Commentary: The Hemodynamic Basis of Hypertensive Vasculopathy, Heart Failure, and Chronic Kidney Disease

Fu and co-investigators reported that patients with acute heart failure (HF), impaired renal function (IRF), and altered arterial pulsatility (high aortic pulse wave velocity (PWV), and backward wave pressure, Pb) are less likely to experience in-hospital or posthospital improvement in renal function (estimated glomerular filtration rate [eGFR]) and more likely to experience adverse cardiovascular disease (CVD) outcomes.1 They opined that the presence of altered arterial pulsatility “may facilitate the development of novel strategies to prevent and manage IRF in patients hospitalized for acute HF.” The individual associations among several closely related disorders (sustained hypertension, increased arterial stiffness, chronic kidney disease (CKD), as well as acute and chronic HF) are very well established and, in that sense, present data are confirmatory rather than novel. What has value but was underemphasized is the close pathophysiological linkage among these interrelated conditions, which is the main rationale for this commentary. To add perspective, we have developed a new hemodynamic “cardio-vasculo-renal” disease model. It is also necessary to address several historical misconceptions that often lead to mistakes in interpretation or extrapolation, including the authors’ speculation that abnormal pulsatility can or should influence clinical management.