Acute pulmonary edema secondary to a hidden hypertensive emergency

Severe stenosis of the subclavian artery is a rare clinical finding, even more so for bilateral existence of the condition. Subclavian artery stenosis leads to erroneously normal or even low blood pressure values when measured at the brachial artery on the ipsilateral side. The poor control of blood pressure may cause cardiovascular complications such as heart failure and acute pulmonary edema without the patient having high blood pressure in the arms. Widespread clinical reliance on a sole brachial measurement of blood pressure, particularly in the emergency room setting, may result in inappropriate clinical management in patients with conditions that alter brachial blood pressure. We report a case of acute diastolic heart failure secondary to hypertensive emergency hidden due to bilateral stenosis of both subclavian arteries in a patient with severe atherosclerosis, cerebrovascular disease, and symptoms of subclavian steal syndrome.