Hypertension & Heart Dr Akshay Mehta Dr B Nanavati Hospital Asian Heart Institute
Hypertensive Heart DiseaseTrue or False ?ALL the following are examples of hypertensive heart disease : CHD LVH LVF Arrhythmias Conduction system abnormality Aortic Regurgitation
Definition : Hypertensive heart disease is a constellation of abnormalities including coronary artery disease, left ventricular hypertrophy (LVH), systolic and diastolic dysfunction, and their clinical manifestations including arrhythmias, conduction abnormalities and symptomatic heart failure, that are caused by the direct or indirect effects of elevated BP
Hypertensive Heart Disease• Left ventricular hypertrophy• LV dysfunction: Diastolic Systolic• Heart Failure Diastolic Systolic• Arrhythmia, conduction abnormalities• CHD• AR
LVH – concentric v/s eccentric responseGenetic 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 LVH• However, may be as common as 33% in hypertensive without LVH Systolic d dysfunction• Reduced EF with or without IHD
Hypertension and HFo Hypertension accounts for 25% cases of HFo In elderly it accounts for 68% cases of HFo In patients with hypertension, the risk of heart failure is increased by 2-fold in men and by 3- fold in women
Other sequelae of LVH• LA enlargement• Hypertension most common cause of atrial fibrillation in the Western hemisphere• In one study, nearly 50% of patients with atrial fibrillation had hypertension• Dangers of AF : Stroke LV decompensation-HF
Diagnosis of LVH Which is more sensitive: ECG or Echo ?• ECG LVH in 5-10% of hypertensives• Echo LVH in 30 % of hypertensivesEcho sensitivity - 57% for mild and 98% for severe LVHECG sensitivity – 30% to 57 % for severe LVH
Cut-off limits for left ventricular hypertrophy on Echo• The ASE/EAE guidelines :LV septal wall thickness >0.9 cm for women and >1.0 cm for men,LV mass/BSA >95 g/m2 for women and LV mass/BSA >115 g/m2 for men.
ECG abnormalitiesLA enlargementLVHLV strain patternLAHB (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 S wave in V3 of greater than 2.8 mV in men and greater than 2mV in women 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 greater than 2.6mV (most specific) The Gubner-Ungerleider criteria are an R wave in I plus an S wave in III of greater than 2.5mV Romhilt-Estes Criteria (A Point Score System)
Romhilt-Estes Criteria (A Point Score System) Voltage Criteria Points • R wave or S wave in any limb lead >0.2mV or 3 S wave in lead V1 or V2 or R wave in V5 or V6 >0.3mV • LV strain (ST and T waves in direction 3 opposite to QRS direction) without digitalis • LV strain (ST and T waves in direction 1 opposite to QRS direction) with digitalis • LA enlargement (terminal negativity of 3 P waves in V1 >0.1mV deep and 0.04 seconds wide) 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 Probable LVH is 4 points; definite LVH is 5 points. The sensitivity of these criteria is 50%, with a specificity of close to 95%.
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 hypertensionOut of all pts with CRF – 90% have hypertensionOut 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
Absolute risk of CV disease over 5 years inpatients by systolic BP at specified levels ofother risk factors Source: The Lancet 2005; 365:434-441 (DOI:10.1016/S0140-6736(05)17833-7 )
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 vasodilators• Mildly effective – Diu, BB• Most effective- ACEI/ARB, CCB Data indicate that regression of lectrocardiographic LVH is associated with less hospitalization for heart failure in hypertensive patients
Drugs for diastolic dysfn. and diastolic HFACE inhibitors, beta blockers, and non dihydropyridine calcium channel blockersCandesartan (“CHARM added” trial)Careful addition of Diuretics, NitratesAvoid Hydrallazine
Treatment of left ventricular systolic dysfunctionBeta blockers (cardioselective or mixed alpha and beta), such as carvedilol, metoprolol XL, and bisoprololACEI/ARBDiureticsNO CCB
Drugs for Hypertension with high CHD risk• ACEI/ARBs• CCB• BB ??, Diu ??
Drugs for Hypertension with stable anginaBBCCB (Diltiazem, Verapamil)CCB (Amlodepin with BB)NitratesACEI/ARBDiu
Drugs for Hypertension with ACSBBACEI/ARBNitratesCCB –amlo with BB
Drugs for Hypertension post MIBB- Carvedilol, Metoprolol, BisoprololACEI/ARBAldo Antagonists (recommended for use in post-MI patients with diabetes mellitus or who have an LV ejection fraction of less than 40%.)
Goal BP in cardiac patients ?< 140/90< 130/80< 120/80< 110/60
What proportion of hypertensives should take statins ?1. All2. Almost all3. Only 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 ?• Those at high risk only ?• Almost all hypertensives ?
Conclusions:• Hypertension a significant risk factor for CHD and HF• These risks are preventable with early diagnosis and treatment• Not only is it important to bring BP to targets, but also how it is brought down- match the drug with the associated cardiac condition