Oral manifestations in hypertensive patients: a clinical study
Treatment of hypertensive patients with heart failure
description
Transcript of Treatment of hypertensive patients with heart failure
Treatment of hypertensive patients with heart failure
Jamil Mayet
Department of Cardiology and
The Peart-Rose Clinic
St Mary’s Hospital, NHLI
Imperial College, London, UK
Age-adjusted risk of congestive heart failure by hypertensive status
0
20
40
60
80
100
Ann
ual i
ncid
ence
/ 10
,000
Women Men
NormotensiveBorderlineHypertensive <140/90
>160/90
Kannel WB.Framingham
The progression from hypertension to congestive heart failure
• 5143 subjects in Framingham study• 392 new cases of clinical CCF after mean
follow up of 20 years • In 91% hypertension antedated CCF• MI present in 52% of hypertensive men and
34% of hypertensive women with CCF• Median survival after CCF diagnosis in ht
1.37 years in men and 2.48 in women
Levy et al. JAMA 1996;275:1557-62
Age-adjusted BP parameters and CHF risk
0
0.5
1
1.5
2
2.5
SBP (mmHg) DBP (mmHg) PP (mmHg)<120 120-
139140-159
>159 <70 70-79
80-89
>89 <54 54-67
>67
Hazard
Ratio
Chae et al. JAMA1999;281:634-9
Treatments that improve CCF and lower BP
• Non-pharmacological (salt restriction, exercise)
• ACE inhibitors (SOLVD, CONSENSUS)
• Beta blockers (CIBIS 2, MERIT-HF)
• Diuretics
Age-adjusted BP parameters and CHF risk
0
0.5
1
1.5
2
2.5
SBP (mmHg) DBP (mmHg) PP (mmHg)<120 120-
139140-159
>159 <70 70-79
80-89
>89 <54 54-67
>67
Hazard
Ratio
Chae et al. JAMA199;281:634-9
Arterial stiffening in hypertension
• Increased PW velocity with early wave reflection
• Increased central systolic pressure and lower diastolic pressure
• Discrepancy between central and peripheral pressures lessened
• Therefore peripheral BP underestimates central effects
Reducing arterial stiffness as a therapeutic goal
• Later wave reflection reduces peak central pressure which is caused by summation of systolic wave and reflected wave
• In periphery peak pressure is not a summation wave and so there is less of a decrease
• Reducing stiffness causes preferential decrease in central compared with peripheral pressures
Non-pharmacological approaches to reducing arterial stiffness
• Increased arterial stiffness in obese subjects with improvement following weight reduction
• Moderate aerobic exercise increases arterial compliance
• Subjects with high salt intake have better arterial distensibility than those with low intake.
• Improvement following salt restriction
Stiffnessimpact
LVregression
Outcomedata
-blockers ?+ + No
ACE-inhibitors +++ +++ No
-blockers + + Yes
-blockers ‘extra’ ++ ?? No
Ca++ antagonists +++ ++ Yes
thiazides + +/++ Yes +
Relation between vascular and LV impacts of antihypertensives
Diastolic heart failure
• Symptoms/signs of heart failure with normal or mildly impaired LV systolic function
• Prevalence depends on clinical definition of heart failure
• May be up to 30% of cases with heart failure
• Diastolic dysfunction in hypertensives is very common, particularly in those with LVH
Pathophysiology of diastolic dysfunction
• Impaired relaxation– Energy dependent and sensitive to ischaemia
• Coronary artery disease
• Microvascular ischaemia (arteriolar rarefaction, arteriole wall thickening, perivascular fibrosis, endothelial dysfunction, relative myocyte hypertrophy)
• Decreased compliance– Increase in myocardial collagen
Treatment of diastolic dysfunction
• Treat underlying cause eg coronary intervention
• Most patients are elderly and hypertensive +/- LVH– Beta blockers may improve filling by reducing heart rate
and prolonging diastole; also may reduce myocardial O2 demand and regress LVH
– Ca antagonists, particularly rate limiting, may have similar effects
• BUT VERY LITTLE FUNCTIONAL DATA
Treatment of diastolic dysfunction
• Beta blockers and Ca antagonists unlikely to be effective when restrictive physiology with raised LA pressure
• Drugs that reduce fibrosis and reduce LA pressure likely to be effective– ACEI, AII antagonists, spironolactone, diuretics
• BUT VERY LITTLE FUNCTIONAL DATA
Treatment of diastolic dysfunction
• Echo guided strategy– Impaired relaxation
• Verapamil
• Beta-blockers
– Restriction with increased LA pressure• ACEI
• AII blockers
• Diuretics (spironolactone)