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DEFINITION OF HYPERTENSION• HTN IS DEFINED AS THE PRESENCEOF THE BLOOD PRESSUREELEVATION TO A LEVEL THATPLACES THE PATIENT AT AN INCREASEDRISK FOR TOD IN SEVERAL OF VASCULARBEDS INCLUDING RETINA, BRAIN KIDNEY, HEART AND LARGE CONDUIT ARTERIES
HYPERTENSIVE HEART DISEASE - DEFINITIONHTNve heart disease is aterm applied generally toheart diseases, such as• LVH,• CAD,• Cardiac Arrhythmias, and• CHF, that are caused by the direct or indirecteffects of elevated BP.
EPIDEMIOLOGYHTN IS A GLOBAL EPIDEMIC.• IN MANY COUNTRIES 50% OF THE POPULATIONOLDER THAN 60 YEARS HAS HTN.• OVERALL APPROX. 20% OF THE WORLD’SADULTS ARE ESTIMATED TO HAVE HTN.• THE PREVALENCE DRAMATICALLY INCREASES INPATIENTS OLDER THAN 60 YEARS• HTN CONTRIBUTES TO > 7.1 MILLION DEATHS /YEAR
• HTN IS A GLOBALPROBLEM.• AN ESTIMATED 1BILLION PEOPLEWORLDWIDE HAVE HIGHBP . ( SBP > 140 mm HgOR DBP >90 mm Hg )• AN EXPECTEDPROJECTED INCREASETO 1.56 BILLIONS BY2025THE GLOBAL PROBLEM
• THE PUBLIC HEALTHBURDEN OFHYPERTENSION ISENORMOUS• INDEED FOR NON HTN-VEINDIVIDUALS AGED 55- 65YEARS THE LIFE TIME RISKOF DEVELOPING HTN ISABOUT 90%EPIDEMIOLOGY
EPIDEMIOLOGY - HHDSystolic BP increases with age.The prevalence of HTN is higher in men than inwomen , but the rate is higher in women older than55 years.The prevalence of HHD probably follows the samepattern and is affected by the severity of BPincrease.The rate of LVH based on echo findings is 15-20%.
DIFFERENTIALSThe following conditions should be considered whenevaluating hypertensive heart disease:• Coronary artery atherosclerosis• HCM• Athletes heart (with LVH)• Congestive heart failure, AF and DiastolicDysfunction due to other etiologies• Sleep apnea
AETIOPATHOLOGY 1. LVH …….Various patterns of LVH includes :• concentric remodeling,• concentric LVH, and• eccentric LVH.LVH plays a protective role in response toincreased wall stress to maintain adequate COit later leads to the development of diastolicand, ultimately, systolic myocardialdysfunction.
2.LA ABNORMALITIES, & OTHER COMORBIDITIESELEVATED LVEDP OF HIGH BP >>>>INCREASED LA AFTERLOAD.• THIS RESULTS IN LA & LAA FUNCTIONALIMPAIRMENT WITH INCREASED LA SIZE AND THICKNESS• THESE PTS.ARE PRONE FOR AF AND IT MAY PRECIPITATEOVERT HF IN PRESENCE OF DIASTOLIC DYSFUNCTION.• CHRONIC AND SEVERE HTN CAN CAUSE AO.ROOTDILATATION LEADING TO SIG.AR.• ANY RISE IN BP MAY ACCELARATE THE DEGREE OF AR.• HTN ALSO ACCELARATE THE PROCESS OF AORTICSCLEROSIS AND CAUSE MR
3. HEART FAILURE• HTN as a cause of CHF isfrequently under recognized,partly because at the time heart failure develops, thedysfunctioning LV is unable to generate the high BP,thus obscuring the heart failures etiology.• The prevalence of asymptomatic diastolicdysfunction in patients with hypertension andwithout LVH may be as high as 33%.• Chronically elevated afterload and the resulting LVHcan adversely affect the active early relaxation phaseand the late compliance phase of ventricular diastole.
4. DIASTOLIC DYSFUNCTION• Diastolic dysfunction is common in persons with HTN.• It is often, accompanied by LVH.• Other factors that may contribute to the development ofdiastolic dysfunction:• Coexistent CAD,• Aging,• Systolic dysfunction,• and Structural abnormalities such as fibrosis andLVH.
5. SYSTOLIC DYSFN. & DECOMPENSATION• IN THE FACE OF ELEVATED BP LV CAVITY DILATESTO INCREASE THE CARDIAC OUTPUT AS THE LVHFAILS TO COMPENSATE.• AS THE DISEASE ENTERS END STAGE, LV SYSTOLICFUNCTION DECREASES FURTHER >>>>>>>• THERE IS ACTIVATION OF NEUROHUMERAL ANDRENIN ANGIOTENSIN SYSTEM >>>>>>>>• RESULTS IN SALT AND WATER RETENTION AS WELLAS INCREASED PERIPHERAL VASOCONSTRICTION• EVENTUALLY PATIENT PROGRESSES TOSYMPTOMATIC SYSTOLIC DYSFUNCTION
5. MYOCARDIAL ISCHAEMIA• HTN an established risk factor for CAD, and almostdoubles the risk.• Angina can occur in the absence of epicardial coronaryartery disease.• The reason for this is 2-fold.Increased afterload secondary to hypertension leads to anincrease in LV wall tension and transmuralpressure, compromising coronary blood flow duringdiastole.The dysfunctional microvasculature beyond the epicardialcoronary arteries , may be unable to compensate forincreased metabolic and oxygen demand.
6. ARRHYTHMIACommon Arrhythmias :*Atrial fibrillation(paroxysmal, chronicrecurrent, or chronic persistent) ,* Premature ventricular contractions (PVCs),* Ventricular tachycardia (VT)PVCs, ventricular arrhythmias, andS CD areobserved more often in patients with LVH than inthose without LVH.The etiology of these arrhythmias is thought to beconcomitant CAD and myocardial fibrosis.
STAGING OF HYPERTENSIONHTNve HD USUALLYPROGRESSES IN THEFOLLOWING SEQUENCE:• INCREASED WALL STRESS LEADSTO LVH >>>>• DIASTOLIC DYSFUNCTION >>>>>>SYSTOLIC LV DYSFUNCTION
• BASED ON THERECOMMENDATION OFJNC 7, CLASSIFICATIONOF BP FOR ADULTS AGED18 YEARS OR OLDER ISAS FOLLOWS.• THIS CLASSIFICATION ISBASED ON THE AVERAGEOF 2 OR MORE READINGSTAKEN AT EACH OF 2 ORMORE VISITS AFTERINITIAL SCREENING.JNC 7
PRE HYPERTENSION• A NEW CATEGORY DESIGNATED IN THE JNC 7 EMPHASIZES THATPATIENTS WITH PREHTN ARE AT RISK FOR PROGRESSION TOHYPERTENSION AND THAT LIFESTYLE MODIFICATIONS AREIMPORTANT PREVENTIVE STRATEGIES
THE BLOOD PRESSURE GOALSTHE MEDICAL CARE OF PATIENTS WITHHHD FALLS UNDER 2 CATEGORIES-1. TREATMENT OF THE ELEVATED BP2. PREVENTION AND TREATMENT OF HHD.ACCORDING TO JNC 7 , BP GOALS SHOULD BE AS FOLLOWS:• LESS THAN 140/90 mm Hg IN PTS. WITH UNCOMPLICATEDHTN• LESS THAN 130/85mm Hg IN PTS. WITH RENAL DISEASEWITH LESS THAN 1G/24 HOUR PROTEINURIA• LESS THAN 125/75mm Hg IN PTS. WITH RENAL DISEASEAND MORE THAN 1G/24- HOUR PROTEINURIA
JNC7 ALGORITHM FORTREATMENT OF HYPERTENSIONNot at Goal BP <140/90 mm Hg for most<130/80 for those with diabetes or CKDInitial Drug ChoicesDrug(s) for compellingindications+ BP meds as neededCompellingIndicationsLifestyle ModificationsStage 2 BP 160/ 1002-drug combo for most(diuretic + ACEI, or ARB, orBB, or CCB)Stage 1 140-159/90-99Diuretics for most; considerACEI, ARB, B, CCBNo CompellingIndicationsNot at Goal BPOptimize dosages or add drugsuntil goal BP is achieved. Considerhypertension specialist consult.Chobanian AV, et al. JAMA.2003;289:2560-2572.ACEI = ACE inhibitorCCB = calcium channel blockerARB = angiotensin receptor blockerB = -blockerCKD = chronic kidney disease
DASH DIET• The DASH diet significantly lowerthe BP (8-14mm Hg) in patients with HTN• The DASH diet is rich in important nutrients andfiber• DASH diet includes foods with morepotassium, calcium, and magnesium than arefound in the average American diet.• This diet should be advised in pts .with HTN
DIETARY MODIFICATIONS• In various epidemiologic studies, a high-potassium diethas been associated with lowering of BP.• Fresh fruits and vegetables rich in potassium, suchas bananas, oranges, avocados, and tomatoes,should be recommended for patients with normalrenal function.• High intakes of red or processed meat were associatedwith modest increases in total mortality, cancer mortality,and cardiovascular disease mortality.(Sinha et al National Institutes of Health (NIH)-AARP Diet and Health Study.)
OTHER AGENTS• IV drugs used in patients with a hypertensive emergencyincludenitroprusside, labetalol, hydralazine, enalapril, and betablockers (avoided in patients with acutelydecompensated heart failure).• Some evidence shows that PPAR-gamma agonistameliorates oxidative stress and leads to reversal ofsystemic hypertension-associated cardiac remodeling inchronic pressure overload myocardium and LVH.• Current guidelines indicate the use of acetaminophen asa first-line analgesic in patients with coronary arterydisease. However, a study demonstrated thatacetaminophen induced a significant increase inambulatory BP in these patients.
TREATMENT OF LVH• LVH should be treated aggressively because patients withLVH represent the subgroup of patients at the highest riskfor cardiovascular events and mortality.• Limited data support the hypothesis that regerssion in LVHleads to improvement in CV mortality and morbidity.• Data also indicate that regression of electrocardiographicLVH is associated with less hospitalization for heart failurein hypertensive patients.• Medications for the treatment of HTN have been shown toreduce LVH. Limited meta-analysis data suggest a slightadvantage to ACE inhibitors.
LV DIASTOLIC DYSFUNCTION• ACE inhibitors, BB, and nondihydropyridine CCB -have been shown to improve echocardiographicparameters in symptomatic and asymptomaticdiastolic dysfunction and the symptomatology ofheart failure.• Candesartan, an ARB, has been shown to decreasehospitalization in patients with diastolic heart failure.• Use diuretics and nitrates with caution .• By increasing the intracellular ca++ level, digoxincan worsen LV stiffness.
LV SYSTOLIC DYSFUNCTION• Diuretics (predominantly loop diuretics) are used in the Rx of LV systolicdysfunction.• Low-dose spironolactone has been shown to decrease the rates ofmorbidity and mortality in patients in NYHA class III or IV heart failure whoare already taking ACE inhibitors.• ACE inhibitors are used for preload and afterload reduction and theprevention of pulmonary or systemic congestion.• ACE inhibitors are also indicated in patients with asymptomatic LVdilatation and dysfunction.• Beta blockers (cardioselective or mixed alpha and beta), such ascarvedilol, metoprolol XL, and bisoprolol, have been shown to improve LVfunction and decrease rates of mortality and morbidity from heart failure.• Trials have also shown improvement in outcomes for patients in NYHAclass IV heart failure with carvedilol administration. These drugs should bestarted when the patient has no signs of fluid overload and is incompensated heart failure.
ARRHYTHMIASThe treatment of these conditions dependsupon the specific arrhythmia and theunderlying LV function.Anticoagulation should be considered inpatients with atrial fibrillation.In addition, treat anxiety, stress, sleep apnea,Treat other contributing or precipitatingfactors.
RENAL DENERVATION AND BATThe Symplicity HTN-2 trialThe effectiveness and safety of catheter-based renal denervation to reduce BP inpatients with treatment-resistanthypertension.This approach can safely reducehypertension in these patients.
BAT using animplantablestimulator canpotentially reducesystolic BP safelyover the long term inpts. with resistanthypertension.BAROREFLEX ACTIVATION THERAPY
TAKE HOME MESSAGE• DISEASE ASSOCIATED MORBIDITY AND MORTALITYINCLUDING ATHEROSCLEROTIC CVD, STROKE, HEARTFAILURE AND RENAL INSUFFICIENCY INCREASE WITHHIGHER LEVELS OF SYST. AND DIASTOLIC BP• OVER THE PAST THREE DECADES AGGRESSIVE Rx. OFHTN HAS RESULTED IN SUBSTANTIAL DECREASE INDEATH RATES FROM STROKE AND CORONARY HEARTDISEASE.• UNFORTUNATELY RATES OF ESRD ANDHOSPITALISATIONS FOR CHF HAVE CONTINUED TOINCREASE• BP CONTROL RATE REMAINS POOR WITH ONLY 34% OFTREATED HTN VE PTS. BELOW THEIR GOAL BP LEVEL