Treatment of acute hypertensive heart failure. The left ventricular (LV) end‐ diastolic pressure‐volume relationships (compliance curves) in acute hypertensive heart failure (AHHF) before and after treatment with sodium nitroprusside are rep­resented schematically. In AHHF, the pressure‐volume curve is shifted up and to the left, reecting an acute decrease in LV compliance caused by severe systemic hypertension. In this setting, a higher than normal LV end‐diastolic pressure (LVEDP) is required to achieve any given level of LV end‐diastolic volume (LVEDV). Normal LV systolic function (ejection fraction and cardiac output) is maintained but at the expense of a very high wedge pressure that results in acute pulmonary edema. Treatment with sodium nitroprusside causes a reduction in the elevated systemic vascular resistance, with a concomitant decrease in impedance to LV ejection. As a result, LV compliance improves. Pulmonary edema resolves owing to a reduction in LVEDP, despite the fact that LVEDV actually increases dur­ing treatment. Sodium nitroprusside is the preferred drug for treatment of AHHF. There is no absolute blood pressure goal. The infusion should be titrated until signs and symptoms of pulmonary edema resolve or the blood pressure decreases to hypotensive levels. Rarely is it necessary to lower the blood pressure to this extent, however, because reduction to levels still within the hypertensive range is usually associated with dramatic clinical improvement. Although hemodynamic monitoring is not always required, it is essential in patients in whom concomitant myocardial ischemia or compromised cardiac output is suspected. After the hyper­tensive crisis has been controlled and pulmonary edema has resolved, oral antihy­pertensive therapy can be substituted as the patient is weaned from the nitroprusside