathetic surge from substance abuse and agitation, rather than chronic heart failure. This represents a form of non-cardiogenic pulmonary edema or flash pulmonary edema. BNP is primarily released in response to chronic myocardial stretch, and in acute settings like this, there may not have been sufficient time for BNP elevation, as noted in studies such as 1. The normal jugular venous pressure (JVP) further supports that this is not due to chronic heart failure.

Management should focus on blood pressure control with IV antihypertensives like nicardipine (initial dose 5 mg/hr, titrated every 5-15 minutes) or clevidipine (1-2 mg/hr, doubled every 90 seconds as needed). Continuing sedation with propofol helps reduce sympathetic drive. Once stabilized, a thorough substance toxicology screen should be performed, particularly for stimulants like cocaine or amphetamines which can cause this presentation. An echocardiogram should be obtained to evaluate cardiac function once the patient is stabilized, as recommended by guidelines such as 1. This condition typically resolves rapidly with appropriate blood pressure management and supportive care.

Key points to consider in management include:

• Blood pressure control to reduce strain on the heart and lungs
• Sedation to reduce sympathetic drive and alleviate agitation
• Substance toxicology screening to identify potential causes of the presentation
• Echocardiogram to evaluate cardiac function and guide further management
• Monitoring for signs of heart failure, such as increased BNP levels or worsening symptoms, as discussed in 1.

By prioritizing these aspects of care, it is possible to effectively manage the patient's condition and improve outcomes.

From the Research

Patient Presentation

• The patient is a 46-year-old male with a history of poly substance abuse, presenting with acute agitation, severely elevated systolic blood pressure (200-220 mmHg), and hypoxia respiratory failure.
• A chest X-ray (CXR) shows pulmonary edema, but surprisingly, the brain natriuretic peptide (BNP) level is normal, and renal function and white blood cell (WBC) count are within normal limits.
• The patient required intubation and was managed with mechanical ventilation and propofol.

Possible Explanation for Normal BNP

• It is possible that the patient's normal BNP level is due to the fact that the pulmonary edema is hydrostatic in nature, related to the severely elevated blood pressure and agitation, rather than cardiogenic in origin 2, 3, 4, 5.
• The lack of jugular venous distension (JVD) and normal renal function also support this possibility.
• The patient's presentation is consistent with sympathetic crashing acute pulmonary edema (SCAPE), a condition characterized by acute hypertensive cardiogenic pulmonary edema, often precipitated by a sympathetic surge 2, 3, 4, 5.

Management of SCAPE

• The management of SCAPE typically involves the use of high-dose nitrates, such as nitroglycerin, to reduce blood pressure and afterload, as well as non-invasive positive pressure ventilation (NIPPV) to maintain oxygenation 2, 3, 4, 5.
• In some cases, the addition of other medications, such as nicardipine, may be necessary to control blood pressure and prevent intubation 3.
• The use of repeated buccal administrations of nitroglycerin ointments has also been shown to be effective in preventing intubation in patients with SCAPE 4.
• High-dose nitroglycerin bolus therapy has also been studied as a potential treatment for SCAPE, with promising results 5.