The Overworked Heart
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The transition from Hyper tension to "Heart tension" and its progression to Heart Failure and Vascular disease
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The Overworked Heart
- 2. 75 years-old male patient, Moderate HTN, abnormal ECG, exertional dyspnea 10/4/2016 F.N. Dec/2012 2
- 3. The overworked heart Uncontrolled High Blood Pressure causes the Heart Muscle to Overwork itself in order to pump blood under high pressure toughout the body 10/4/2016 F.N. Dec/2012 3
- 4. FROM HYPER-TENSION TO HEART-TENSION 10/4/2016 F.N. Dec/2012 4
- 5. Hypertension remains a major public health problem “One in three adults worldwide, according to the report, has raised blood pressure – a condition that causes around half of all deaths from stroke and heart disease. One in 10 adults has diabetes” 10/4/2016 F.N. Dec/2012 5
- 6. Date of download: 12/1/2012 Copyright © The American College of Cardiology. All rights reserved. Ethnicity and Left Ventricular Diastolic Function in Hypertension: An ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial) Substudy J Am Coll Cardiol. 2008;52(12):1015-1021. doi:10.1016/j.jacc.2008.04.065 Relationship of Age Group and Ethnicity to Diastolic Function, as Measured by E′ and the E/E′ Ratio The magnitude of the ethnic difference in these markers of diastolic function in comparison with that of each decade of aging is demonstrated. Diastolic function was assessed using the tissue Doppler early diastolic velocity (E′) and the ratio of this and the transmitral early filling velocity (E/E′). 10/4/2016 F.N. Dec/2012 6
- 7. From Hyper-tension to Heart-tension Peripheral BP vs. Central Aortic BP Chronically increased workoad on the left ventricle: pressure- overload Increased wall thickness to normalize myocardial wall stress Adapted from : Phil Chowienczyk and Ajay Shah, Hypertension. 2012;60:10-11,10/4/2016 F.N. Dec/2012 7
- 8. Factors promoting LVH Hypertension • Systolic > Diastolic Hypertension Neurohumoral factors (growth stimulation) • Angiotensine II, Aldosterone • Norepinephrine, Insulin Genetic Influences 10/4/2016 F.N. Dec/2012 8
- 9. Classic pathway in the progression from Hypertension to Heart Tension Hypertension Pressure overload Increase in LV Mass LVH Concentric LVH Eccentric LVH Heart Failure HF with Preserved LVEF HF with reduced LVEF Adapted from :Kamran Diaz, Yasmin Subhi , Hypertensive Heart Disease, Medscape Reference, Jan 201210/4/2016 F.N. Dec/2012 9
- 10. Structural Remodeling : the LV Geometry Normal Relative Wall Thickness ( < 0.42) Increased Relative Wall Thickness ( > 0.42) Normal LV Mass Index g/m2 < 0.95 ♀ < 115 ♂ Normal Concentric Remodelling Increased LV Mass Index g/m2 0.95 ♀ 115 ♂ Eccentric Hypertrophy Concentric Hypertrophy Adapted from : J Am Soc Echocardiogr 2005;18:1440-1463. 10/4/2016 F.N. Dec/2012 10
- 11. The hypertensive heart Structural Remodeling Micro and Macrovascular disease (aortopathy) Myocardial Fibrosis Left Atrial myopathy Adapted from : Subha V. Raman, The Hypertensive heart. J Am Coll Cardiol. 2010;55(2):91-96.10/4/2016 F.N. Dec/2012 11
- 12. Beyond the myocardial remodelling : The many aspects of Hypertensive Heart Disease (HHD) Subha V. Raman, The Hypertensive heart. J Am Coll Cardiol. 2010;55(2):91-96. 10/4/2016 F.N. Dec/2012 12
- 13. This ECG from a 62-year-old woman shows left ventricular hypertrophy by the Cornell voltage criteria, the Cornell product criteria, the Sokolow-Lyon voltage criteria, and the Romhilt-Estes point score system. BAUML M A , UNDERWOOD D A Cleveland Clinic Journal of Medicine 2010;77:381-387 ©2010 by Cleveland Clinic Assessment of myocardial remodelling assessment: ECG Cornell voltage criteria: SV3 + RaVL ≥ 2.0 mV (28 mm) in men SV3 + RaVL ≥ 2.8 mV (20 mm) in women Cornell voltage— median sensitivity 15%, median specificity 96% 10/4/2016 F.N. Dec/2012 13
- 14. Myocardial Remodeling assessment : Echocardiography Janardhanan R., Kramer C., Imaging in hypertensive heart disease. Expert Rev. Cardiovasc. Ther. 2011; 9(2), 199–209 10/4/2016 F.N. Dec/2012 14
- 15. Myocardial area: estimating LV mass (2D Echo) Lang R. Bierigh M., Devereux R. Recommendations for chamber quantification . Eur J Echocardiography 2006; 7:79-108 Lang R. Bierigh M., Devereux R. Recommendations for chamber quantification . Eur J Echocardiography 2006; 7:79-108 10/4/2016 F.N. Dec/2012 15
- 16. Myocardial Remodeling assessment : Cardiac Magnetic Resonance Janardhanan R., Kramer C., Imaging in hypertensive heart disease. Expert Rev. Cardiovasc. Ther. 2011; 9(2), 199–20910/4/2016 F.N. Dec/2012 16
- 17. Cardiac Magnetic Resonance –late galodinium enhancement (LGE)-T1 Mapping for Myocardial Fibrosis Quantification Subha V. Raman, The Hypertensive heart. J Am Coll Cardiol. 2010;55(2):91-96.10/4/2016 F.N. Dec/2012 17
- 18. Cardiovascular adaptations to arterial stiffening that occur with aging Aronow W., Fleg J., Pepine C. ACCF/AHA 2011 Expert Consensus Document on Hypertension in the elderly JACC 2011; 57 ( 20 10/4/2016 F.N. Dec/2012 18
- 19. Reduced Aortic Distensibility (cine CMR) in Diastolic HF patients Subha V. Raman, The Hypertensive heart. J Am Coll Cardiol. 2010;55(2):91-96.10/4/2016 F.N. Dec/2012 19
- 20. From Pressure overload to Diastolic Heart Failure Adapted from: CHHABI SATPATHY , RUBY SATPATHY Am Fam Physician. 2006 Mar 1;73(5):841-846. Diastolic Dysfunction Diastolic Heart Failure Pressure overload Ischemia Abnormal Relaxation Abnormal LV early filling Normal exercise tolerance Diastolic abnormalities Hypertrophy/ Myocardial Infarction Abnormal Relaxation Increased Stiffness Elevated LV filling pressure Elevated Pulmonary Pressure during exercise Elevated Left atrial pressure and size Atrial Fibrillation Decreased cardiac output Reduced exercise tolerance And signs of Congestive Heart Failure 10/4/2016 F.N. Dec/2012 20
- 21. Normal Doppler Mitral flow Little C William: Circulation 2009: 120;802-80910/4/2016 F.N. Dec/2012 21
- 22. Diastolic dysfunction can be found in 25% of asymptomatic hypertensives without LV hypertrophy but in 90% of those having LV hypertrophy. Little C William: Circulation 2009: 120;802-80910/4/2016 F.N. Dec/2012 22
- 23. Tissue Doppler (TD) in Hypertensive patients Naguegh S., EAE/ASE Recommendations for the evaluationof the left ventricular diastolic function by Echocardiography. Europan Journal of Echocardiography 2009; 10:165-193 10/4/2016 F.N. Dec/2012 23
- 24. Tissue Doppler Imaging : reduced early diastolic mitral annular velocity (Ea) , suggestive of diastolic dysfunction Janardhanan R., Kramer C., Imaging in hypertensive heart disease. Expert Rev. Cardiovasc. Ther. 2011; 9(2), 199–209 10/4/2016 F.N. Dec/2012 24
- 25. Assessment of reduced Diastolic Reserve: Exercise Doppler recording of Mitral inflow and TDI Naguegh S., EAE/ASE Recommendations for the evaluationof the left ventricular diastolic function by Echocardiography. Europan Journal of Echocardiography 2009; 10:165-193 10/4/2016 F.N. Dec/2012 25
- 26. Beyond the myocardial remodelling : The many aspects of Hypertensive Heart Disease (HHD) LEFT ATRIAL MYOPHATHY Subha V. Raman, The Hypertensive heart. J Am Coll Cardiol. 2010;55(2):91-96. 10/4/2016 F.N. Dec/2012 26
- 27. Figure 1. Example of LA strain curves. Kurt M et al. Circ Cardiovasc Imaging 2009;2:10-15 Copyright © American Heart Association Left Atrial Strain during Atrial Systole 10/4/2016 F.N. Dec/2012 27
- 28. Pathways in the progression from hypertension to Heart Failure (HF) Hypertension Concentric LVH Hypertension Dilated cardiac failure Symptomatic HF with low EF MI No MI MI No MI Adapted from: Drazner M, The progression of hypertensive heart disease, Circulation 20011; 123:327-33410/4/2016 F.N. Dec/2012 28
- 29. Challenges to the classic paradigm of the progression of Hypertensive Heart Disease In animals models of pressure overload , concentric LVH can be blocked, and dilated cardiac failure does not develop In humans, concentric LVH does not commonly progress to dilated cardiac failure in the absence of myocardial infarction Some hypertensive subjects develop dilated cardiac failure without antecedent of concentric LVH or Myocardial Infarction Adapted from: Drazner M, The progression of hypertensive heart disease, Circulation 20011; 123:327-33410/4/2016 F.N. Dec/2012 29
- 30. The overworked Heart LVH is a maladaptive response to chronic pressure overload Major Risk Factor in patients with Hypertension (atrial fibrillation, CAD, Diastolic HF, Systolic HF, sudden death. Choice of antihypertensive agents may be important when treating a patient with hipertensive LV hypertrophy ACE inhibitors, ARB, carvelidol , Aldosterone receptor blockers , aliskiren, statins, renal sympathetic denervation, facillitate regresion of LVH With regression of LVH, diastolic function and coronary flow reserve improve, and cardiovascular risks decreases. Adapted from: Kathori R., Couri D. Left ventricular hypertrophy: a major risk factor in patients with hypertension. International Journal of Hypertension April, 2011 10/4/2016 F.N. Dec/2012 30
- 31. The overworked Heart 10/4/2016 F.N. Dec/2012 31
Editor's Notes
- Hypertensive heart disease involves disparate elements, ranging from aortopathy to myocardial remodeling and even peripheral energy utilization that interact to produce sequelae such as heart failure, arrhythmias, and ischemic events
- This electrocardiogram from a 62-year-old woman shows left ventricular hypertrophy by the Cornell voltage criteria, the Cornell product criteria, the Sokolow-Lyon voltage criteria, and the Romhilt-Estes point score system.
- Marked left ventricular hypertrophy noted on 2D-guided M-mode echo.
- Two methods for estimating LV mass based on the areaelength (AL) formula and the truncated ellipsoid (TE) formula, from short axis (left) and apical four-chamber (right) 2-D echo views. A1 ¼ total LV area; A2 ¼ LV cavity area; Am ¼ myocardial area,
- Four-chamber long-axis view on an end-diastolic frame from a steady-state free precession cine image set demonstrating left ventricular hypertrophy by cardiac magnetic resonance.
- A) Images obtained at multiple inversion times show recovery of myocardial signal after initial inversion. (B) Plot of myocardial signal intensity versus inversion time (Tl) shows an exponential recovery curve from which myocardial T1 can be calculated. (C) Conventional late post-gadolinium image shows minimal grossly apparent hyperenhancement, underscoring the need for more quantitative approaches. Reproduced, with permission, from Iles et al
- Conceptual Framework for Cardiovascular Adaptations to Arterial Stiffening That Occur With Aging
- Aortic distensibility obtained with cine cardiac magnetic resonance imaging as one proceeds from healthy young to healthy old individuals; distensibility is mos treduced in diastolic heart failure patients
- Tissue Doppler (TD) recording from the lateral mitral annulus from a normal subject aged 35 years (left) (e´ ¼ 14 cm/s) and a 58-year-old patient with hypertension, LV hypertrophy, and impaired LV relaxation (right) (e´ ¼ 8 cm/s).
- Tissue Doppler imaging in a patient with hypertension demonstrating reduced early diastolic mitral annular velocity (Ea), suggestive of diastolic dysfunction.
- Exercise Doppler recordings from a patient with reduced diastolic reserve. At baseline, mitral inflow shows an impaired relaxation pattern, with an E/e´ ratio of 7, and the peak velocity of the TR jet was 2.4 m/s (PA systolic pressure 23 mm Hg). During supine bike exercise, mitral E velocity and the E/A ratio increase with shortening of DT. The E/e´ ratio is now 11, and the PA systolic pressure is increased to 58 mm
- Hypertensive heart disease involves disparate elements, ranging from aortopathy to myocardial remodeling and even peripheral energy utilization that interact to produce sequelae such as heart failure, arrhythmias, and ischemic events
- Figure 1. Example of LA strain curves. Septal LA strain is shown in yellow, and lateral strain is shown in blue. LAS strain refers to LA strain during the systolic phase of the cardiac cycle, and LAA strain refers to LA strain during atrial contraction.