2. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
Hypertensive Heart Disease
⢠Hypertension accounts for about 25% of all heart
failure cases overall and about 70% in the
elderly (ADHERE Registry)
⢠In patients with hypertension, the risk of HF is
increased 2 to 3 times
⢠In-hospital mortality ~ 4% & 5year survival
rate~30-40% (Framingham study)
⢠Chronically uncontrolled hypertension can lead
to LVH, CAD and systolic & diastolic dysfunction,
which in turn manifests as angina, MI and CHF
3. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
Case Presentation
⢠A 78-year-old woman with a history of hypertension is
admitted to the hospital with CHF. Physical examination
reveals BP of 180/90 mm Hg, increased jugular venous
pressure, peripheral edema, & pulmonary rales.
⢠Chest X-ray shows pulmonary edema and mild
cardiomegaly. 2-D echo shows increased thickness of the
left ventricular wall, a left ventricular cavity of normal
size, left atrial enlargement, and a left ventricular ejection
fraction of 70 percent. The left ventricular Doppler filling
pattern is abnormal and consistent with an elevated
pulmonary-capillary wedge pressure.
⢠How should this patient be treated?
6. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
Impaired Response to Stress
⢠They tolerate atrial fibrillation poorly
⢠They do not tolerate tachycardia as well
⢠Sudden elevations in systemic BP, will increase
LV wall stress, which can worsen myocardial
relaxation
⢠The acute induction or worsening of diastolic
dysfunction by ischemia raises left atrial and
pulmonary venous pressures.
ďśBoth ischemia and accelerated hypertension will
precipitate flash pulmonary edema
Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
7. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
Diastolic Dysfunction
⢠Diastolic dysfunction is common and usually
accompanied by LVH.
⢠This is because the chronically elevated
afterload adversely affects the active early
relaxation phase and the late compliance phase
of the ventricular diastole.
⢠The level of diastolic dysfunction appears to
correlate with increasing severity of hypertension
10. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
Treatment
General Principles:
â˘Control of systolic and diastolic hypertension
â˘Diuretics to relieve symptoms of volume overload
â˘Pneumococcal vaccination recommended annually
Choice of Medications:
â˘Diuretics with nitroglycerin to control CHF, hypertension
and ischemia
â˘Sodium Nitroprusside if BP is very high
11. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
Regression of LVH:
â˘A meta-analysis published in 2003 assessed the relative
efficacy of different antihypertensive drugs for their ability to
reverse LVH in patients with hypertension
⢠The relative reductions in LV mass index were
ďźARBs- 13 %
ďźCCBs- 11%
ďźACE inhibitors- 10%
ďźBeta blockers- 6%
ďźDiuretics- 8%
Klingbeil AU, et al. A meta-analysis of the effects of treatment on left ventricular mass in essential
hypertension. Am J Med. 2003;115(1):41.
12. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
Atrial Fibrilation:
â˘Restoration of sinus rhythm is preferred
â˘If not rate control becomes important
â˘Beta blockers and calcium channel blockers are the usual first-line
agents, with digoxin most often being used in patients with systolic HF
â˘An important component of management of AF, regardless of whether
rhythm control or rate control is chosen, is anticoagulation to prevent
systemic embolization
Anti-ischemic Therapy:
â˘Beta blockers
â˘CCBs
â˘Nitrates
â˘Anti-Platelets
â˘Coronary revascularization may be required in patients with drug-
resistant ischemic DHF
13. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
Beta Blockers
⢠Direct evidence of benefit is lacking
⢠Potential beneficial effects are:
â Slowing heart rate, reducing myocardial oxygen demand and by
decreasing BP, promoting LV regression
⢠OPTIMIZE HF trial (n=7154)
â Beta blocker therapy reduced mortality in systolic HF but not in
diastolic heart failure.
⢠SENIORS trial (n=2128)
â > 70 yrs of age
â LVEF > 35%
â Nebivolol when compared to placebo resulted in decreased
hospitalization and mortality
14. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
CCBs:
â˘Verapamil has shown some benefit in DHF
especially in HCM
ACE inihbitors:
â˘Beneficial in patients with hypertension, CHD and
diabetes
â˘More useful in mixed systolic and diastolic HF
â˘Limit the progression of diastolic dysfunction
â˘PEP-CHF trial:
â Perindopril evaluated in DHF in patients > 70 yrs of
age, out of which 80% were hypertensives
â Reduced all cause mortality and hospitalization at 1yr
(RR- 31%)
15. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
ARBs:
â˘CHARM Preserve trial:
â 3023 patients with HF and LVEF >40%
â Candesartan 25 mg for 37 months reduced
hospitalization rates (Absolute RR -23%)
â Cardiovascular mortality was not different
⢠I-PRESERVE(n=4128):
- Irbesartan 300mg vs placebo.
- After 50 months, there was no significant difference
between irbesartan and placebo groups.
16. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
Aldosterone Antagonists:
â˘Benefit in DHF is uncertain
â˘TOPCAT trial(n=3445):
â Spironolactone Vs placebo
â Composite primary outcome similar in both groups but
decreased rate of hospitalization in spironolactone
group
â Decreased HF incidence in subgroup of patients who
were enrolled according to BNP or NT-proBNP criteria
17. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
Phosphodiesterase Inhibitors (n=44):
â˘In patients of DHF with normal LVEF with moderate PAH
â˘Symptomatology improved after 1 year of therapy
Statin Therapy:
⢠Intensive lipid lowering with statin therapy is
recommended for the secondary prevention of CV disease,
independent of the presence of diastolic dysfunction
Exercise Conditioning:
â˘Long term exercise training will increase diastolic function
18. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
Prognosis:
â˘Asymptomatic diastolic dysfunction: Moderate to
severe diastolic dysfunction without HF is a
predictor of mortality
â˘Symptomatic patients(DHF): Compared to systolic
HF the prognosis is better.
â˘Predictors of mortality:
ďź Older age
ďź Male Gender
ďź NYHA class
ďź Extent of CAD
ďź Lower EF
ďź DM/PVD/RF
21. Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014
SUMMARY AND RECOMMENDATIONS
⢠Hemodynamic stress including atrial fibrillation, tachycardia,
abrupt ,severe or refractory elevations in systemic blood pressure,
and myocardial ischemia are associated with worsening of diastolic
dysfunction
⢠Treatment of DHF remains empiric since trials are limited
⢠Diuretics, nitrates and venodilators should be used with caution in
patients with HCM & in patients with gross LV hypertrophy
⢠Direct evidence to support a specific drug regimen to treat DHF is
lacking.
⢠Cornerstones of therapy would be Symptomatic control of HF,
Control of HTN & Treatment of Ischemia.