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Hypertension & heart
1. Hypertension & Heart
Dr Akshay Mehta
Dr B Nanavati Hospital
Asian Heart Institute
2. Hypertensive Heart Disease
True or False ?
ALL the following are examples of hypertensive heart
disease :
CHD
LVH
LVF
Arrhythmias
Conduction system abnormality
Aortic Regurgitation
3. Definition :
Hypertensive heart disease is a constellation of abnormalities
including coronary artery disease, left ventricular hypertrophy
(LVH), systolic and diastolic dysfunction, and their clinical
manifestations including arrhythmias, conduction
abnormalities and symptomatic heart failure, that are caused
by the direct or indirect effects of elevated BP
11. Hypertension and LV Dysfunction
Diastolic dysfunction : Normal EF
• Usually, but not invariably, accompanied by
LVH
• However, may be as common as 33% in
hypertensive without LVH
Systolic d dysfunction
• Reduced EF with or without IHD
12. Hypertension and HF
o Hypertension accounts for 25% cases of HF
o In elderly it accounts for 68% cases of HF
o In patients with hypertension, the risk of heart
failure is increased by 2-fold in men and by 3-
fold in women
15. Other sequelae of LVH
• LA enlargement
• Hypertension most common cause of atrial fibrillation in the
Western hemisphere
• In one study, nearly 50% of patients with atrial fibrillation had
hypertension
• Dangers of AF : Stroke
LV
decompensation-HF
16. Diagnosis of LVH
Which is more sensitive: ECG or Echo ?
• ECG LVH in 5-10% of hypertensives
• Echo LVH in 30 % of hypertensives
Echo sensitivity - 57% for mild and 98% for severe LVH
ECG sensitivity – 30% to 57 % for severe LVH
17. Cut-off limits for left ventricular
hypertrophy on Echo
• The ASE/EAE guidelines :
LV septal wall thickness >0.9 cm for women
and >1.0 cm for men,
LV mass/BSA >95 g/m2 for women and LV
mass/BSA >115 g/m2 for men.
20. LVH criteria by ECG
The Cornell criteria (most sensitive) are R wave in aVL plus an
S wave in V3 of greater than 2.8 mV in men and greater than
2mV in women
The Sokolow-Lyon criteria are an S wave in V1 plus an R wave
in V5 or V6 of greater than 3.5mV or an R wave in V5 or V6 of
greater than 2.6mV (most specific)
The Gubner-Ungerleider criteria are an R wave in I plus an S
wave in III of greater than 2.5mV
Romhilt-Estes Criteria (A Point Score System)
21. Romhilt-Estes Criteria (A Point Score System)
Voltage Criteria Points
• R wave or S wave in any limb lead >0.2mV or 3
S wave in lead V1 or V2 or R wave in V5 or V6 >0.3mV
• LV strain (ST and T waves in direction 3
opposite to QRS direction) without digitalis
• LV strain (ST and T waves in direction 1
opposite to QRS direction) with digitalis
• LA enlargement (terminal negativity of 3
P waves in V1 >0.1mV deep and 0.04 seconds wide)
Left-axis deviation greater than -30° 2
QRS duration greater than 0.09 seconds 1
Intrinsicoid deflection in V5 or V6 >0.05 seconds 1
Probable LVH is 4 points; definite LVH is 5 points. The sensitivity of these criteria is
50%, with a specificity of close to 95%.
22. Risks of LVH
Are due to Pressure overload & Neurohormonal activation
• Myocyte hypertrophy
• Collagen deposition & fibrosis
• Medial hypertrophy of intramyocardial coronary arteries
• Impaired cor reserve + Fibrosis :
• Diastoic Dysfn and Diastolic HF
• Also V arrhthymia, AF, stroke
23. Hypertension and IHD
• At least one RF for IHD present in almost all pts with hypertn
• Abn LDLC in more than 75%
• Diabetes in about 25%
• Obesity in 60-70% of patients with hypertension
----------------------------------------------------------
Out of all Diabetics – 75% have hypertension
Out of all pts with CRF – 90% have hypertension
Out of all obese patients- 50% have some degree of
hypertension
25. IHD mortality rate in each decade of age versus usual
BP at the start of that decade
26. Absolute risk of CV disease over 5 years in
patients by systolic BP at specified levels of
other risk factors
Source: The Lancet 2005; 365:434-441 (DOI:10.1016/S0140-6736(05)17833-7 )
27. Symptoms & Signs of Hypertensive
Heart Disease
• LVH – No Symptoms, Loud S2, heaving
apex, paradoxic split S2
• Diastolic HF, Systolic HF – Dyspnea, S4,
S3, JVP, Lung rales
• CAD- Angina, MI
• AF –syncope, palpitations
-Precipitation of angina
-Precipitation of heart failure
28. Prognosis of LVH
Increase in the cardiovascular mortality rate esp an increase
in the risk of sudden cardiac death
Concentric LVH poses the greatest risk of such events, as
much as a 30% risk over a 10-year period
15% risk with asymmetric LVH and a 9% risk without any LVH.
The degree of LVH, as assessed by LV mass index (LVMI), is
also related to the cardiovascular mortality rate,
a relative risk of 1.73 for men and 2.12 for women for each
50g/m2 increase in the LVMI over a 4-year period.
29. Prognosis of Left ventricular diastolic
dysfunction
• Poor and affected by the presence of underlying coronary
artery disease.
• In one study, survival rates at 3 months, 1 year, and 5 years in
patients with heart failure due to diastolic dysfunction were
86%, 76%, and 46%, respectively.
• Even in patients with asymptomatic diastolic dysfunction due
to hypertension, the risk of all-cause mortality and
cardiovascular events is significantly increased, particularly
with an increase in the pulmonary artery wedge pressure
(PAWP).
30. Prognosis of Left ventricular
systolic dysfunction
High mortality rate and depends on the symptoms and NYHA
heart failure classification.
The 5-year mortality rate for patients with heart failure due to
systolic dysfunction approaches 20%
2-year mortality rate in patients with NYHA class IV
classification is as high as 50%.
Mortality rates have decreased with the use of ACE inhibitors
and beta blockers, which improve LV function.
31. Drugs for LVH regression
• Least effective- direct vasodilators
• Mildly effective – Diu, BB
• Most effective- ACEI/ARB, CCB
Data indicate that regression of lectrocardiographic LVH is
associated with less hospitalization for heart failure in
hypertensive patients
32. Drugs for diastolic dysfn. and diastolic
HF
ACE inhibitors, beta blockers, and non
dihydropyridine calcium channel blockers
Candesartan (“CHARM added” trial)
Careful addition of Diuretics, Nitrates
Avoid Hydrallazine
33. Treatment of left ventricular
systolic dysfunction
Beta blockers (cardioselective or mixed alpha
and beta), such as carvedilol, metoprolol XL,
and bisoprolol
ACEI/ARB
Diuretics
NO CCB
34. Drugs for Systolic HF
o Diuretics (predominantly loop diuretics)
o Low-dose spironolactone
o ACEI/ARB
o BB
o Avoid CCB
38. Drugs for Hypertension post MI
BB- Carvedilol, Metoprolol, Bisoprolol
ACEI/ARB
Aldo Antagonists (recommended for use in
post-MI patients with diabetes mellitus or
who have an LV ejection fraction of less than
40%.)
39. Goal BP in cardiac patients ?
< 140/90
< 130/80
< 120/80
< 110/60
40. What proportion of hypertensives
should take statins ?
1. All
2. Almost all
3. Only the few with significant dyslipidemia
41. Why almost all ?
Hypertension significant RF for CHD
Dyslipidemia v common in hypertensives
Antihypertensives often inadequate to reduce risk
Residual risk even when BP is normalized
Good evidence from RCT’s
Follow the Chinese - they ALL take lovastatin in form
of red rice and other preparations
42. Will you recommend aspirin for
primary prevention in…
• All hypertensives ?
• Those at high risk only ?
• Almost all hypertensives ?
43. Conclusions:
• Hypertension a significant risk factor for CHD
and HF
• These risks are preventable with early
diagnosis and treatment
• Not only is it important to bring BP to targets,
but also how it is brought down- match the
drug with the associated cardiac condition