1. DR.RISHIKESAN K.V
SPECIALIST PHYSICIAN
HYPERTENSIVE HEART DISEASE

2. DEFINITION OF HYPERTENSION
• HTN IS DEFINED AS THE PRESENCE
OF THE BLOOD PRESSURE
ELEVATION TO A LEVEL THAT
PLACES THE PATIENT AT AN INCREASED
RISK FOR TOD IN SEVERAL OF VASCULAR
BEDS INCLUDING RETINA, BRAIN KIDNEY
, HEART AND LARGE CONDUIT ARTERIES

3. HYPERTENSIVE HEART DISEASE - DEFINITION
HTNve heart disease is a
term applied generally to
heart diseases, such as
• LVH,
• CAD,
• Cardiac Arrhythmias, and
• CHF, that are caused by the direct or indirect
effects of elevated BP.

10. EPIDEMIOLOGY
HTN IS A GLOBAL EPIDEMIC.
• IN MANY COUNTRIES 50% OF THE POPULATION
OLDER THAN 60 YEARS HAS HTN.
• OVERALL APPROX. 20% OF THE WORLD’S
ADULTS ARE ESTIMATED TO HAVE HTN.
• THE PREVALENCE DRAMATICALLY INCREASES IN
PATIENTS OLDER THAN 60 YEARS
• HTN CONTRIBUTES TO > 7.1 MILLION DEATHS /
YEAR

11. • HTN IS A GLOBAL
PROBLEM.
• AN ESTIMATED 1
BILLION PEOPLE
WORLDWIDE HAVE HIGH
BP . ( SBP > 140 mm Hg
OR DBP >90 mm Hg )
• AN EXPECTED
PROJECTED INCREASE
TO 1.56 BILLIONS BY
2025
THE GLOBAL PROBLEM

12. • THE PUBLIC HEALTH
BURDEN OF
HYPERTENSION IS
ENORMOUS
• INDEED FOR NON HTN-VE
INDIVIDUALS AGED 55- 65
YEARS THE LIFE TIME RISK
OF DEVELOPING HTN IS
ABOUT 90%
EPIDEMIOLOGY

13. EPIDEMIOLOGY - HHD
Systolic BP increases with age.
The prevalence of HTN is higher in men than in
women , but the rate is higher in women older than
55 years.
The prevalence of HHD probably follows the same
pattern and is affected by the severity of BP
increase.
The rate of LVH based on echo findings is 15-20%.

14. CV MORTALITY RISK

15. DIFFERENTIALS
The following conditions should be considered when
evaluating hypertensive heart disease:
• Coronary artery atherosclerosis
• HCM
• Athlete's heart (with LVH)
• Congestive heart failure, AF and Diastolic
Dysfunction due to other etiologies
• Sleep apnea

17. AETIOPATHOLOGY 1. LVH …….
Various patterns of LVH includes :
• concentric remodeling,
• concentric LVH, and
• eccentric LVH.
LVH plays a protective role in response to
increased wall stress to maintain adequate CO
it later leads to the development of diastolic
and, ultimately, systolic myocardial
dysfunction.

18. 2.LA ABNORMALITIES, & OTHER COMORBIDITIES
ELEVATED LVEDP OF HIGH BP >>>>
INCREASED LA AFTERLOAD.
• THIS RESULTS IN LA & LAA FUNCTIONAL
IMPAIRMENT WITH INCREASED LA SIZE AND THICKNESS
• THESE PTS.ARE PRONE FOR AF AND IT MAY PRECIPITATE
OVERT HF IN PRESENCE OF DIASTOLIC DYSFUNCTION.
• CHRONIC AND SEVERE HTN CAN CAUSE AO.ROOT
DILATATION LEADING TO SIG.AR.
• ANY RISE IN BP MAY ACCELARATE THE DEGREE OF AR.
• HTN ALSO ACCELARATE THE PROCESS OF AORTIC
SCLEROSIS AND CAUSE MR

19. 3. HEART FAILURE
• HTN as a cause of CHF is
frequently under recognized,
partly because at the time heart failure develops, the
dysfunctioning LV is unable to generate the high BP,
thus obscuring the heart failure's etiology.
• The prevalence of asymptomatic diastolic
dysfunction in patients with hypertension and
without LVH may be as high as 33%.
• Chronically elevated afterload and the resulting LVH
can adversely affect the active early relaxation phase
and the late compliance phase of ventricular diastole.

20. 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 of
diastolic dysfunction:
• Coexistent CAD,
• Aging,
• Systolic dysfunction,
• and Structural abnormalities such as fibrosis and
LVH.

21. 5. SYSTOLIC DYSFN. & DECOMPENSATION
• IN THE FACE OF ELEVATED BP LV CAVITY DILATES
TO INCREASE THE CARDIAC OUTPUT AS THE LVH
FAILS TO COMPENSATE.
• AS THE DISEASE ENTERS END STAGE, LV SYSTOLIC
FUNCTION DECREASES FURTHER >>>>>>>
• THERE IS ACTIVATION OF NEUROHUMERAL AND
RENIN ANGIOTENSIN SYSTEM >>>>>>>>
• RESULTS IN SALT AND WATER RETENTION AS WELL
AS INCREASED PERIPHERAL VASOCONSTRICTION
• EVENTUALLY PATIENT PROGRESSES TO
SYMPTOMATIC SYSTOLIC DYSFUNCTION

22. 5. MYOCARDIAL ISCHAEMIA
• HTN an established risk factor for CAD, and almost
doubles the risk.
• Angina can occur in the absence of epicardial coronary
artery disease.
• The reason for this is 2-fold.
Increased afterload secondary to hypertension leads to an
increase in LV wall tension and transmural
pressure, compromising coronary blood flow during
diastole.
The dysfunctional microvasculature beyond the epicardial
coronary arteries , may be unable to compensate for
increased metabolic and oxygen demand.

23. 6. ARRHYTHMIA
Common Arrhythmias :
*Atrial fibrillation
(paroxysmal, chronic
recurrent, or chronic persistent) ,
* Premature ventricular contractions (PVCs),
* Ventricular tachycardia (VT)
PVCs, ventricular arrhythmias, andS CD are
observed more often in patients with LVH than in
those without LVH.
The etiology of these arrhythmias is thought to be
concomitant CAD and myocardial fibrosis.

24. STAGING OF HYPERTENSION
HTNve HD USUALLY
PROGRESSES IN THE
FOLLOWING SEQUENCE:
• INCREASED WALL STRESS LEADS
TO LVH >>>>
• DIASTOLIC DYSFUNCTION >>>>>>
SYSTOLIC LV DYSFUNCTION

25. • BASED ON THE
RECOMMENDATION OF
JNC 7, CLASSIFICATION
OF BP FOR ADULTS AGED
18 YEARS OR OLDER IS
AS FOLLOWS.
• THIS CLASSIFICATION IS
BASED ON THE AVERAGE
OF 2 OR MORE READINGS
TAKEN AT EACH OF 2 OR
MORE VISITS AFTER
INITIAL SCREENING.
JNC 7

26. PRE HYPERTENSION
• A NEW CATEGORY DESIGNATED IN THE JNC 7 EMPHASIZES THAT
PATIENTS WITH PREHTN ARE AT RISK FOR PROGRESSION TO
HYPERTENSION AND THAT LIFESTYLE MODIFICATIONS ARE
IMPORTANT PREVENTIVE STRATEGIES

30. EVALUATION

34. ENDOCRINE CAUSES

35. CV RISK REDUCTION

36. THE BLOOD PRESSURE GOALS
THE MEDICAL CARE OF PATIENTS WITH
HHD FALLS UNDER 2 CATEGORIES-
1. TREATMENT OF THE ELEVATED BP
2. PREVENTION AND TREATMENT OF HHD.
ACCORDING TO JNC 7 , BP GOALS SHOULD BE AS FOLLOWS:
• LESS THAN 140/90 mm Hg IN PTS. WITH UNCOMPLICATED
HTN
• LESS THAN 130/85mm Hg IN PTS. WITH RENAL DISEASE
WITH LESS THAN 1G/24 HOUR PROTEINURIA
• LESS THAN 125/75mm Hg IN PTS. WITH RENAL DISEASE
AND MORE THAN 1G/24- HOUR PROTEINURIA

37. JNC7 ALGORITHM FOR
TREATMENT OF HYPERTENSION
Not at Goal BP <140/90 mm Hg for most
<130/80 for those with diabetes or CKD
Initial Drug Choices
Drug(s) for compelling
indications
+ BP meds as needed
Compelling
Indications
Lifestyle Modifications
Stage 2 BP 160/ 100
2-drug combo for most
(diuretic + ACEI, or ARB, or
BB, or CCB)
Stage 1 140-159/90-99
Diuretics for most; consider
ACEI, ARB, B, CCB
No Compelling
Indications
Not at Goal BP
Optimize dosages or add drugs
until goal BP is achieved. Consider
hypertension specialist consult.
Chobanian AV, et al. JAMA.
2003;289:2560-2572.
ACEI = ACE inhibitor
CCB = calcium channel blocker
ARB = angiotensin receptor blocker
B = -blocker
CKD = chronic kidney disease

40. LIFESTYLE TREATMENT

41. LIFE STYLE TREATMENT

42. DASH DIET
• The DASH diet significantly lower
the BP (8-14mm Hg) in patients with HTN
• The DASH diet is rich in important nutrients and
fiber
• DASH diet includes foods with more
potassium, calcium, and magnesium than are
found in the average American diet.
• This diet should be advised in pts .with HTN

43. DIETARY MODIFICATIONS
• In various epidemiologic studies, a high-potassium diet
has been associated with lowering of BP.
• Fresh fruits and vegetables rich in potassium, such
as bananas, oranges, avocados, and tomatoes,
should be recommended for patients with normal
renal function.
• High intakes of red or processed meat were associated
with modest increases in total mortality, cancer mortality,
and cardiovascular disease mortality.
(Sinha et al National Institutes of Health (NIH)-AARP Diet and Health Study.)

44. PHARMACOTHERAPY

47. PHARMACOLOGIC TREATMENT

50. COMBINATIONS

52. OTHER AGENTS
• IV drugs used in patients with a hypertensive emergency
include
nitroprusside, labetalol, hydralazine, enalapril, and beta
blockers (avoided in patients with acutely
decompensated heart failure).
• Some evidence shows that PPAR-gamma agonist
ameliorates oxidative stress and leads to reversal of
systemic hypertension-associated cardiac remodeling in
chronic pressure overload myocardium and LVH.
• Current guidelines indicate the use of acetaminophen as
a first-line analgesic in patients with coronary artery
disease. However, a study demonstrated that
acetaminophen induced a significant increase in
ambulatory BP in these patients.

53. TREATMENT OF LVH
• LVH should be treated aggressively because patients with
LVH represent the subgroup of patients at the highest risk
for cardiovascular events and mortality.
• Limited data support the hypothesis that regerssion in LVH
leads to improvement in CV mortality and morbidity.
• Data also indicate that regression of electrocardiographic
LVH is associated with less hospitalization for heart failure
in hypertensive patients.
• Medications for the treatment of HTN have been shown to
reduce LVH. Limited meta-analysis data suggest a slight
advantage to ACE inhibitors.

55. LV DIASTOLIC DYSFUNCTION
• ACE inhibitors, BB, and nondihydropyridine CCB -
have been shown to improve echocardiographic
parameters in symptomatic and asymptomatic
diastolic dysfunction and the symptomatology of
heart failure.
• Candesartan, an ARB, has been shown to decrease
hospitalization in patients with diastolic heart failure.
• Use diuretics and nitrates with caution .
• By increasing the intracellular ca++ level, digoxin
can worsen LV stiffness.

56. LV SYSTOLIC DYSFUNCTION
• Diuretics (predominantly loop diuretics) are used in the Rx of LV systolic
dysfunction.
• Low-dose spironolactone has been shown to decrease the rates of
morbidity and mortality in patients in NYHA class III or IV heart failure who
are already taking ACE inhibitors.
• ACE inhibitors are used for preload and afterload reduction and the
prevention of pulmonary or systemic congestion.
• ACE inhibitors are also indicated in patients with asymptomatic LV
dilatation and dysfunction.
• 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.
• Trials have also shown improvement in outcomes for patients in NYHA
class IV heart failure with carvedilol administration. These drugs should be
started when the patient has no signs of fluid overload and is in
compensated heart failure.

58. ARRHYTHMIAS
The treatment of these conditions depends
upon the specific arrhythmia and the
underlying LV function.
Anticoagulation should be considered in
patients with atrial fibrillation.
In addition, treat anxiety, stress, sleep apnea,
Treat other contributing or precipitating
factors.

59. TREATMENT OF HTN AND CAD

62. RESISTANT HYPERTENSION

63. CAUSES OF RESISTANT HTN

64. RENAL DENERVATION AND BAT
The Symplicity HTN-2 trial
The effectiveness and safety of catheter-
based renal denervation to reduce BP in
patients with treatment-resistant
hypertension.
This approach can safely reduce
hypertension in these patients.

65. BAT using an
implantable
stimulator can
potentially reduce
systolic BP safely
over the long term in
pts. with resistant
hypertension.
BAROREFLEX ACTIVATION THERAPY

66. TAKE HOME MESSAGE
• DISEASE ASSOCIATED MORBIDITY AND MORTALITY
INCLUDING ATHEROSCLEROTIC CVD, STROKE, HEART
FAILURE AND RENAL INSUFFICIENCY INCREASE WITH
HIGHER LEVELS OF SYST. AND DIASTOLIC BP
• OVER THE PAST THREE DECADES AGGRESSIVE Rx. OF
HTN HAS RESULTED IN SUBSTANTIAL DECREASE IN
DEATH RATES FROM STROKE AND CORONARY HEART
DISEASE.
• UNFORTUNATELY RATES OF ESRD AND
HOSPITALISATIONS FOR CHF HAVE CONTINUED TO
INCREASE
• BP CONTROL RATE REMAINS POOR WITH ONLY 34% OF
TREATED HTN VE PTS. BELOW THEIR GOAL BP LEVEL

67. THANK YOU FOR THE PATIENT HEARING