Management of Hypertensive Heart Disease

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

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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?

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

Key Points in this case

Age > 75 years

Signs & symptoms s/o Heart Failure

Accelerated Hypertension

LVEF: Normal

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

Management

Control of HF

Control of Hypertension

Treatment of Ischaemia (if present)

Maintenance of sinus rhythm OR control of heart rate

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

Patterns of LV Diastolic Filling as Shown by Standard Doppler Echocardiography

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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 wereARBs- 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.

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

CCBs:•Verapamil has shown some benefit in DHF especially in HCMACE 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%)

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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.

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

Available at: http://emedicine.medscape.com/article/162449-overview, updated Dec 2014

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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