Dr Akshay MehtaDr Akshay Mehta Dr B Nanavati Hospital

Asian Heart Institute

Hypertension & HeartHypertension & Heart

Hypertensive Heart DiseaseTrue or False ?

ALL the following are examples of hypertensive heart ALL the following are examples of hypertensive heart disease :disease :

CHDCHDLVHLVHLVFLVFArrhythmiasArrhythmiasConduction system abnormalityConduction system abnormalityAortic RegurgitationAortic Regurgitation

Definition :

Hypertensive heart disease is a constellation of abnormalities Hypertensive heart disease is a constellation of abnormalities

including coronary artery disease, left ventricular hypertrophy including coronary artery disease, left ventricular hypertrophy

(LVH), systolic and diastolic dysfunction, and their clinical (LVH), systolic and diastolic dysfunction, and their clinical

manifestations including arrhythmias, conduction manifestations including arrhythmias, conduction

abnormalities and symptomatic heart failure, that are caused abnormalities and symptomatic heart failure, that are caused

by the direct or indirect effects of elevated BPby the direct or indirect effects of elevated BP

Hypertensive Heart Disease• Left ventricular hypertrophyLeft ventricular hypertrophy• LV dysfunction:LV dysfunction: DiastolicDiastolic SystolicSystolic• Heart FailureHeart Failure DiastolicDiastolic SystolicSystolic• Arrhythmia, conduction abnormalitiesArrhythmia, conduction abnormalities• CHDCHD• ARAR

Hypertensive CARDIO VASCULAR DISEASE includes:

Aortic aneurysmAortic aneurysm

Aortic dissectionAortic dissection

PADPAD

Left Ventricular Hypertrophy- LVH

Increase in mass of LV

LVH

15-20% of hypertension pts develop LVH15-20% of hypertension pts develop LVH

The risk of LVH is increased 2-fold by The risk of LVH is increased 2-fold by

associated obesity associated obesity

Classification of LV geometry based on LV mass and relative wall thickness (the ratio of LV wall thickness to

diastolic dimension)

Drazner M H Circulation 2011;123:327-334

Copyright © American Heart Association

LVH – concentric v/s eccentric response

Genetic factors may influence the response to pressure overload and, specifically, whether concentric or eccentric hypertrophy develops

Is regression of LVH possible ?

Yes

No

Hypertension and LV Dysfunction

Diastolic dysfunction : Normal EF• Usually, but not invariably, accompanied by Usually, but not invariably, accompanied by

LVHLVH• However, may be as common as 33% in However, may be as common as 33% in

hypertensive without LVH hypertensive without LVH

Systolic d dysfunction• Reduced EF with or without IHDReduced EF with or without IHD

Hypertension and HF

o Hypertension accounts for 25% cases of HFHypertension accounts for 25% cases of HF

o In elderly it accounts for 68% cases of HFIn elderly it accounts for 68% cases of HF

o In patients with hypertension, the risk of heart In patients with hypertension, the risk of heart

failure is increased by 2-fold in men and by 3-failure is increased by 2-fold in men and by 3-

fold in womenfold in women

The 7 pathways in the progression from hypertension to heart failure.

Drazner M H Circulation 2011;123:327-334

Copyright © American Heart Association

• The 7 pathways in the progression from hypertension to heart failure.• Hypertension progresses to concentric (thick-walled) LVH (cLVH; pathway 1).• The direct pathway from hypertension to dilated cardiac failure (increased LV volume with reduced LVEF) can occur without (pathway 2) or with (pathway 3) an interval myocardial infarction (MI). Concentric hypertrophy progresses to dilated cardiac failure (transition to failure) most commonly via an interval myocardial infarction (pathway 4). • Recent data suggest that it is not common for concentric hypertrophy to progress to dilated cardiac failure without interval myocardial infarction (pathway 5). • Patients with concentric LVH can develop symptomatic heart failure with a preserved LVEF (pathway 6), and patients with dilated cardiac failure can develop symptomatic heart failure with reduced LVEF (pathway 7). • The influences of other important modulators of the progression of hypertensive heart disease, including obesity, diabetes mellitus, age, environmental exposures, and genetic factors, are not shown to simplify the diagram. • A thicker arrow depicts a more common pathway compared with a thinner arrow. • Adapted from Drazner.2 Copyright 2005 ©, the American Heart Association.

Other sequelae of LVH

• LA enlargementLA enlargement

• Hypertension most common cause of atrial fibrillation in the Hypertension most common cause of atrial fibrillation in the

Western hemisphereWestern hemisphere

• In one study, nearly 50% of patients with atrial fibrillation had In one study, nearly 50% of patients with atrial fibrillation had

hypertension hypertension

• Dangers of AF : Dangers of AF : StrokeStroke

LV LV

decompensation-HF decompensation-HF

Diagnosis of LVH

Which is more sensitive: ECG or Echo ?

• ECG LVH in 5-10% of hypertensivesECG LVH in 5-10% of hypertensives

• Echo LVH in 30 % of hypertensivesEcho LVH in 30 % of hypertensives

Echo sensitivity - 57% for mild and 98% for severe LVH Echo sensitivity - 57% for mild and 98% for severe LVH

ECG sensitivity – 30% to 57 % for severe LVHECG sensitivity – 30% to 57 % for severe LVH

Cut-off limits for left ventricular hypertrophy on Echo

• The ASE/EAE guidelines : The ASE/EAE guidelines :

LV septal wall thickness >0.9 cm for women LV septal wall thickness >0.9 cm for women

and >1.0 cm for men, and >1.0 cm for men,

LV mass/BSA >95 g/m2 for women and LV LV mass/BSA >95 g/m2 for women and LV

mass/BSA >115 g/m2 for men. mass/BSA >115 g/m2 for men.

ECG abnormalities

LA enlargement

LVH

LV strain pattern

LAHB (50% had hypertn in one series)

LBBB (70-80% had hypertension)

LA enlargement, LVH with strain

LVH criteria by ECG The Cornell criteria (most sensitive) are R wave in aVL plus an The Cornell criteria (most sensitive) are R wave in aVL plus an

S wave in V3 of greater than 2.8 mV in men and greater than S wave in V3 of greater than 2.8 mV in men and greater than

2mV in women2mV in women

The Sokolow-Lyon criteria are an S wave in V1 plus an R wave The Sokolow-Lyon criteria are an S wave in V1 plus an R wave

in V5 or V6 of greater than 3.5mV or an R wave in V5 or V6 of in V5 or V6 of greater than 3.5mV or an R wave in V5 or V6 of

greater than 2.6mV (most specific)greater than 2.6mV (most specific)

The Gubner-Ungerleider criteria are an R wave in I plus an S The Gubner-Ungerleider criteria are an R wave in I plus an S

wave in III of greater than 2.5mV wave in III of greater than 2.5mV

Romhilt-Estes Criteria (A Point Score System) Romhilt-Estes Criteria (A Point Score System)

Romhilt-Estes Criteria (A Point Score System)

Probable LVH is 4 points; definite LVH is 5 points. The sensitivity of these criteria is Probable LVH is 4 points; definite LVH is 5 points. The sensitivity of these criteria is 50%, with a specificity of close to 95%.50%, with a specificity of close to 95%.

Voltage Criteria Points• R wave or S wave in any limb lead >0.2mV or S wave in lead V1 or V2 or R wave in V5 or V6 >0.3mV

3

• LV strain (ST and T waves in direction opposite to QRS direction) without digitalis

3

• LV strain (ST and T waves in direction opposite to QRS direction) with digitalis

1

• LA enlargement (terminal negativity of P waves in V1 >0.1mV deep and 0.04 seconds wide)

3

Left-axis deviation greater than -30° 2

QRS duration greater than 0.09 seconds 1

Intrinsicoid deflection in V5 or V6 >0.05 seconds 1

Risks of LVH

Are due to Pressure overload & Neurohormonal activation

• Myocyte hypertrophy

• Collagen deposition & fibrosis

• Medial hypertrophy of intramyocardial coronary arteries

• Impaired cor reserve + Fibrosis :

• Diastoic Dysfn and Diastolic HF

• Also V arrhthymia, AF, stroke

Hypertension and IHD• At least one RF for IHD present in almost all pts with hypertn

• Abn LDLC in more than 75%

• Diabetes in about 25%

• Obesity in 60-70% of patients with hypertension

----------------------------------------------------------

Out of all Diabetics – 75% have hypertension

Out of all pts with CRF – 90% have hypertension

Out of all obese patients- 50% have some degree of

hypertension

Continuous gradient of risk with rise in BP

IHD mortality rate in each decade of age versus usual BP at the start of that decade

Source: The Lancet 2005; 365:434-441 (DOI:10.1016/S0140-6736(05)17833-7)

Absolute risk of CV disease over 5 years in patients by systolic BP at specified levels of other risk factors

Symptoms & Signs of Hypertensive Heart Disease

• LVH – No Symptoms, Loud S2, heaving

apex, paradoxic split S2

• Diastolic HF, Systolic HF – Dyspnea, S4,

S3, JVP, Lung rales

• CAD- Angina, MI

• AF –syncope, palpitations

-Precipitation of angina

-Precipitation of heart failure

Prognosis of LVH Increase in the cardiovascular mortality rate esp an increase

in the risk of sudden cardiac death

Concentric LVH poses the greatest risk of such events, as

much as a 30% risk over a 10-year period

15% risk with asymmetric LVH and a 9% risk without any LVH.

The degree of LVH, as assessed by LV mass index (LVMI), is

also related to the cardiovascular mortality rate,

a relative risk of 1.73 for men and 2.12 for women for each

50g/m2 increase in the LVMI over a 4-year period.

Prognosis of Left ventricular diastolic dysfunction

• Poor and affected by the presence of underlying coronary

artery disease.

• In one study, survival rates at 3 months, 1 year, and 5 years in

patients with heart failure due to diastolic dysfunction were

86%, 76%, and 46%, respectively.

• 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).

Prognosis of Left ventricular systolic dysfunction

High mortality rate and depends on the symptoms and NYHA

heart failure classification.

The 5-year mortality rate for patients with heart failure due to

systolic dysfunction approaches 20%

2-year mortality rate in patients with NYHA class IV

classification is as high as 50%.

Mortality rates have decreased with the use of ACE inhibitors

and beta blockers, which improve LV function.

Drugs for LVH regression

• Least effective- direct vasodilatorsLeast effective- direct vasodilators

• Mildly effective – Diu, BBMildly effective – Diu, BB

• Most effective- ACEI/ARB, CCBMost effective- ACEI/ARB, CCB

Data indicate that regression of lectrocardiographic LVH is Data indicate that regression of lectrocardiographic LVH is associated with less hospitalization for heart failure in associated with less hospitalization for heart failure in

hypertensive patients hypertensive patients

Drugs for diastolic dysfn. and diastolic HF

ACE inhibitors, beta blockers, and non

dihydropyridine calcium channel blockers

Candesartan (“CHARM added” trial)

Careful addition of Diuretics, Nitrates

Avoid Hydrallazine

Treatment of left ventricular systolic dysfunction

Beta blockers (cardioselective or mixed alpha

and beta), such as carvedilol, metoprolol XL,

and bisoprolol

ACEI/ARB

Diuretics

NO CCB

Drugs for Systolic HF

o Diuretics (predominantly loop diuretics)Diuretics (predominantly loop diuretics)

o Low-dose spironolactoneLow-dose spironolactone

o ACEI/ARBACEI/ARB

o BBBB

o Avoid CCBAvoid CCB

Drugs for Hypertension with high CHDrisk

• ACEI/ARBs

• CCB

• BB ??, Diu ??

Drugs for Hypertension with stable angina

BBBB

CCB (Diltiazem, Verapamil)CCB (Diltiazem, Verapamil)

CCB (Amlodepin with BB)CCB (Amlodepin with BB)

NitratesNitrates

ACEI/ARBACEI/ARB

DiuDiu

Drugs for Hypertension with ACS

BBBB

ACEI/ARBACEI/ARB

NitratesNitrates

CCB –amlo with BBCCB –amlo with BB

Drugs for Hypertension post MI

BB- Carvedilol, Metoprolol, BisoprololBB- Carvedilol, Metoprolol, Bisoprolol

ACEI/ARBACEI/ARB

Aldo Antagonists (recommended for use in Aldo Antagonists (recommended for use in

post-MI patients with diabetes mellitus or post-MI patients with diabetes mellitus or

who have an LV ejection fraction of less than who have an LV ejection fraction of less than

40%.) 40%.)

Goal BP in cardiac patients ?

< 140/90

< 130/80

< 120/80

< 110/60

What proportion of hypertensives should take statins ?

1.1. AllAll

2.2. Almost allAlmost all

3.3. Only the few with significant dyslipidemiaOnly the few with significant dyslipidemia

Why almost all ?

Hypertension significant RF for CHD

Dyslipidemia v common in hypertensives

Antihypertensives often inadequate to reduce risk

Residual risk even when BP is normalized

Good evidence from RCT’s Follow the Chinese - they ALL take lovastatin in form

of red rice and other preparations

Will you recommend aspirin for primary prevention in…

• All hypertensives ?All hypertensives ?

• Those at high risk only ?Those at high risk only ?

• Almost all hypertensives ?Almost all hypertensives ?

Conclusions:• Hypertension a significant risk factor for CHD Hypertension a significant risk factor for CHD

and HFand HF

• These risks are preventable with early These risks are preventable with early

diagnosis and treatmentdiagnosis and treatment

• Not only is it important to bring BP to targets, Not only is it important to bring BP to targets,

but also how it is brought down- match the but also how it is brought down- match the

drug with the associated cardiac conditiondrug with the associated cardiac condition

THANK YOU!!