Edit concept Create issue ticket

Hypertensive Heart Disease

Hypertensive Cardiovascular Disease

Hypertensive heart disease (HHD) is a term applied to refer to all cardiac pathological conditions which are directly or indirectly caused by high blood pressure.


Presentation

The type of disease, its duration and its severity greatly affect the signs and symptoms of HHD. Hypertension is among the most important of these, and since many patients might not be aware of its presence, hypertension is frequently referred to as the “silent killer”.

Left ventricular hypertrophy

Patients are generally asymptomatic, except in the cases when LVH is pronounced enough to be able to lead to diastolic dysfunction and heart failure.

Heart failure

Symptomatic diastolic heart failure and systolic heart failure can be hard to distinguish due to the similarity of their symptoms, thus the study of the patient’s medical history is paramount. Particular attention should be given to the cases characterized by rapid CHF appearance followed by rapid return to the baseline, a situation more closely related to diastolic dysfunction. Other heart failure symptoms include:

In addition to these, pulmonary edema can also occur due to the sudden decomposition in the LV systolic and diastolic dysfunction, which is turn is caused by a series of precipitating factors like acute rise of the blood pressure, myocardial ischemia, and dietary indiscretion. Cardiac arrhythmia (especially atrial fibrillation) and heart failure can also occur.

Myocardial ischemia

It is particularly difficult to distinguish angina, one of the most frequent HHD complications, from other etiological factors of myocardial ischemia. Among the most frequently reported angina symptoms there is substernal chest pain lasting for less than 15 minutes (contrarily to what happens in infarction, where substernal chest pain lasts for more than 20 minutes). The classical features of the pain reports are indicated as follows:

  • Heaviness
  • Pressure
  • Squeezing
  • The pain radiates to the area around upper back, left arm, neck, and jaw, 
  • Released with rest and the sublingual administration of nitroglycerin
  • Triggered by physical and emotional effort

Atypical symptoms without chest pain might also occur, such as exertional dyspnea or excessive fatigue, and their appearance is particularly frequent in women. Patients might present chronic and stable angina or acute coronary syndrome. In the cases of hypertensive crisis ischemia ECG changes can be detected, even though no significant coronary atherosclerosis can be observed. The sudden rapture of an atherosclerotic plaque might precipitate an acute coronary attach, but this can also be caused by a marked increase of the blood pressure responsible for a sudden rise of transmural pressure with no effect over the plaque stability.

Cardiac arrhythmias

A series of symptoms appear in the cases of irregular or abnormal heart rhythm, which can be summed up as follows:

The predominant cardiac abnormality and the duration and severity of HHD greatly influence the HHD physical signs. The findings might be absent upon physical examination in the early stages of the disease. Physical examination can also detect the clues of a potential hypertension etiology, like abdominal mass in polycystic kidney disease, renal artery bruit in renal artery stenosis, and truncal obesity and striae in Cushing syndrome.

Physical examination

While arterial pulses appear normal in the early phases of HHD, cardiac rhythm appears regular in sinus rhythm and irregular in atrial fibrillation. The general features of the heart rate can be summed up as follows:

  • Normal heart rate in sinus rhythm
  • Not normal heart rate in the cases of decompensated heart failure
  • Tachycardic heart rate in the cases of heart failure and those characterized by atrial fibrillation with rapid ventricular response. 

Generally speaking, the pulse volume is normal, even though it can be decreased when LV dysfunction appears. If coarctation of the aorta is the hypertension etiological factor, radial-femoral delay can be observed.

The blood pressure is elevated in both the systolic and diastolic phase, with a maximum value greater than 140 mmHg and the minimum one greater than 90 mmHg. In the cases of coarctation of the aorta, the blood pressure appears higher when measured at the higher extremities than the lower extremities. In any case, the value of blood pressure is normal if the patient has received a proper antihypertensive treatment or, due to the advanced phase of LV dysfunction, the heart can no longer guarantee the generation of a sufficient cardiac outcome to produce high levels of blood pressure.

Jugular veins might appear distended in the cases of heart failure, which it turn, together with other associated lesions, might affect the predominant waves. In the cases characterized by LVH but without significant systolic LV the apical impulse appears sustained and not displaced. The apical impulse displaces laterally due to LV dilatation when significant systolic LV dysfunction occurs in a later stage of the disease. If significant pulmonary hypertension is present, a lift in the right ventricle might appear later during the heart failure. 

While S1 appears normal both in terms of intensity and character, S2 becomes loaded along the right upper sternal border due to the marked aortic component (A2). Furthermore, S2 might have a reverse or paradoxical split as a consequence of the increased afterload or the related left bundle-branch block. S3 is generally not present in the early stages of the disease, but becomes audible when heart failure occurs. Contrarily, S4 often appear well palpable and audible, something which underlines the presence of a stiffened and noncompliant ventricle following the chronic pressure overload and LVH.

Diastolic murmur of aortic insufficiency can be heard very early along the mid/left parastemal area, particularly when acutely elevated blood pressure occurs. It then often disappears once the blood pleasure is yet again under control. A systolic to midsystolic murmur of the aortic sclerosis can also be heard in a early stage of the disease, while a holosystolic murmur of the mitral regurgitation is frequently observed in the cases of advanced heart failure and dilated mitral annulus.

Upon chest examination, clinical findings frequently appear normal and might include clues of pulmonary congestion like rales, decreased breath sounds, and a dullness to percussion following pleural effusion. In the cases of hypertension due to renal artery stenosis, renal artery bruit can be revealed after abdominal examination, together with a pulsative expansible mass of abdominal aortic aneurysm and ascites/hepatomegaly following an episode of CHF.

The classical sign which involves extremities is the appearance of edema at the level of ankles in the cases of advanced heart failure. No major CNS findings can be detected, unless the patient concerned has experienced previous episodes of cerebrovascular accidents which have left residual physiologic deficit. CNS changes can frequently be seen in those patients in hypertensive crisis. Upon fundi examination, hypertensive retinopathy might be revealed, whose severity depends on the hypertension duration and severity.

Congestive Heart Failure
  • A 1.5-year-old girl developed congestive heart failure 9 months after she presented with hypertension. The hypertension was caused by a renal artery stenosis.[ncbi.nlm.nih.gov]
  • Nephrectomy proved to be the treatment of choice for hypertension and congestive heart failure.[ncbi.nlm.nih.gov]
  • I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart ...[icd10data.com]
  • In advanced cases of hypertensive heart disease, the individual may have an enlarged liver and swelling of the feet and ankles among other signs of congestive heart failure.[nmihi.com]
  • Impression : Hypertensive heart and kidney disease, chronic systolic congestive heart failure (CHF), stage 1 CKD, type 2 diabetes, overweight with a BMI of 30.[codeitrightonline.com]
Coarctation of the Aorta
  • The BP in the upper extremities may be higher than that in the lower extremities in patients with coarctation of the aorta.[emedicine.medscape.com]
Hypertension
  • Myostatin expression was significantly higher in hypertensive donors with CMP compared to non-hypertensive healthy donors.[ncbi.nlm.nih.gov]
  • In 2013 hypertensive heart disease resulted in 1.07 million deaths as compared with 630,000 deaths in 1990. [4] According to ICD-10, hypertensive heart disease (I11), and its subcategories: hypertensive heart disease with heart failure (I11.0) and hypertensive[en.wikipedia.org]
  • Hypertension and hypertensive heart disease is one of the main contributors to a growing burden of non-communicable forms of cardiovascular disease around the globe.[ncbi.nlm.nih.gov]
  • Among the conditions resulting from target organ damage by arterial hypertension, hypertensive cardiopathy is the one that exhibits the highest morbidity and mortality rates.[ncbi.nlm.nih.gov]
  • Increased plasma CT-1 levels are associated with risk for HF in hypertensive patients. CT-1 may serve as a novel biomarker in determining prognosis in hypertensive patients.[ncbi.nlm.nih.gov]
Heart Disease
  • The most common echocardiographic diagnoses were hypertensive heart disease (43.2%), dilated cardiomyopathies (17.6%), ischemic heart diseases (9.6%), and cor pulmonale (8.8%). Rheumatic heart disease affected 6.7% of the patients.[ncbi.nlm.nih.gov]
  • Our objective was to determine whether fibrocyte levels are elevated in individuals with hypertensive heart disease.[ncbi.nlm.nih.gov]
  • heart disease without heart failure (I11.9) are distinguished from chronic rheumatic heart diseases (I05-I09), other forms of heart disease (I30-I52) and ischemic heart diseases (I20-I25).[en.wikipedia.org]
  • The objective of this article is to summarize the state-of-the-art and the future of multimodality imaging of hypertensive heart disease.[ncbi.nlm.nih.gov]
  • Hypertensive heart disease is particularly problematic in pregnancy and is an important contributor to maternal case-fatality.[ncbi.nlm.nih.gov]
Cardiomegaly
  • These cases are regarded as evidence in favour of the hypothesis that many cases of cryptogenic heart disease (cardiomyopathy, congestive cardiomyopathy, idiopathic cardiomegaly) are in fact cases of hypertension presenting with normotensive cardiac failure[ncbi.nlm.nih.gov]
  • The Circulatory System 401-405 Hypertensive Disease Excludes: • that complicating pregnancy, childbirth, or the puerperium ( 642.0-642.9 ) • that involving coronary vessels ( 410.00-414.9 ) 402 Hypertensive heart disease Includes: • hypertensive: • cardiomegaly[coding-pro.com]
  • Convert to ICD-10-CM : 402.90 converts approximately to: 2015/16 ICD-10-CM I11.9 Hypertensive heart disease without heart failure Approximate Synonyms Hypertensive heart disease ICD-9-CM Volume 2 Index entries containing back-references to 402.90 : Cardiomegaly[icd9data.com]
  • […] failure can include: Fatigue Irregular pulse or palpitations Swelling of feet and ankles Weight gain Nausea Shortness of breath Difficulty sleeping flat in bed ( orthopnea ) Bloating and abdominal pain Greater need to urinate at night An enlarged heart ( cardiomegaly[en.wikipedia.org]
Neglect
  • Neglecting transcytolemmal water-exchange caused a significant underestimate of MECVF changes. Ten patients with history of hypertension had significantly higher MECVF (0.446 0.063) compared with healthy controls (0.307 0.030, P 0.001).[ncbi.nlm.nih.gov]
  • Hormones and Heart Disease Connection Don't neglect hormones and heart disease connection. If you want to treat or prevent heart disease you have to balance your hormones.[heart-health-guide.com]

Workup

Laboratory tests

According to the 7th Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, the following baseline laboratory tests are recommended in the evaluation of HHD:

  • Blood glucose/hematocrit levels
  • Lipid profile after a 9 to 12 hour fast , which has to include triglycerides, high density lipoprotein cholesterol and low density lipoprotein cholesterol
  • Potassium, creatine, and calcium levels
  • Urinalysis 
  • Other tests (including urinary albumin excretion and albumin/creatinine ratio)
  • Electrocardiogram

Cardiovascular risk assessment

With its guideline released in 2013, the American Heart Association/American College of Cardiology (AHA/ACC) recommends a revised calculator to measure the 10-years risk of first atherosclerosis cardiovascular disease (ASCVD) event. This is defined as the occurrence in a person with no initial ASCVD risk of nonfatal myocardial infarction, death from coronary disease, and stroke. The calculator requires the use of clinical and laboratory risk factors, such as hypertension treatment and systolic blood pressure [4], as well as diet and physical activity [5]. In the cases with elevated 10-year risk, clinicians are recommended to communicate data risk regarding blood cholesterol [6] and obesity [7] to AHA/ACC guidelines.

Left Ventricular Hypertrophy in ECG
  • Table 2 Advantages and disadvantages of the various methods currently available to assess left ventricular hypertrophy.[ncbi.nlm.nih.gov]
  • Left ventricular hypertrophy by ECG versus cardiac MRI as a predictor for heart failure. Heart. 2017;103(1):49–54. Google Scholar Levy D, Labib SB, Anderson KM, Christiansen JC, Kannel WB, Castelli WP.[bmccardiovascdisord.biomedcentral.com]
Left Ventricular Hypertrophy in ECG
  • Table 2 Advantages and disadvantages of the various methods currently available to assess left ventricular hypertrophy.[ncbi.nlm.nih.gov]
  • Left ventricular hypertrophy by ECG versus cardiac MRI as a predictor for heart failure. Heart. 2017;103(1):49–54. Google Scholar Levy D, Labib SB, Anderson KM, Christiansen JC, Kannel WB, Castelli WP.[bmccardiovascdisord.biomedcentral.com]

Treatment

The treatment for HHD can be divided in two main categories: treatment for the elevated blood pressure and treatment for HHD itself. The treatment goals should be as indicated below [8]:

  • A systolic/diastolic pressure or less than 140/90mm Hg for the patients with show no hypertension complications
  • A systolic/diastolic pressure of 130/85mm Hg for the patients affected by diabetes and renal diseases characterized by less than 1g/24-hour proteinuria
  • A systolic/diastolic pressure of 130/85mm Hg in patients suffering from renal disease with more than 1g/24-hour proteinuria

According to recent data, to reduce the risk of congestive heart failure by at least 64%, the target blood pressure in patients older than 80 years of age should be 150/80mm Hg [9]. Other possible treatment strategies include:

It should be remembered that an efficient treatment of HHD requires the involvement of different professionals with different fields of expertise, such as preventive cardiologists, heart failure specialist and electro-physiologists.

Prognosis

The mortality and morbidity rate of HHD appear to be higher than those observed in the general population and their value is dependent to the specific cardiac pathology concerned [3]. The data collected so far seem to indicate that the increase in the mortality and morbidity rates is due more to the pulse pressure than the absolute systolic or diastolic blood pressure, even through both of them are important in the evaluation of HHD.

Etiology

The etiology of HHD can be seen as a complex interaction of several elements working together, which include hemodynamic, neuroendocrine, structural, cellular, and molecular factors [1]. All these factors are very important in the process of hypertension development, but they are all modulated by high levels of blood pressure.

All in all, elevated levels of blood pressure can influence the cardiac structure directly by increasing afterload or indirectly by inducing related neurohormonal and vascular changes. In particular, it has been shown that the changes most closely related to the cardiac pathologies indicated above are those due to elevated 24-hour ambulatory blood pressure or nocturnal elevated blood pressure, a trend which has been especially observed in people with African origin.

It is interesting to note that obesity has been linked to hypertension and LVH in many epidemiological studies, with at least 50% of obese subjects suffering from hypertension and at least 60-70% of hypertension subjects being obese. For this reason, obesity has to be seen as another risk factor for the development of HHD.

Epidemiology

In 2005 the prevalence of hypertension in the United States has been estimated to be 35.3 millions in men and 38.3 millions in women. The prevalence appears to be higher in people with African origin than people with a Hispanic or non-Hispanic white background, and its value over the last decades has been characterized by a marked increase. For example, according to the data collected between 1988 and 1994 or 1999 and 2002, the prevalence of hypertension in people with African origin has increased from 35, 8% to 41.4%, and this trend can also be seen among people with a white background, although not with the same intensity [2]. It should be noted that this difference is not due to race but to other factors, since similar studies conducted in United Kingdom show the same hypertension prevalence among black and white people and hypertension itself is quite rare in the African continent.

Age is responsible for the increase of systolic blood pressure, even through this increase is more marked in women than men due to the effects of menopause which greatly increases the levels of blood pressure. Generally speaking, the prevalence of hypertension is higher in men than women when considering people under 55 years of age, but higher in women than men when considering people above 55 years of age. It is very probable that the prevalence of HHD follows the same trend. According to the data collected from ECG findings, the frequency of LVH is low, being 2.9% in women and 1.5% in men. However, this rate appears to be much higher when considering the data coming from echocardiographic findings, with a value ranges from 15% and 20%.

Sex distribution
Age distribution

Pathophysiology

An increased amount of work results from the development of myocytic hypertrophy. The thickened myocardium then reduces the compliance of the left ventricle, which in turn impairs diastolic filling. The direct consequence of the myocyte hypertrophy is the increased distance for oxygen and nutrient diffusion between neighboring capillaries. It is interesting to note that in a great number of patients hypertension is followed by coronary atherosclerosis, and this might subsequently lead to the development of ischemia.

As a consequence of all this, marked changes can be observed on the heart structure. The left ventricle wall appears thickened, and this is accompanied by an increase in the heart weight. In fact, in normal conditions, the heart weight ranges between 500 and 600 grams, but in hypertensive conditions it might reach 1100 grams. Furthermore, the papillary muscle and the so called trabeculae carneae become rounded and more prominent, and this to the detriment of the volume of the cardiac chamber which appears to be much smaller as a consequence of its hypertrophic growth called “concentric hypertrophy”. In this condition, if cardiac failure occurs, the dilatation chamber is also more prominent. The effect of the long-lasting hypertension might be the development of endiocardial fibrous thickening in the left ventricle, and if left ventricular failure also occurs dilatation and hypertension appear on the heart right side.

From a cytological point of view, it is possible to observe a marked enlargement of myocytes and nuclei. Furthermore, while the left ventricle chamber is dilating and the wall is thickening, interstitial fibrosis, focal myocyte atrophy and focal myocyte degeneration begin to develop. In the cases of malignant hypertension, it is also possible to observe the appearance of myocardial edema and necrosis foci which are characterized by either intense eosinophilia or complete muscle fiber dissolution.

Prevention

Since HHD symptoms might appear without the patient being aware of them, frequent measurements are recommended. Symptoms often appear after many years of no blood pressure control or when a sudden marked increase occurs. Recommended measurement frequencies are every 2 years if blood pressure is lower than 120/80mm Hg at the time of the most recent reading, or once a year if it is 120-139/80-89 mmHg.

Summary

Blood pressure is an important factor for the heart physiology and its changes might greatly affect the heath structure, its conduction system, and the coronary vasculature. This is the reason why pathological changes in blood pressure might lead to the development of important cardiac diseases such as left ventricular hypertrophy (LVH), coronary heart disease (CAD) systolic and diastolic dysfunctions, several conduction system diseases, or a whole host of other complications such as angina, myocardial infarction, cardiac arrhythmias (in particular atrial fibrillation), and congestive heart failure (CHF). The term hypertensive heart disease (HHD) has been defined to refer to this series of related cardiac diseases and complications which, as mentioned previously, are ultimately caused directly or indirectly by marked changes and elevated levels of blood pressure. These diseases generally manifest themselves in the case of chronically elevated blood pressure, but cases of marked or acute blood pressure can still have an effect on them by increasing the underlying predisposition to their development at some point during lifetime. For the purposes of differential diagnosis, the following conditions should also be taken into consideration during the evaluation of HHD:

Patient Information

The term “hypertensive heart disease” refers to all those pathologies which occur because of elevated blood pressure. These might include:

  • Heart muscle thickening (a condition called hyperthrophy)
  • Coronary artery disease
  • Angina (chest pain, discomfort of tightness occuring when an area of the heart does not receive a sufficient supply of oxygen)
  • Heart failure

In high blood pressure conditions, the heart pumps against this high pressure and therefore has to work harder to obtain the same cardiac outcome. Over the time this situation causes the heart to thicken and to reduce the volume of the cardiac chamber. If this condition is not timely treated, the symptoms of HHD begin to appear. Heart failure might develop, and frequently heart walls can become so thick that the heart itself can no longer pump a sufficient quantity of oxygen. This in turn provokes chest pain, in a condition called angina.

The high blood pressure also causes the blood vessel walls to thicken which, together with cholesterol deposits, greatly increase the risk of heart attack and stroke.

References

Article

  1. Patel SK, Velkoska E, Freeman M, Wai B, Lancefield TF, Burrell LM. From gene to protein-experimental and clinical studies of ACE2 in blood pressure control and arterial hypertension. Front Physiol. 2014. 5:227.
  2. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009 Jan 27. 119(3):e21-181.
  3. Kannel WB, Cobb J. Left ventricular hypertrophy and mortality--results from the Framingham Study. Cardiology. 1992. 81(4-5):291-8.
  4. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Nov 12.
  5. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jul 1. 63(25 Pt B):2960-84.
  6. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jul 1. 63(25 Pt B):2889-934.
  7. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014 Jul 1. 63(25 Pt B):2985-3023.
  8. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003 May 21. 289(19):2560-72.
  9. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008 May 1. 358(18):1887-98.
  10. Elmer PJ, Grimm R Jr, Laing B, et al. Lifestyle intervention: results of the Treatment of Mild Hypertension Study (TOMHS). Prev Med. 1995 Jul. 24(4):378-88.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-21 21:01