hypertensive heart disease pathophysiology

January 25, 2021

Clinical Review, You are being redirected to The presence or absence of additional risk factors and/or the use of coronary artery calcium (CAC) scanning can help guide decisions about preventive interventions in select individuals. A.D.A.M. Patients with left ventricular hypertrophy (LVH) alone are totally asymptomatic, unless the LVH leads to the development of diastolic dysfunction and heart failure. The development of left ventricular (LV) hypertrophy (LVH) is clearly related to an increase in the cardiovascular mortality rate. [Comparison of the sensitivity and specificity of the electrocardiography criteria for left ventricular hypertrophy according to the methods of Romhilt-Estes, Sokolow-Lyon, Cornell and Rodriguez Padial]. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Cardiac catheterization is used for the diagnosis of coronary artery disease and helps to assess the severity of elevated pulmonary artery pressure in patients with heart failure. Am J Med. 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. [Guideline] Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston Miller N, Hubbard VS, et al. 289(19):2560-72. [21]. Pharmacol Ther. 2016 May 17. 2014 Apr 10. Hypertensive heart disease is the leading cause of illness and death from high blood pressure. 2008 May 1. The tissue Doppler profile shows a reversed E:A ratio, which is especially helpful in patients who have a pseudonormal pattern on transmitral flow velocity Doppler studies. [22], In a study of 125 patients with acute chest pain, elevated cardiac enzymes, and a negative coronary angiogram, Emrich and colleagues found that cardiac magnetic resonance imaging (CMRI) has a high diagnostic value. Circulation. 2010 Dec 4. 334(7599):885. Hajjar IM, Grim CE, George V, Kotchen TA. 2001 Feb 26. Hypokalemia is found in patients with primary hyperaldosteronism and in patients with secondary hyperaldosteronism, Cushing disease, and Bartter syndrome. Romhilt-Estes Criteria (A Point Score System. Diet and lifestyle risk factors associated with incident hypertension in women. [51] The findings suggested that this approach can safely reduce hypertension in these patients, but the Symplicity HTN-3 blinded trial did not show a significant reduction of systolic BP (SBP) in patients with resistant hypertension 6 months after renal-artery denervation as compared with a sham control. At every healthcare visit, assess all adults for tobacco use. Emrich T, Emrich K, Abegunewardene N, et al. In patients 40 to 75 years of age with diabetes mellitus and an LDL-C level of ≥70 mg/dL: Start moderate-intensity statin therapy without calculating their 10-year ASCVD risk. 26th ed. [Medline]. [Medline]. Kamran Riaz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Society of Echocardiography, Ohio State Medical Association, Royal College of PhysiciansDisclosure: Nothing to disclose. Central nervous system (CNS) examination findings are usually unremarkable unless the patient has had previous cerebrovascular accidents with residual deficit. [10] The risk of sudden cardiac death is increased. Cardiac arrhythmias commonly observed in patients with hypertension include atrial fibrillation, premature ventricular contractions (PVCs), and ventricular tachycardia (VT). In addition, screen for complications related to hypertension, such as cerebrovascular disease, hypertensive retinopathy, worsening heart failure, and renal failure, and assess for LV hypertrophy (LVH) by electrocardiography or echocardiography. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. [8] The level of diastolic dysfunction appears to correlate with increasing severity of hypertension, and peak myocardial systolic strain rate may be an independent factor in the extent of LV remodeling and diastolic function. Other studies include the above-mentioned urinalysis, GFR, and urinary albumin excretion or albumin/creatinine ratio measurements. However, a large, randomized trial has not shown any increase in mortality rate. The angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan has been shown to be superior to ACE inhibitor alone in reducing the risk of death and hospitalization in patients with heart failure due to systolic dysfunction and is now preferred over ACE Inhibitots and ARBs. Left ventricular hypertrophy on electrocardiogram: prognostic implications from a 10-year cohort study of older subjects: a report from the Bronx Longitudinal Aging Study. Investigators found that native T1 was an independent discriminator between HCM and hypertension, above and beyond extracellular volume fraction, LV wall thickness, and indexed LV mass. [46], Left ventricular (LV) hypertrophy (LVH), a marker of increased risk of cardiovascular morbidity and mortality, should be treated aggressively because patients with LVH represent the subgroup of patients at the highest risk for cardiovascular events and mortality. 1 Despite major achievements in the treatment of chronic heart failure (HF) over the last decades, which led to marked improvement in long-term survival, outcomes of AHF remain poor with 90-day … Aspirin should be used infrequently in the routine primary prevention of ASCVD because of a lack of net benefit. Thus, the prevalence of hypertension is higher in men than in women younger than 55 years, but the rate is higher in women older than 55 years. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 19(4):358-67. A sudden increase in BP can lead to acute pulmonary edema without necessarily changing the LV ejection fraction. Beta blockers (cardioselective or mixed alpha and beta), such as carvedilol, metoprolol XL, and bisoprolol, have been shown to improve LV function and decrease rates of mortality and morbidity from heart failure. Diseases & Conditions, 2003 Over the past two decades, there has been significant clarification of the various pathways implicated in the pathogenesis of DKD. A presystolic S4 may be felt. Ghali JK, Kadakia S, Cooper RS, Liao YL. Concentric LVH poses the greatest risk of such events, as much as a 30% risk over a 10-year period in one study, compared with a 15% risk with eccentric remodeling and a 9% risk without any LVH. Table 2. [11] Various mechanisms thought to play a part in the pathogenesis of arrhythmias include altered cellular structure and metabolism, inhomogeneity of the myocardium, poor perfusion, myocardial fibrosis, and fluctuation in afterload. In patients aged 40 to 75 years evaluated for primary ASCVD prevention: Have a clinician–patient risk discussion before starting statin therapy. Nonetheless, very little has changed in the way clinicians manage patients with this disorder. [13] This difference between the groups is attributed to factors other than race, because the prevalence of hypertension among blacks and whites is the same in the United Kingdom and because hypertension is not very common on the African continent. Rogers JG, O'Connor CM. 2002 Chest radiographs may show notching of the undersurface of the ribs from the development of collateral circulation in coarctation of the aorta; cardiomegaly in late stages of the disease, due to LV dilatation; cephalization of pulmonary blood flow, Kerley B lines, and alveolar infiltrates in the presence of elevated left ventricular (LV) end-diastolic pressure and pulmonary congestion; and blunting of the costophrenic angle in the presence of pleural effusion. Thus, hypertensive heart disease is a term applied generally to heart diseases, such as LVH (seen in the images below), coronary artery disease, cardiac arrhythmias, and CHF, that are caused by the direct or indirect effects of elevated BP. A study by Leung et al found a 30% incidence of hyponatremia (Na < 130 mmol) in long-term follow-up of patients who were exposed to thiazide diuretics for treatment of hypertension. [Medline]. 21(3):519-24. Hypertensive heart disease refers to heart problems that occur because of high blood pressure that is present over a long time. Importantly, in patients with hypertension, angina can occur in the absence of epicardial coronary artery disease. Some degree of hemodynamically insignificant aortic insufficiency is often found in patients with uncontrolled hypertension. Medications for the treatment of hypertension have been shown to reduce LVH. Circ Cardiovasc Imaging. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Aguilera MT, de la Sierra A, Coca A, et al. 1999 Sep. 34(3):472-7. 2014 Feb 5. 1996 Dec 15. Philadelphia, PA: Elsevier; 2020:chap 52. [Medline]. [Medline]. A.D.A.M., Inc. is accredited by URAC, for Health Content Provider (www.urac.org). [31] : Vigorous exercise for a daily mean period of 30 minutes, A high score on the Dietary Approaches to Stop Hypertension (DASH) diet, Nonnarcotic analgesic use less than once weekly, Intake of 400 mcg/day or more of supplemental folic acid, A low-sodium diet, alone or in combination with pharmacotherapy, has been shown by numerous studies to reduce BP in patients with hypertension, with a more prominent response in a subset of patients with hypertension—mainly black individuals—with low renin levels. [Guideline] James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. Efficacy and tolerability of adding an angiotensin receptor blocker in patients with heart failure already receiving an angiotensin-converting inhibitor plus aldosterone antagonist, with or without a beta blocker. The following conditions should also be considered when evaluating hypertensive heart disease: Congestive heart failure due to other etiologies, Atrial fibrillation due to other etiologies, Diastolic dysfunction due to other etiologies. [48]. J Am Coll Cardiol. [Guideline] Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA, et al. Two-dimensional echocardiogram (parasternal short axis view) from a 70-year-old woman showing concentric left ventricular hypertrophy. Findings upon chest examination may be normal or may include signs of pulmonary congestion, such as rales, decreased breath sounds, and dullness to percussion due to pleural effusion. Thus, hypertensive heart disease is a term applied generally to heart diseases, such as LVH (seen in the images below), coronary artery disease, cardiac arrhythmias, and CHF, that are caused by the direct or indirect effects of elevated BP. Association of left ventricular hypertrophy with incident hypertension: the multi-ethnic study of atherosclerosis. If a >10 mmHg difference is consistent between the arms on repeated measurements, use the arm with the higher BP. Impact of diet on blood pressure and age-related changes in blood pressure in the US population: analysis of NHANES III. [Medline]. JAMA. A simplified regimen with once-daily dosing and single pill combinations is ideal. These drugs may cause severe hypotension by inappropriately decreasing the preload, which is required for adequate LV filling pressures. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Patients may present with chronic, stable angina or acute coronary syndrome, including myocardial infarction without ST-segment elevation and acute myocardial infarction with ST elevation. URAC's accreditation program is an independent audit to verify that A.D.A.M. [9]. For adults with T2DM, lifestyle changes (eg, improving dietary habits, achieving exercise recommendations) are crucial. These drugs have been shown to decrease morbidity and mortality rates in patients with heart failure due to systolic dysfunction. 58(7):765-73. For adults aged 20-39 years and for those aged 40-59 years whose 10-year ASCVD risk is below 7.5%, consider estimating their lifetime or 30-year ASCVD risk. (See the images below.). CAC is ≥100, or is in ≥75th percentile: Initiating statin therapy is reasonable. A holosystolic murmur of mitral regurgitation may be present in patients with advanced heart failure and a dilated mitral annulus. 2010 Nov 2. Impact of left ventricular hypertrophy on ventricular arrhythmias in the absence of coronary artery disease. [47]. In a large cohort study of women, the following six modifiable lifestyle and dietary factors for lowering the risk of hypertension were identified 63(25 Pt B):2985-3023. S1 is normal in intensity and character. The recommended daily sodium intake is 50-100 mmol, equivalent to 3-6 g of salt per day, which leads to an average 2-8 mmHg reduction in BP. Mortality and morbidity rates from hypertensive heart disease are higher than those of the general population and depend on the specific cardiac pathology. Call 911 for all medical emergencies. The development of atrial fibrillation can cause decompensation of systolic and, more importantly, diastolic dysfunction, owing to loss of atrial kick, and it also increases the risk of thromboembolic complications, most notably stroke. Treatment of hypertension in patients 80 years of age or older. Regular aerobic exercise sessions of at least 30 minutes for most days of the week can produce an average reduction in BP of 4-9 mmHg. The etiology of hypertensive heart disease is a complex interplay of various hemodynamic, structural, neuroendocrine, cellular, and molecular factors. Although symptomatic diastolic heart failure and systolic heart failure are indistinguishable, the clinical history may be quite revealing. The slide shows myocardial hypertrophy, contraction bands (typical of left ventricular hypertrophy), and "car box" nuclei. Reduce LDL-C levels by ≥30%; for optimal ASCVD risk reduction, particularly in high-risk patients (≥20% 10-year ASCVD risk), reduce LDL-C levels by ≥50%. WebMD Inc. Share cases and questions with Physicians on Medscape consult. 311(5):507-20. 2014 Jul 1. Moore TJ, Vollmer WM, Appel LJ, et al. In addition, it is important to reinforce dietary advice and advice regarding the importance of regular exercise. Uncontrolled and prolonged elevation of BP can lead to a variety of changes in the myocardial structure, coronary vasculature, and conduction system of the heart. [7] In summary, the development of LVH is characterized by myocyte hypertrophy and by an imbalance between the myocytes and the interstitium of the myocardial skeletal structure. [41] It also has additional favorable cardiovascular effects, including improved endothelial function, peripheral vasodilatation, reduced resting heart rate, improved heart rate variability, and reduced plasma levels of catecholamines. [49, 50]. J Hypertens. Int J Biol Sci. A 5-20 mmHg BP reduction occurs with each 10 kg of weight loss. Later in the course of disease, when significant systolic LV dysfunction supervenes, the apical impulse is displaced laterally, owing to LV dilatation. As the disease enters the end stage, LV systolic function decreases further. Arch Intern Med. Hypertension. [Medline]. The recommendations on management of blood cholesterol were released in November 2018 by the American College of Cardiology (ACC), American Heart Association (AHA), and multiple other medical societies. The Hypertension Prevention Trial: three-year effects of dietary changes on blood pressure. 1999 Apr 20. Extremely high blood pressure — a top number (systolic pressure) of 180 millimeters of mercury (mm Hg) or higher or a bottom number (diastolic pressure) of 120 mm Hg or higher — can damage blood vessels. Gandhi SK, Powers JC, Nomeir AM, et al. Physical signs of hypertensive heart disease depend on the predominant cardiac abnormality and the duration and severity of the hypertensive heart disease. Encephalopathy is a term that means brain disease, damage, or malfunction. Even in patients with asymptomatic diastolic dysfunction due to hypertension, the risk of all-cause mortality and cardiovascular events is significantly increased, particularly with an increase in the pulmonary artery wedge pressure (PAWP). LDL-C levels ≥70-189 mg/dL (≥1.8-4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5-19.9%: If a decision about statin therapy is uncertain, consider measuring coronary artery calcium (CAC) levels. 285(18):2370-5. Hypertension is more prevalent in black persons than in Hispanic and non-Hispanic white persons, and this prevalence is increasing. Ann Intern Med. The pathogenesis of acute pulmonary edema associated with hypertension. The estimated prevalence of hypertension in the United States in 2005 was 35.3 million for men and 38.3 million for women. The sensitivity of these criteria is 50%, with a specificity of close to 95%. J Am Geriatr Soc. They were also more likely to have a history of heart failure and were more likely to have higher brain-type natriuretic peptide (BNP) and creatinine levels and lower left ventricular (LV) ejection fraction (EF). Acute heart failure (AHF) is a relevant public health problem causing the majority of unplanned hospital admissions in patients aged of 65 years or more. 2001 Jan 4. Circulation. Examination of the fundi may reveal evidence of hypertensive retinopathy, the severity of which depends on the duration and severity of the patient's hypertension, or earlier signs of hypertension, such as arteriovenous nicking. Intravenous drugs used in patients with a hypertensive emergency include nitroprusside, labetalol, hydralazine, enalapril, and beta blockers (avoided in patients with acutely decompensated heart failure). (Although the prevalence in whites is increasing as well, it is not as dramatic a rise.) Diastolic heart failure occurs when signs and symptoms of heart failure are present but left ventricular systolic function is preserved (i.e., … If HBPM < 135/85 mmHg or 24-hour ABPM < 130/80 mmHg, remeasure after 1 year; If HBPM ≥135/85 mmHg or 24-hour ABPM ≥130/80 mmHg, then hypertension is diagnosed. Findings from the physical examination may be entirely normal in the very early stages of the disease, or the patient may have classic signs upon examination. 2003 May. Symptoms most often do not occur until after many years of poor blood pressure control, when damage to the heart has occurred. Diastolic dysfunction is common in persons with hypertension. BP may be normal at the time of evaluation if the patient is on adequate antihypertensive medications or if the patient has advanced LV dysfunction and the LV cannot generate enough stroke volume and cardiac output to produce an elevated BP. The DASH diet has been shown to significantly lower the BP (8-14 mmHg) in patients with hypertension regardless of whether or not they maintain a constant sodium content in their diet. [Medline]. [Medline]. 2009;34(5):HS-8-HS-12. 's editorial policy editorial process and privacy policy. The relationships between alcoholic beverage use and other traits to blood pressure: a new Kaiser Permanente study. Left ventricular hypertrophy has a greater impact on survival in women than in men. Available at https://www.medscape.com/viewarticle/904736. Risk of Thiazide-induced Hyponatremia in Patients with Hypertension. In addition to generalized findings attributable directly to high blood pressure (BP), the physical examination may reveal clues to a potential etiology of hypertension, such as truncal obesity and striae in Cushing syndrome, renal artery bruit in renal artery stenosis, and abdominal mass in polycystic kidney disease. The Gubner-Ungerleider criteria are an R wave in I plus an S wave in III of greater than 2.5 mV. In: Goldman L, Schafer AI, eds. 73(4):628-36. Introduction. J Am Diet Assoc. A 12-lead electrocardiogram (ECG) may show a variety of abnormalities. J Am Coll Cardiol. The transmitral flow velocity pattern, characterized by abnormally prolonged isovolumic relaxation time, a reversed "E:A" ratio (ie, reversed velocity of early diastole to peak flow velocity of atrial contraction), and a prolonged deceleration time, is abnormal. Svetkey LP, Sacks FM, Obarzanek E. The DASH Diet, Sodium Intake and Blood Pressure Trial (DASH-sodium): rationale and design. WebMD Inc. 302(4):401-11. Because there are often no symptoms with high blood pressure, people can have the problem without knowing it. Philadelphia, PA: Elsevier; 2020:chap 70. 1999 Feb. 33(2):653-7. 2015 Jan 20. [Medline]. [Medline]. Br J Radiol. [Medline]. Without appropriate blood pressure control, the heart can weaken over time and heart failure may develop. The guideline's top 10 key recommendations for reducing the risk of atherosclerotic cardiovascular disease through cholesterol management are summarized below. The apical impulse is sustained and nondisplaced in patients without significant systolic LV dysfunction but with LVH. [12] In fact, elevated BP is the most common cause of atrial fibrillation in the Western hemisphere. If your blood pressure is high, you need to lower it and keep it under control. Hinojar R, Varma N, Child N, et al. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. All material on this website is protected by copyright, Copyright © 1994-2021 by WebMD LLC. 358(18):1887-98. [Medline]. [19]. The definition of the LVH based on echocardiography findings is somewhat controversial in the absence of any criterion standards. Furthermore, the effectiveness and choice of antihypertensive treatment, medication effectiveness and compliance, the presence or absence of coronary artery disease and degree of left ventricular (LV) systolic function, and the patient's dietary habits and exercise pattern require assessment. The prognosis of patients with diastolic dysfunction is poor and is affected by the presence of underlying coronary artery disease. The sensitivity of these criteria is 25%, with a specificity of close to 95%. 1997 Jan. 50(1):31-5. 2011 Nov. 124(11):1064-72. The heart rate is as follows: Not normal in decompensated heart failure, Tachycardic in patients with heart failure and in patients with atrial fibrillation and a rapid ventricular response, The pulse volume is usually normal, but it is decreased in patients with left ventricular (LV) dysfunction. Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. 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