DR.RISHIKESAN K.V

SPECIALIST PHYSICIAN

HYPERTENSIVE HEART DISEASE

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

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.

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

• 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

• 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

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%.

CV MORTALITY RISK

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

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.

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

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 .

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.

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

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 .

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 .

STAGING OF HYPERTENSION

HTNve HD USUALLY PROGRESSES IN THE FOLLOWING SEQUENCE:• INCREASED WALL STRESS LEADS

TO LVH >>>>• DIASTOLIC DYSFUNCTION >>>>>>

SYSTOLIC LV DYSFUNCTION

• 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

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

EVALUATION

ENDOCRINE CAUSES

CV RISK REDUCTION

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

JNC7 ALGORITHM FOR TREATMENT OF HYPERTENSIONJNC7 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 inhibitorCCB = calcium channel blockerARB = angiotensin receptor blockerB = -blockerCKD = chronic kidney disease

LIFESTYLE TREATMENT

LIFE STYLE TREATMENT

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

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.)

PHARMACOTHERAPY

PHARMACOLOGIC TREATMENT

COMBINATIONS

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.

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.

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.

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.

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.

TREATMENT OF HTN AND CAD

RESISTANT HYPERTENSION

CAUSES OF RESISTANT HTN

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.

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

BAROREFLEX ACTIVATION THERAPY

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

THANK YOU FOR THE PATIENT HEARING