PENYAKIT JANTUNG

HIPERTENSI
Dr.Suhaemi,SpPD,Finasim
FDRs 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)
2
0
5
10
15
20
25
30
35
40
45
50
18
12
8
16
50
Renal
Failure
Stroke Enceph MI Angina CHF
MI, myocardial infarction; CHF, chronic heart failure.
Perera GA J. Chron Dis. 1955;1:33-42.
Event
rate
(%)
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 Hypertension
to Heart Failure
Hypertension
Smoking
Dyslipidemia
Diabetes
Obesity
Diabetes
MI
LVH
CHF
Normal LV
Structure
and Function
LV
Remodeling
Subclinical LV
Dysfunction
Overt Heart
Failure
Diastolic
Dysfunction
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.
AP
5%
DM
6%
LVH
4%
VHD
7%
MI
34%
HTN
39%
Men Women
HTN
59%
DM
12%
LVH
5%
VH
D
8%
AP
5%
MI
12%
UKPDSHypertension Study:
Benefits of 144/82 vs 154/87
Tight BP control, with either a -blocker or an ACEI,
in type 2 diabetes decreases
1
:
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 7
2

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 2001

Department 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
CV
Disease
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 DIASTOLE SYSTOLE
STROKE
VOLUME
RESISTANCE
ARTERIOLES
AORTA
PRESSURE
(FLOW)
STROKE
VOLUME
RESISTANCE
ARTERIOLES
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
Obesity
Diabetes
Smoking
Dyslipidemia
Systolic
Dysfunction
Diastolic
Dysfunction
Subclinical
Left Ventricular
Dysfunction
CHF
Overt Heart
Failure
Time, months
Hypertension
LVH
MI
Left Ventricular
Remodeling
Adapted from Dzau V, et al. Am Heart J. 1991;2(4 pt 1):1244-1263.
Risk factors
Hyperlipidemia
Hypertension
Diabetes
Insulin resistance
Atherosclerosis
LVH
CAD
Myocardial ischemia
Coronary
thrombosis
Myocardial
infarction
Loss of
muscle
Arrhythmia
Sudden
death
Remodeling
Ventricular
dilatation
Heart
failure
Death
From Risk Factors to Heart Failure:
The Cardiovascular Continuum
A
B
c
D