Harvard

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School

Hypertensive Heart Disease

Gene Bukhman
January 12th, 2005

Epidemiology I
Number of Patients with
Hypertension in the United States:
50 million
Number of Patients with Heart
Failure: 5 million
Percent of Heart Failure Patients
with Hypertension: 75%
JNC 7. 2004
Jessup and Brozena. NEJM. 2003

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School

Mosterd et al. NEJM. 1997

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School

Mortality in Hypertension
50% from ischemic heart disease or
heart failure
33% from cerebrovascular disease
10 to 15% from renal failure

Kaplan in Zipes, Libby, Bonow, and Braunwald. 2005

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Medical
School

Hypertensive Heart Disease

Coronary Artery Disease
Heart Failure
Diastolic Dysfunction
Impaired relaxation
Left ventricular myocyte hypertrophy
Interstitial fibrosis

Systolic Dysfunction
Ischemic cardiomyopathy
Late consequence of afterload

Arrhythmias
Atrial fibrillation
Left atrial enlargement

Ventricular Arrythmias
Kaplan in Zipes, Libby, Bonow, and Braunwald. 2005

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Left Ventricular Hypertrophy I

Concentric increase in LV mass
Compensatory response to
increased afterload
Collagen
Myocyte hypertrophy
Lorell and Carabello. Circulation. 2000

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School

Left Ventricular Hypertrophy II

Effect of mechanical loading most clear in
rapid regression following aortic valve
replacement
In systemic hypertension confounded by role
of angiotensin II and sympathetic hormones
LVH often develops after other signs of
diastolic dysfunction in HTN
LVH also seen to precede development of
systemic HTN

Lorell and Carabello. Circulation. 2000

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Medical
School

Jessup and Brozena. NEJM. 2003

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School

Consequences of LVH

Although initially compensatory, LVH ultimately associated with risk of

cardiovascular events similar to history of prior myocardial infarction
Ischemia
Decreased coronary reserve with increased LV mass
angina

Greater risk of death following myocardial infarction

Heart Failure
Depressed LV systolic and diastolic function

Arrhythmia
Atrial fibrillation
Ventricular arrhythmias

Nonuniform action potential prolongation

Altered repolarization
Specific vulnerability to torsades
Ischemic ventricular arrhythmia

Dunn and Pfeffer. NEJM. 1999

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School

Echocardiography Findings in
Systemic HTN
Left atrial enlargement
Mitral annular calcification
Mild to moderate mitral regurgitation

Aortic root dilatation

Aortic valve sclerosis
Mild aortic regurgitation

Diastolic dysfunction
Impaired relaxation
Restrictive pattern

Reduced ejection fraction

Usually late consequence with ventricular dilatation

Symmetric left ventricular hypertrophy

Otto. 2000

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School

Aurigemma and Gaasch. NEJM. 2004

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School

Diastolic Dysfunction

Aurigemma and Gaasch. NEJM. 2004

Redfield. NEJM. 2004

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School

Possible Role
of LVH determination
in systemic HTN
1.
2.
3.

Selection of patients for treatment

Choice of treatment agent
Monitoring

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School

Echocardiographic
evaluation of LVH
Framingham adds echocardiography in
1979
ECG probably has 1/8th the sensitivity of
echocardiography
Probably 20 percent prevalence in
those over 40 years old
Present in 20 to 30 percent of otherwise
low risk patients with HTN
Lorell and Carabello. Circulation. 2000

Harvard
Medical
School

Multiple methods of
echocardiographic left ventricular
mass calculation

LVM = 0.8 x [1.04 x (LVID + LVPWT + IVST)3 LVID3]

Limits set by 2 standard deviations of the
Framingham cohort mean
Poor reproducibility
Possible advantage of cardiac MR (Manning 2004)
Lorell and Carabello. Circulation. 2000

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School

Treatment of Hypertension and

Absolute Cardiovascular Risk
Benefit of treatment proportional to overall
cardiovascular risk
Risk increases with level of blood pressure
without clear threshold

MacMahon. NEJM. 2000

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School

LVH and treatment of HTN

Regression of LVH with treatment by all
classes of agents except direct vasodilators
Possible superiority of ace inhibitors and
angiotensin receptor blockers
Not clear if benefit to LVH regression
independent from overall benefit of blood
pressure reduction

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School

Losartan Intervention for endpoint

reduction (LIFE) trial

Dahlof et al. Lancet. 2002

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School

ACC/AHA/ASE 2003 Guidelines:

Echocardiography in HTN I
Class I Indications:
1. When assessment of resting LV function, hypertrophy, or
concentric remodeling is important in clinical decision
making
2. Detection and assessment of functional significance of
concomitant CAD by stress echocardiography.
3. Follow-up assessment of LV size and function in patients
with LV dysfunction when there has been a documented
change in clinical status or to guide medical therapy.

Cheitlin et al. ACC/AHA/ASE. 2003

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ACC/AHA/ASE 2003 Guidelines:

Echocardiography in HTN II
Class IIa Indications:
1. Identification of LV diastolic filling abnormalities
with or without systolic abnormalities.
2. Assessment of LV hypertrophy in a patient with
borderline hypertension without LV hypertrophy
on ECG to guide decision making regarding
initiation of therapy. A limited goal-directed
echocardiogram may be indicated for this
purpose.

Cheitlin et al. ACC/AHA/ASE. 2003

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School

ACC/AHA/ASE 2003 Guidelines:

Echocardiography in HTN III

Class IIb Indications:

1. Risk stratification for prognosis by determination
of LV performance.

Class III Indications:

1. Re-evaluation to guide antihypertensive therapy based on
LV mass regression.
2. Re-evaluation in asymptomatic patients to assess LV
function.

Cheitlin et al. ACC/AHA/ASE. 2003

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Medical
School

Common indications for

echocardiography in HTN
Borderline hypertension with no other risk
factors
As many as 30 percent of patient with low to
medium risk HTN will have LVH
Pharmacologic treatment preferred

Patients with severe hypertension in the office,

but not on initial ambulatory monitoring
If no LVH suggests either white coat hypertension
Or HTN of recent onset
Continued ambulatory monitoring

Heart Failure
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School

Role of Limited echocardiography

Cost
$600 for complete
echocardiogram
$150 for limited study including
m-mode and doppler
$70 for ECG
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School

Workers Compensation
Hypertension considered an
occupational injury for selected
professions in some states if
can show end organ damage

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Medical
School

For example, Virginia Code

Section 65.2-402(B)
"hypertension or heart disease causing the death of, or
any health condition or impairment resulting in total or
partial disability of (i) salaried or volunteer firefighters,
(ii) members of the State Police Officers' Retirement
System, (iii) members of county, city or town police
departments, (iv) sheriffs and deputy sheriffs, (v)
Department of Emergency Services hazardous
materials officers, and (vi) city sergeants or deputy
city sergeants of the City of Richmond shall be
presumed to be occupational diseases, suffered in
the line of duty, that are covered by this title unless
such presumption is overcome by a preponderance
of competent evidence to the contrary."
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Future directions for LVH

assessment in patients with HTN
If absolute risk approach adopted more
extensively, question of role of LVH
assessment as an independent risk factor
Question of superiority of some anti-hypertensive
agents for patients with LVH
Improvements in accuracy of LV mass assessment
with cardiac MR

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Medical
School

References

Aurigemma and Gaasch. Clinical Problem Solving. Diastolic Heart Failure.

NEJM. 2004.
Cheitlin et al. ACC-AHA-ASE 2003 Guideline Update for the Clinical Application
of Echocardiography. 2003.
Dahlof et al. Cardiovascular morbidity and mortality in the Losartan Intervention
For Endpoint reduction in hypertension study (LIFE). a randomised trial against
atenolol. Lancet. 2002.
Dunn and Pfeffer. Left Ventricular Hypertrophy in Hypertension. NEJM. 1999.
Kaplan. Systemic Hypertension: Mechanisms and Diagnosis. Zipes, Libby,
Bonow, Braunwald. Braunwalds Heart Disease. 2005.
Lorrell and Carabello. Left Ventricular Hypertrophy. Pathogenesis, Detection,
and Prognosis. Circulation. 2000.
Jessup and Brozena. Medical Progress. Heart Failure. NEJM. 2003.
MacMahon. Blood Pressure and the Risk of Cardiovascular Disease. NEJM.
2000.
Mosterd et al. Trends in the prevalence of hypertension, antihypertensive
therapy, and left ventricular hypertrophy from 1950 to 1989. NEJM. 1997.
Otto. Textbook of Clinical Echocardiography. 2000.
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