PENYAKIT JANTUNG HIPERTENSI

Dr.Suhaemi,SpPD,Finasim

FDR’s Final Picture (April 11, 1945)

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

Hypertensive Heart Disease

Results in LVH to maintain normal wall stress

Initially impaired diastolic function

Normal systolic function

Hypertensive Heart Disease

End Organ Damage as a consequence of systemic hypertension.

Chronic systemic pressure overload

CV Complications of Untreated Hypertension (N=500)

20

5

10

15

20

25

30

35

40

45

50

18

128

16

50

RenalFailure

Stroke Enceph MI Angina CHF

MI, myocardial infarction; CHF, chronic heart failure.Perera GA J. Chron Dis. 1955;1:33-42.

Eventrate(%)

LVH, left ventricular hypertrophy; MI, myocardial infarction; CHF, chronic heart failure.Vasan RS and Levy D. Arch Intern Med. 1996;156:1789-1796.

Progression From Hypertensionto Heart Failure

Hypertension

Smoking

Dyslipidemia

Diabetes

Obesity

Diabetes

MI

LVH

CHF

Normal LV Structure

and Function

LV Remodeling

Subclinical LV Dysfunction

Overt Heart Failure

DiastolicDysfunction

Systolic Dysfunction

Population-attributable risk defined as: (100 x prevalence x [hazard ratio – 1])/(prevalence x [hazard ratio – 1] + 1)

Population-Attributable Risks for Development of CHF

CHF, chronic heart failure; AP, angina pectoris; DM, diabetes mellitus; LVH, left ventricular hypertrophy;VHD, valvular heart disease; HTN, hypertension; MI, myocardial infarction.Levy D et al. JAMA. 1996;275:1557-1562.

AP5%DM

6%LVH4%

VHD7%

MI34%

HTN 39%

Men Women

HTN 59%

DM12%

LVH5%

VHD

8%

AP5%

MI12%

UKPDSHypertension Study:

Benefits of 144/82 vs 154/87 Tight BP control, with either a β-blocker or an

ACEI, in type 2 diabetes decreases1: Death related to diabetes by - 32% Stroke by - 44% Microvascular disease by - 37% HF by - 56% Progression of retinopathy by - 34% Deterioration of visual acuity by - 47%

BP target <130/80 for patients with diabetes and in chronic renal disease, JNC 72 1. UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713. 2. National Institutes of Health, National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, MD: National Institutes of Health; December 2003. NIH Publication No. 03-5233.

Effects of Hypertension on The Heart

Left Ventricular Hypertrophy Vascular Disease: -Atherosclerosis -Arteriosclerosis

Jessup and Brozena. NEJM. 2003

Aurigemma and Gaasch. NEJM. 2004

Kieran McGlade Nov 2001Department of General Practice QUB

The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.

Left Ventricular Hypertrophy

Independent Predictor of: Myocardial infarction Stroke Heart Failure Total Mortality Sudden Death

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

Effects of Hypertension on The Heart

Left Ventricular Hypertrophy Vascular Disease: -Atherosclerosis -Arteriosclerosis

ATHERO- ARTERIO- SCLEROSIS SCLEROSIS

(Increased vascular stiffness Decreased vascular compliance)

Focal, Occlusive Inflammatory Endothelial

dysfunction Related to LDL

cholesterol oxidation “Inside-out” Sensitive to A II and

other substances

Diffuse, Dilatory Fibrotic (elastin

breakdown, collagen increase)

Adventitial and medial hypertrophy

Related to age and BP “Outside-in” Sensitive to A II and

other substances

Integrated Perspective on CV Risk Factors and Vascular Disease

CVDisease

Ross. N Engl J Med. 1999;340:115-126.

Oxidative Stress & Inflammation

Endothelial Dysfunction

Ross. N Engl J Med. 1999;340:115-126.

)

AGING AND ARTERIAL STIFFNESS PATHOPHYSIOLOGY

Young elastic vessels Old inelastic vessels

Adapted from Izzo JL. J Am Geriatr Soc. 1981;29:520-524.

SYSTOLE DIASTOLE DIASTOLESYSTOLE

STROKEVOLUME

RESISTANCEARTERIOLES

AORTA

PRESSURE(FLOW)

STROKEVOLUME

RESISTANCEARTERIOLES

AORTA

PRESSURE(FLOW)

(Increased systolic

Decreased diastolic

Hypertension: A Major Risk Factor for CHF

Time, decades

Vasan RS, Levy D. Arch Intern Med. 1996;156:1789-1796.

Death

ObesityDiabetes

SmokingDyslipidemia

Systolic Dysfunction

Diastolic Dysfunction

SubclinicalLeft Ventricular

Dysfunction

CHF

Overt HeartFailure

Time, months

Hypertension

LVH

MI

Left VentricularRemodeling

Adapted from Dzau V, et al. Am Heart J. 1991;2(4 pt 1):1244-1263.

Risk factors• Hyperlipidemia• Hypertension• Diabetes• Insulin resistance

AtherosclerosisLVH

CAD

Myocardial ischemia

Coronarythrombosis

Myocardialinfarction

Loss ofmuscle

Arrhythmia

Suddendeath

Remodeling

Ventriculardilatation

Heart failure

Death

From Risk Factors to Heart Failure: The Cardiovascular Continuum

A B

cD