Hypertension & heart

1. Dr Akshay MehtaDr Akshay Mehta
Dr B Nanavati Hospital
Asian Heart Institute
Hypertension & HeartHypertension & Heart

2. Hypertensive Heart Disease
True or False ?
ALL the following are examples of hypertensive heart ALL the following are examples of hypertensive heart
disease :disease :
CHDCHD
LVHLVH
LVFLVF
ArrhythmiasArrhythmias
Conduction system abnormalityConduction system abnormality
Aortic RegurgitationAortic Regurgitation

3. Definition :
Hypertensive heart disease is a constellation of abnormalities Hypertensive heart disease is a constellation of abnormalities
including coronary artery disease, left ventricular hypertrophy including coronary artery disease, left ventricular hypertrophy
(LVH), systolic and diastolic dysfunction, and their clinical (LVH), systolic and diastolic dysfunction, and their clinical
manifestations including arrhythmias, conduction manifestations including arrhythmias, conduction
abnormalities and symptomatic heart failure, that are caused abnormalities and symptomatic heart failure, that are caused
by the direct or indirect effects of elevated BPby the direct or indirect effects of elevated BP

4. Hypertensive Heart Disease
•Left ventricular hypertrophyLeft ventricular hypertrophy
•LV dysfunction:LV dysfunction:
DiastolicDiastolic
SystolicSystolic
•Heart FailureHeart Failure
DiastolicDiastolic
SystolicSystolic
•Arrhythmia, conduction abnormalitiesArrhythmia, conduction abnormalities
•CHDCHD
•ARAR

5. Hypertensive CARDIO VASCULAR
DISEASE includes:
Aortic aneurysmAortic aneurysm
Aortic dissectionAortic dissection
PADPAD

6. Left Ventricular Hypertrophy- LVH
Increase in mass of LV

7. LVH
15-20% of hypertension pts develop LVH15-20% of hypertension pts develop LVH
The risk of LVH is increased 2-fold by The risk of LVH is increased 2-fold by
associated obesity associated obesity

8. Classification of LV geometry based on LV mass and
relative wall thickness (the ratio of LV wall thickness to
diastolic dimension)
Drazner M H Circulation 2011;123:327-334
Copyright © American Heart Association

9. LVH – concentric v/s eccentric
response
Genetic factors may influence the response to pressure overload
and, specifically, whether concentric or eccentric hypertrophy
develops

10. Is regression of LVH possible ?
Yes
No

11. Hypertension and LV Dysfunction
Diastolic dysfunction : Normal EF
•Usually, but not invariably, accompanied by Usually, but not invariably, accompanied by
LVHLVH
•However, may be as common as 33% in However, may be as common as 33% in
hypertensive without LVH hypertensive without LVH
Systolic d dysfunction
•Reduced EF with or without IHDReduced EF with or without IHD

12. Hypertension and HF
oHypertension accounts for 25% cases of HFHypertension accounts for 25% cases of HF
oIn elderly it accounts for 68% cases of HFIn elderly it accounts for 68% cases of HF
oIn patients with hypertension, the risk of heart In patients with hypertension, the risk of heart
failure is increased by 2-fold in men and by 3-failure is increased by 2-fold in men and by 3-
fold in womenfold in women

13. The 7 pathways in the progression from
hypertension to heart failure.
Drazner M H Circulation 2011;123:327-334
Copyright © American Heart Association

14. •The 7 pathways in the progression from hypertension to heart failure.
•Hypertension progresses to concentric (thick-walled) LVH (cLVH; pathway 1).
•The direct pathway from hypertension to dilated cardiac failure (increased LV
volume with reduced LVEF) can occur without (pathway 2) or with (pathway 3)
an interval myocardial infarction (MI). Concentric hypertrophy progresses to
dilated cardiac failure (transition to failure) most commonly via an interval
myocardial infarction (pathway 4).
•Recent data suggest that it is not common for concentric hypertrophy to
progress to dilated cardiac failure without interval myocardial infarction
(pathway 5).
•Patients with concentric LVH can develop symptomatic heart failure with a
preserved LVEF (pathway 6), and patients with dilated cardiac failure can
develop symptomatic heart failure with reduced LVEF (pathway 7).
•The influences of other important modulators of the progression of
hypertensive heart disease, including obesity, diabetes mellitus, age,
environmental exposures, and genetic factors, are not shown to simplify the
diagram.
•A thicker arrow depicts a more common pathway compared with a thinner
arrow.
•Adapted from Drazner.2 Copyright 2005 ©, the American Heart Association.

15. Other sequelae of LVH
•LA enlargementLA enlargement
•Hypertension most common cause of atrial fibrillation in the Hypertension most common cause of atrial fibrillation in the
Western hemisphereWestern hemisphere
•In one study, nearly 50% of patients with atrial fibrillation had In one study, nearly 50% of patients with atrial fibrillation had
hypertension hypertension
•Dangers of AF : Dangers of AF : StrokeStroke
LV LV
decompensation-HF decompensation-HF

16. Diagnosis of LVH
Which is more sensitive: ECG or Echo ?
•ECG LVH in 5-10% of hypertensivesECG LVH in 5-10% of hypertensives
•Echo LVH in 30 % of hypertensivesEcho LVH in 30 % of hypertensives
Echo sensitivity - 57% for mild and 98% for severe LVH Echo sensitivity - 57% for mild and 98% for severe LVH
ECG sensitivity – 30% to 57 % for severe LVHECG sensitivity – 30% to 57 % for severe LVH

17. Cut-off limits for left ventricular
hypertrophy on Echo
•The ASE/EAE guidelines : The ASE/EAE guidelines :
LV septal wall thickness >0.9 cm for women LV septal wall thickness >0.9 cm for women
and >1.0 cm for men, and >1.0 cm for men,
LV mass/BSA >95 g/m2 for women and LV LV mass/BSA >95 g/m2 for women and LV
mass/BSA >115 g/m2 for men. mass/BSA >115 g/m2 for men.

18. ECG abnormalities
LA enlargement
LVH
LV strain pattern
LAHB (50% had hypertn in one series)
LBBB (70-80% had hypertension)

19. LA enlargement, LVH with strain

20. LVH criteria by ECG
The Cornell criteria (most sensitive) are R wave in aVL plus an 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 S wave in V3 of greater than 2.8 mV in men and greater than
2mV in women2mV in women
The Sokolow-Lyon criteria are an S wave in V1 plus an R wave 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 in V5 or V6 of greater than 3.5mV or an R wave in V5 or V6 of
greater than 2.6mV (most specific)greater than 2.6mV (most specific)
 The Gubner-Ungerleider criteria are an R wave in I plus an S The Gubner-Ungerleider criteria are an R wave in I plus an S
wave in III of greater than 2.5mV wave in III of greater than 2.5mV
Romhilt-Estes Criteria (A Point Score System) Romhilt-Estes Criteria (A Point Score System)

21. Romhilt-Estes Criteria (A Point Score System)
Probable LVH is 4 points; definite LVH is 5 points. The sensitivity of these criteria is Probable LVH is 4 points; definite LVH is 5 points. The sensitivity of these criteria is
50%, with a specificity of close to 95%.50%, with a specificity of close to 95%.
Voltage Criteria Points
•R wave or S wave in any limb lead >0.2mV or
S wave in lead V1 or V2 or R wave in V5 or V6 >0.3mV
3
•LV strain (ST and T waves in direction
opposite to QRS direction) without digitalis
3
•LV strain (ST and T waves in direction
opposite to QRS direction) with digitalis
1
•LA enlargement (terminal negativity of
P waves in V1 >0.1mV deep and 0.04 seconds wide)
3
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

22. 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

23. 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 hypertension
Out of all pts with CRF – 90% have hypertension
Out of all obese patients- 50% have some degree of
hypertension

24. Continuous gradient of risk with rise in BP

25. IHD mortality rate in each decade of age versus usual
BP at the start of that decade

26. Source: The Lancet 2005; 365:434-441 (DOI:10.1016/S0140-6736(05)17833-7)
Absolute risk of CV disease over 5 years in
patients by systolic BP at specified levels of
other risk factors

27. 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

28. 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.

29. 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).

30. 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.

31. Drugs for LVH regression
•Least effective- direct vasodilatorsLeast effective- direct vasodilators
•Mildly effective – Diu, BBMildly effective – Diu, BB
•Most effective- ACEI/ARB, CCBMost effective- ACEI/ARB, CCB
Data indicate that regression of lectrocardiographic LVH is Data indicate that regression of lectrocardiographic LVH is
associated with less hospitalization for heart failure in associated with less hospitalization for heart failure in
hypertensive patients hypertensive patients

32. Drugs for diastolic dysfn. and diastolic
HF
ACE inhibitors, beta blockers, and non
dihydropyridine calcium channel blockers
Candesartan (“CHARM added” trial)
Careful addition of Diuretics, Nitrates
Avoid Hydrallazine

33. Treatment of left ventricular
systolic dysfunction
Beta blockers (cardioselective or mixed alpha
and beta), such as carvedilol, metoprolol XL,
and bisoprolol
ACEI/ARB
Diuretics
NO CCB

34. Drugs for Systolic HF
oDiuretics (predominantly loop diuretics)Diuretics (predominantly loop diuretics)
oLow-dose spironolactoneLow-dose spironolactone
oACEI/ARBACEI/ARB
oBBBB
oAvoid CCBAvoid CCB

35. Drugs for Hypertension with high CHD
risk
•ACEI/ARBs
•CCB
• BB ??, Diu ??

36. Drugs for Hypertension with stable
angina
BBBB
CCB (Diltiazem, Verapamil)CCB (Diltiazem, Verapamil)
CCB (Amlodepin with BB)CCB (Amlodepin with BB)
NitratesNitrates
ACEI/ARBACEI/ARB
DiuDiu

37. Drugs for Hypertension with ACS
BBBB
ACEI/ARBACEI/ARB
NitratesNitrates
CCB –amlo with BBCCB –amlo with BB

38. Drugs for Hypertension post MI
BB- Carvedilol, Metoprolol, BisoprololBB- Carvedilol, Metoprolol, Bisoprolol
ACEI/ARBACEI/ARB
Aldo Antagonists (recommended for use in Aldo Antagonists (recommended for use in
post-MI patients with diabetes mellitus or post-MI patients with diabetes mellitus or
who have an LV ejection fraction of less than who have an LV ejection fraction of less than
40%.) 40%.)

39. Goal BP in cardiac patients ?
< 140/90
< 130/80
< 120/80
< 110/60

40. What proportion of hypertensives
should take statins ?
1.1.AllAll
2.2.Almost allAlmost all
3.3.Only the few with significant dyslipidemiaOnly the few with significant dyslipidemia

41. 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

42. Will you recommend aspirin for
primary prevention in…
•All hypertensives ?All hypertensives ?
•Those at high risk only ?Those at high risk only ?
•Almost all hypertensives ?Almost all hypertensives ?

43. Conclusions:
•Hypertension a significant risk factor for CHD Hypertension a significant risk factor for CHD
and HFand HF
•These risks are preventable with early These risks are preventable with early
diagnosis and treatmentdiagnosis and treatment
•Not only is it important to bring BP to targets, Not only is it important to bring BP to targets,
but also how it is brought down- match the but also how it is brought down- match the
drug with the associated cardiac conditiondrug with the associated cardiac condition

44. THANK YOU!!