Management of Heart Failure in hypertension

1. Management of
Hypertensive Heart Disease

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

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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?

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Key Points in this case
Age > 75 years
Signs & symptoms s/o Heart Failure
Accelerated Hypertension
LVEF: Normal

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Management
Control of HF
Control of Hypertension
Treatment of Ischaemia (if present)
Maintenance of sinus rhythm OR control
of heart rate

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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.
Both ischemia and accelerated hypertension will
precipitate flash pulmonary edema
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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

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Left Ventricular Pressure–Volume Loops in
Systolic and Diastolic Dysfunction.

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Patterns of LV Diastolic Filling as Shown by
Standard Doppler Echocardiography

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Treatment
General Principles:
•Control of systolic and diastolic hypertension
•Diuretics to relieve symptoms of volume overload
•Pneumococcal vaccination recommended annually
Choice of Medications:
•Diuretics with nitroglycerin to control CHF, hypertension
and ischemia
•Sodium Nitroprusside if BP is very high

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Regression of LVH:
•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
ARBs- 13 %
CCBs- 11%
ACE inhibitors- 10%
Beta blockers- 6%
Diuretics- 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.

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Atrial Fibrilation:
•Restoration of sinus rhythm is preferred
•If not rate control becomes important
•Beta blockers and calcium channel blockers are the usual first-line
agents, with digoxin most often being used in patients with systolic HF
•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:
•Beta blockers
•CCBs
•Nitrates
•Anti-Platelets
•Coronary revascularization may be required in patients with drug-
resistant ischemic DHF

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Beta Blockers
• Direct evidence of benefit is lacking
• Potential beneficial effects are:
– Slowing heart rate, reducing myocardial oxygen demand and by
decreasing BP, promoting LV regression
• OPTIMIZE HF trial (n=7154)
– Beta blocker therapy reduced mortality in systolic HF but not in
diastolic heart failure.
• SENIORS trial (n=2128)
– > 70 yrs of age
– LVEF > 35%
– Nebivolol when compared to placebo resulted in decreased
hospitalization and mortality

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CCBs:
•Verapamil has shown some benefit in DHF
especially in HCM
ACE inihbitors:
•Beneficial in patients with hypertension, CHD and
diabetes
•More useful in mixed systolic and diastolic HF
•Limit the progression of diastolic dysfunction
•PEP-CHF trial:
– Perindopril evaluated in DHF in patients > 70 yrs of
age, out of which 80% were hypertensives
– Reduced all cause mortality and hospitalization at 1yr
(RR- 31%)

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ARBs:
•CHARM Preserve trial:
– 3023 patients with HF and LVEF >40%
– Candesartan 25 mg for 37 months reduced
hospitalization rates (Absolute RR -23%)
– 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.

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Aldosterone Antagonists:
•Benefit in DHF is uncertain
•TOPCAT trial(n=3445):
– Spironolactone Vs placebo
– Composite primary outcome similar in both groups but
decreased rate of hospitalization in spironolactone
group
– Decreased HF incidence in subgroup of patients who
were enrolled according to BNP or NT-proBNP criteria

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Phosphodiesterase Inhibitors (n=44):
•In patients of DHF with normal LVEF with moderate PAH
•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:
•Long term exercise training will increase diastolic function

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Prognosis:
•Asymptomatic diastolic dysfunction: Moderate to
severe diastolic dysfunction without HF is a
predictor of mortality
•Symptomatic patients(DHF): Compared to systolic
HF the prognosis is better.
•Predictors of mortality:
 Older age
 Male Gender
 NYHA class
 Extent of CAD
 Lower EF
 DM/PVD/RF

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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.

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