Hypertensive heart disease

Overview 

Hypertensive heart disease is characterized by a series of alterations in the left ventricle, left atrium, and coronary arteries caused by prolonged blood pressure increase. Hypertension puts more strain on the heart, causing anatomical and functional alterations in the myocardium. These alterations include left ventricular enlargement, which can lead to heart failure. Patients with left ventricular hypertrophy have much higher morbidity and mortality, although current treatment adheres to typical hypertension recommendations since the effects of medication on regression of left ventricular hypertrophy are unknown.

Hypertensive heart disease is subclassified by the presence or absence of heart failure as the management of heart failure requires more intensive goal-directed therapy. Hypertensive heart disease can lead to either diastolic heart failure, systolic failure, or a combination of the two. Such patients are at a higher risk for developing acute complications such as decompensated heart failure, acute coronary syndrome, or sudden cardiac death. 

Hypertension disturbs the endothelium system, increasing the risk of coronary artery disease and peripheral arterial disease, and is thus a substantial risk factor for the development of atherosclerotic disease. However, hypertensive heart disease eventually incorporates all of the direct and indirect consequences of persistent high blood pressure, such as systolic or diastolic heart failure, conduction arrhythmia, particularly atrial fibrillation, and an increased risk of coronary artery disease.

 

How common is Hypertensive heart disease?

Hypertension is one of the most common diseases in the United States, affecting roughly 75 million individuals, or one in every three US adults. Only 54% of these individuals with hypertension had sufficient blood pressure management. The global prevalence of hypertension is 26.4 percent, accounting for 1.1 billion individuals, yet only one in every five persons has their blood pressure under control. According to one research, chronic hypertension finally leads to heart failure after a median of 14.1 years.

Meta-analyses have revealed a log-linear link between high blood pressure and an increased risk of cardiovascular disease, which grows significantly with age:

  • In patients age 45-54 years old - 36.1% of males, 33.2% of females.
  • In patients age 55-64 - 57.6% of males and 55.5% of females.
  • In patients age 65-74 - 63.6% of males and 65.8% of females.
  • In patients age 75 or older 73.4% of males and 81.2% of females.

In comparison to males, women have a slightly higher prevalence of hypertension and a threefold greater risk of heart failure (2-fold). Women are more likely than males to have uncontrolled blood pressure, and new research suggests that certain antihypertensive drugs may be less helpful in women.

Certain ethnic groups have a higher predisposition for hypertension. The prevalence of hypertension among the African American population is among the highest of any ethnic group in the world at 45.0% for males and 46.3% for females. 

The rate is 34.5% for Caucasian males with 32.3% for females and 28.9% among Hispanic males with 30.7% for females. In addition to the highest rate of hypertension, black Americans have a higher risk of developing heart failure, higher average blood pressure which develops at an earlier age, and are less amenable to treatment. All these factors contribute to increased mortality and a higher burden of disease.

 

What are the causes of Hypertensive heart disease?

Chronic elevated blood pressure causes hypertensive heart disease. According to the 2017 American Cardiology Association/American Heart Association recommendations, hypertension is defined as blood pressure with a systolic pressure greater than 120 mm Hg or a diastolic pressure greater than 80 mm Hg. Every 20mmHg systolic and 10mmHg diastolic pressure increase above a baseline blood pressure of 115/75 doubles the risk of cardiovascular death.

The great majority of hypertensive individuals (90 to 95 %) will be classified as having primary or essential hypertension. The cause of primary hypertension remains unknown. However, it is most likely a complicated combination of genetic and environmental influences. Increasing age, family history, obesity, high salt diets (more than 3g/day), physical inactivity, and excessive alcohol intake are all risk factors for the development of hypertension. Hypertension has been observed to occur 14.1 years before the onset of heart failure.

Hypertensive heart disease accounts for approximately one-fourth of all causes of heart failure. When particular risk factors and age are taken into account, the Framingham Heart Study found that hypertension increases the development of heart failure by a ratio of two in men and a factor of three in women. 

The 2015 SPRINT study found a lower risk of heart failure progression in individuals with more intense blood pressure management, with a target systolic blood pressure of 120mmHg (1.3 %) compared to 140mmHg (2.1%). Proper hypertension control is associated with a 64% decrease in the development of heart failure. 

 

Symptoms and signs of Hypertensive heart disease

Because most patients with hypertension do not have symptoms until late in the course, the history and physical exam are critical components of hypertensive heart disease therapy. Patients with left ventricular hypertrophy are asymptomatic; nevertheless, due to the higher oxygen demand required by the hypertrophied myocardiocytes, left ventricular hypertrophy can cause anginal/ischemic chest discomfort.

Patients with angina or coronary artery disease may manifest with exertional chest pain. Some individuals with acutely decompensated heart failure may initially manifest with shortness of breath. Patients with high blood pressure are at risk of developing atrial fibrillation. Patients may have palpitations, stroke, dizziness, syncope, or even abrupt heart death as a result of conduction abnormalities.

The history should focus on the severity, duration, and current therapy of hypertension. Hypertension is a major risk factor for the development of a variety of cardiovascular disorders, including coronary artery disease, congestive heart failure, atrial fibrillation, cerebrovascular disease, peripheral arterial disease, aortic aneurysm, and chronic kidney disease. Other important modifiable cardiovascular risk factors, such as hyperlipidemia, diabetes, alcohol consumption, smoking, drug use, and other concomitant illnesses such as chronic renal disease or pulmonary disease, should be evaluated in patients.

Diabetes is quite widespread in this patient group and serves as a cardiovascular analogue for the development of cardiovascular disease or chronic renal disease. Glycemic control may be determined by hemoglobin A1C. Sleep apnea, certain medicines, cigarettes, obesity, and alcohol usage all aggravate hypertension and, if left untreated, can develop to treatment-resistant hypertension.

Premature cardiovascular mortality, sudden cardiac death, valve disease, metabolic disease, stroke, or heart failure should always be assessed using a detailed family history.

 

What can clinical examination reveal?

Except in the case of severe cardiovascular disease, the physical exam is usually performed on a regular basis. An S3 or S4 may be discovered during a cardiac auscultation. An aberrant S4 sound indicates stiff, hypertrophic ventricles and is extremely specific to hypertensive heart disease. An abnormal S3 implies thin, eccentric hypertrophy with systolic cardiac failure.

Carotid bruits or reduced peripheral pulses may occur in patients at risk of atherosclerotic disease. Bilateral blood pressure readings should be taken, especially in individuals with acute symptomatic illness, to rule out aortic dissection. Every visit should include a blood pressure check, and ambulatory home blood pressure monitoring is advised.

The ophthalmic exam is frequently neglected in clinical practice, despite the fact that it might give information on the amount and duration of hypertension. The ophthalmic examination should look for AV narrowing or nicking, cotton wool spots, exudate and hemorrhage, and papilledema. The Keith-Wagener-Barker classification is commonly used to classify hypertensive retinopathy:

  • Grade 1: Mild nonproliferative retinopathy: mild narrowing or tortuosity of the retinal arterioles which indicates mild, asymptomatic hypertension.
  • Grade 2: Moderate nonproliferative retinopathy: definite narrowing or constriction with AV nicking or sclerosis present which often indicates more elevated but likely asymptomatic chronic hypertension.
  • Grade 3: Severe nonproliferative retinopathy: shows hemorrhage and exudative, cotton wool spots - blood pressure is often significantly elevated and symptomatic, but end-organ damage is minimal and usually reversible.
  • Grade 4: Severe proliferative retinopathy: additionally, demonstrates papilledema and retinal edema - blood pressure is persistently elevated, and patients will present with symptoms such as headache, visual disturbances, malaise, or dyspnea; these patients need urgent evaluation and close follow up as they have significant cardiovascular mortality.

 

Diagnosis of Hypertensive heart disease

The workup for hypertensive heart disease should focus on checking for probable end-organ damage, assessing for other cardiovascular risk factors, and assessing for possible secondary causes of hypertension if clinical symptoms or a physical exam suggest it. 

Patients should be evaluated for the existence of renal disease, diabetes and glycemic control, hyperlipidemia, pulmonary disease, and other concomitant diseases, including baseline creatinine. Obese male patients are at increased risk for sleep apnea and should be tested with STOP-BANG and referred for sleep apnea examination if necessary. To measure their cardiovascular risk and establish the amount of intervention required, all patients should be evaluated using a 10-year cardiovascular risk calculator.

  • EKG is the recommendation for initial evaluation of hypertensive heart disease - it may demonstrate ventricular hypertrophy, left axis deviation, or conduction abnormalities, EKGs have high specificity (75 to 95%) but low sensitivity (25 to 61%) for the detection of cardiovascular disease
  • Basic metabolic panel - sodium, potassium, calcium, blood urea nitrogen, creatinine
  • Lipid Panel
  • CBC
  • Urinalysis with consideration for checking the urine protein albumin ratio
  • TSH especially in the setting of atrial fibrillation

An echocardiography is not indicated for regular hypertension assessment because the presence of LVH does not modify therapy. An echocardiography should be explored in patients with signs of heart failure, in young children under the age of 18, and in individuals with chronic, uncontrolled hypertension.

 

Treatment of Hypertensive heart disease

The American Cardiology Association/American Heart Association revised the previous JNC8 recommendations and released updated 2017 guidelines, classifying blood pressure into one of four categories: normal, elevated, stage 1 hypertension, or stage 2 hypertension.

  • Normal blood pressure is defined as blood pressure as a systolic blood pressure under 120 mm Hg and a diastolic pressure less than 80mm Hg.
  • Elevated blood pressure occurs when systolic pressure ranges from 120-129mmHg with a diastolic pressure less than 80mm Hg.
  • Stage 1 hypertension is defined as systolic pressure ranges from 130-139mmHg or diastolic blood pressure between 80-89mmHg.
  • Stage 2 Hypertension has a systolic blood pressure greater than 140mmHg or diastolic blood pressure of 90mmHg or higher.

 

The treatment of hypertension involves the use of antihypertensive medications:

  • Thiazide diuretics especially chlorthalidone are the first line for hypertension - diuretics are necessary for patients with resistant hypertensive disease.
  • Angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers are the first line for hypertension especially in patients with diabetes or chronic kidney disease.
  • Calcium channel blockers are the first line for hypertension.
  • Beta-blockers are not currently a recommendation for use in isolated hypertension - they are first-line for use in heart failure, ischemic heart disease, atrial fibrillation.
  • Vasodilators such as hydralazine are not first-line and should only be added when a third or fourth medication is needed for difficult to control hypertension or when contraindications exist for first-line medications

Two or more antihypertensives are usually required for optimal management, especially in individuals with stage 2 hypertension. Patients with stage 2 hypertension should start on two antihypertensives and be reviewed in thirty days to see if they are responding to medication. It is not recommended to take two drugs from the same class at the same time, such as an ACEI and an ARB. Heart failure should be managed in accordance with goal-directed medical therapy.

 

What's the outcome of Hypertensive heart disease?

Hypertensive heart disease is a chronic, progressive disease that increases the risk of cardiovascular mortality dramatically. Hypertension is a major risk factor for the development of a variety of cardiovascular disorders, including coronary artery disease, congestive heart failure, atrial fibrillation, cerebrovascular disease, peripheral arterial disease, aortic aneurysm, and chronic kidney disease.

The overall prognosis of hypertensive heart disease is diverse and varies on a number of circumstances, including the specific manifestations of the disease, the existence of concurrent cardiovascular disease or risk factors, and other comorbid disorders. Cardiovascular risk calculators are accessible, and individuals should be classified as either high or low risk for cardiovascular events. Specific forms of HHD, such as heart failure or atrial fibrillation, are associated with a significantly elevated risk of cardiovascular death.

Diastolic heart failure patients have the same risk and morbidity as those with low ejection heart failure, with 6-month death rates as high as 16%.

 

Complications of Hypertensive heart disease

Hypertensive heart disease is a complication condition related to the cardiovascular problems associated with persistent hypertension. Hypertension is the most common modifiable risk factor for early cardiovascular disease and cardiovascular death, and it need continuous monitoring to detect problems and delay their progression.

Prolonged hypertension increases left ventricular hypertrophy, which leads to heart failure (both systolic and diastolic). Eccentric hypertrophy causes the myocardium's oxygen demand to rise, which might result in angina or ischemia symptoms. Muscle hypertrophy can alter conduction pathways, leading to atrial fibrillation and ischemic stroke.

Acute blood pressure changes can predispose individuals to intracerebral hemorrhage or retinopathy. Prolonged hypertension is the most common risk factor for the development of cardiac illness, which includes atherosclerotic disease, heart failure, valvular disease, atrial fibrillation, and cerebrovascular disease, chronic renal disease, retinal disease, and metabolic disease. Sustained hypertension is responsible for over half of all strokes and ischemic heart disease.

 

How Hypertensive heart disease can be prevented?

People with high blood pressure may be unaware of their disease since there are no symptoms. Early detection of high blood pressure can help avoid heart disease, stroke, vision issues, and chronic kidney disease.

Lifestyle changes, such as dietary counseling, encouragement of weight reduction and regular aerobic activity, moderation of alcohol intake, and smoking cessation, can minimize the risk of cardiovascular disease and mortality. Controlling hypertension and lowering the risk of cardiovascular disease may also necessitate drug therapy, as may managing heart failure or controlling cardiac arrhythmias. 

Patients with hypertensive heart disease should avoid using nonsteroidal anti-inflammatory medicines (NSAIDs), cough suppressants, and decongestants containing sympathomimetics unless otherwise directed by their doctor, as they might aggravate hypertension and heart failure.

According to JNC 7, BP goals should be as follows:

  • Less than 140/90mm Hg in patients with uncomplicated hypertension.
  • Less than 130/85mm Hg in patients with diabetes and those with renal disease with less than 1g/24-hour proteinuria.
  • Less than 125/75mm Hg in patients with renal disease and more than 1 g/24-hour proteinuria.

 

Conclusion

Hypertensive heart disease refers to a group of high blood pressure issues that damage the heart. When a causative association between the heart disease and hypertension is indicated or suggested on the death certificate, the term encompasses heart failure and other cardiac consequences of hypertension. In 2013, hypertensive heart disease killed a total of 1.07 million people.

Hypertensive heart disease is characterized by physical alterations as well as changed physiology of the heart muscle, coronary arteries, and great vessels. Left ventricular hypertrophy is the most potent cardiovascular risk factor, as well as a target organ response to increasing afterload. Hypertrophy regression lowers morbidity and death.

Heart failure may occur in the absence of a decrease in myocardial contractility. Ischemic heart disease develops when there is no epicardial coronary disease. There is a link between left atrial size and atrial fibrillation. Hypertensive individuals are more likely to experience potentially fatal ventricular arrhythmias and abrupt cardiac death. 

The association between aortic root size and blood pressure is weaker than predicted; however, the relationship between aortic dissection and blood pressure is greater. Survival will improve with careful monitoring and treatment of left ventricular hypertrophy, heart failure, ischemic heart disease, and atrial fibrillation.