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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 Harvard
Medical
Jessup and Brozena. NEJM. 2003 School
 Harvard
Mosterd et al. NEJM. 1997 Medical
School
 Mortality in Hypertension

• 50% from ischemic heart disease or

heart failure
• 33% from cerebrovascular disease
• 10 to 15% from renal failure

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

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Kaplan in Zipes, Libby, Bonow, and Braunwald. 2005 Medical
School
Left Ventricular Hypertrophy I

• Concentric increase in LV mass

• Compensatory response to
increased afterload
• Collagen
• Myocyte hypertrophy

Harvard
Lorell and Carabello. Circulation. 2000 Medical
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

Harvard
Lorell and Carabello. Circulation. 2000 Medical
School
 Harvard
Jessup and Brozena. NEJM. 2003 Medical
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

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Dunn and Pfeffer. NEJM. 1999 Medical
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
Harvard
Otto. 2000 Medical
School
 Harvard
Aurigemma and Gaasch. NEJM. 2004 Medical
School
Diastolic Dysfunction

Aurigemma and Gaasch. NEJM. 2004 Harvard

Medical
Redfield. NEJM. 2004 School
 Possible Role
of LVH determination
in systemic HTN
1. Selection of patients for treatment
2. Choice of treatment agent
3. Monitoring

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 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
Harvard
Lorell and Carabello. Circulation. 2000 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)

Harvard
Lorell and Carabello. Circulation. 2000 Medical
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

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MacMahon. NEJM. 2000 Medical
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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Losartan Intervention for endpoint
reduction (LIFE) trial

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Dahlof et al. Lancet. 2002 Medical
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.

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Cheitlin et al. ACC/AHA/ASE. 2003 Medical
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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.

Harvard
Cheitlin et al. ACC/AHA/ASE. 2003 Medical
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.

Harvard
Cheitlin et al. ACC/AHA/ASE. 2003 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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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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 Worker’s Compensation

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

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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. Braunwald’s 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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