Magdy El-Masry

Prof. of Cardiology
Tanta University
 Hypertensive heart disease refers to heart conditions
caused by high blood pressure.

It’s not a single disease, but rather, a number of different

heart disorders all caused by the same thing :
the heart working under increased pressure
 Left ventricular hypertrophy

Heart failure ( HFpEF & HFrEF )

Sudden
Cardiac
Coronary artery disease Death

Arrhythmias : AF & PVCs

Careful attention and treatment of LVH, HF, CAD, and AF will improve survival.
 Dzau V, Braunwald E. Resolved and unresolved issues in the prevention and treatment of
coronary artery disease: a workshop consensus statement. Am Heart J 1991;121:1244–1263.
Staging of Hypertensive Heart Disease

HFpEF

HFrEF
How High Blood Pressure Can Lead to Heart Failure ?

Role of RAAS
 Physiological and detrimental roles of RAAS molecules
in cardiac, vascular tissues and kidneys.

Aldosterone and Ang II are the principal RAAS molecules involved in cardiovascular and renal system changes during
hypertension. Both molecules are also involved in the physiological control of blood pressure (blue text), directly
impacting cardiomyocytes, kidney epithelial cells, and vascular smooth muscle cells. During hypertension, excesses of
these molecules have also been linked with cardiovascular and kidney tissue hypertrophy and fibrosis (red text)
 An imbalance in collagen metabolism

In hypertensive heart disease an excess of collagen is found in the extracellular matrix of

the myocardium. This is thought to be due to an imbalance in collagen metabolism
resulting from both increased synthesis as well as normal or reduced degradation.
PIP = carboxy-terminal propetide of procollagen type, PIIIP = carboxy-terminal propetide of
procollagen type III, CITP = carboxy-terminal telopeptide of collagen type I,
TIMP-1 = tissue inhibitor of matrix metalloproteinases type I.
Pathological changes of the left ventricle during long-term exposure to chronic pressure
overload include an increase in the size of the cardiomyocyte, alterations in the
extracellular matrix with accumulation of fibrosis, and abnormalities of the intramyocardial
coronary vasculature, including medial hypertrophy and perivascular fibrosis
Precipitants and clinical sequelae related to
LVH and myocardial fibrosis

Systolic BP

RAAS

LVH + Myocardial fibrosis→ a common end point in hypertensive heart disease

 left ventricular properties associated with increasing systolic blood pressure

SBP of 180 mmHg

SBP of 100 mmHg

3D Model of the Regional Changes in LV Geometry Associated With SBP

A long-axis section of the 3D CMR–derived fitted regression model taken at SBP of 100 mmHg (red filled
contour) and 180 mm Hg (black outline) shows how LV geometry varies between these 2 BP.
Arrows indicate the relationship between each coefficient and SBP.
JACC: Cardiovascular Imaging Volume 8, Issue 11, November 2015
 Imaging in hypertensive heart disease : Left ventricular hypertrophy

Advantages and disadvantages of the various methods currently available to assess LVH.
+ : Low ++ : Moderate +++ : High
Echocardiography : M-Mode
Echocardiography : 2D
Cardiac Magnetic Resonance
 LV hypertrophy − a disease of many faces

The prevalence and influenced age among the differential diagnosis of LVH.
Curr Cardiol Rep (2017) 19: 65
Differential diagnosis of LVH : Cardiac Imaging
 Differential diagnosis of LVH :Cardiac Imaging

Curr Cardiol Rep (2017) 19: 65

Understanding left ventricular hypertrophy
What is Left Ventricular Mass ( LVM ) and Relative Wall Thickness ( RWT ) and how do
we obtain these values?

→
Left Ventricular Mass ( LVM )

LVM (g) = 0.8 x 1.04 x [(IVSd + LVd + PWd)3 – LVd3] + 0.6g

Concentric LVH = increased LVM

Eccentric LVH = increased LVM
Concentric remodeling = normal LVM
Relative wall thickness (RWT) allows further classification of LV mass increase as
either concentric hypertrophy (RWT >0.42) or eccentric hypertrophy (RWT ≤0.42).
Relative Wall Thickness ( RWT )
 The RWT is calculated by doubling the dimension of the posterior wall and
dividing by the LV dimension. RWT = ( 2 x PWd ) / LVd
 Another variable of this equation would be to add the IVS and PW instead of
multiplying the PW by two. The reason this method is less preferred is
because septal measurements may be confounded by the presence of septal
bulge. RWT = (IVSd + PWd) / LVd

Concentric LVH = increased RWT

Eccentric LVH = decreased RWT
Concentric remodeling = increased RWT
Understanding left ventricular hypertrophy
Understanding left ventricular hypertrophy
Understanding left ventricular hypertrophy
Diagrammatic representation of the classification of left ventricular hypertrophy
Common and often co-existing cardiovascular conditions with
a risk for adverse events including sudden death.
 Pathophysiology of hypertensive heart disease.
Note the similarity of manifestations of coronary artery disease and hypertensive heart disease.
Potential pathogenic mechanisms linking hypertension and atrial fibrillation.
Aetiology of ventricular arrhythmias in hypertension.
 Some angiotensin II related effects of relevance for arrhythmogenesis

RAA system plays an important role for the control of LV mass and structure. Consequently,
recent interest has focused on ARB , because this class of drugs might interact with several
possible arrhythmogenic mechanistic factors induced by angiotensin II acting on type 1 receptor
Combined Hypertension and Heart Failure
Navigating Troubled Waters
Drug Compliance ( Medication Adherence )
 HTN increases
the risk of HF by two or
Hypertension three-folds and probably Heart Failure
accounts for about 25%
of all cases of HF.
 Angiotensin-converting enzyme
inhibitors

Angiotensin receptor blockers

Drugs for Hypertension Beta-blockers

The A,B,C,D drug classes

Calcium channel blockers

Diuretics

Treatment of HTN : First‐line drugs

In the absence of any compelling condition, any of the following three classes of
agents can be used as a first‐line therapy:
 Thiazide diuretic
 ACE‐I or ARB
 CCB
Core drug treatment strategy for uncomplicated hypertension

The core algorithm is also appropriate for most patients with

HMOD, cerebrovascular disease, diabetes, or PAD.
Drug treatment strategy for hypertension and CAD
 Drug treatment strategy for hypertension and AF.

a Non-DHP CCB (non-DHP CCB, e.g. verapamil or diltiazem).

CHA2DS2-VASc = Cardiac failure , Hypertension, Age

≥75 (Doubled), Diabetes, Stroke (Doubled) – Vascular
disease, Age 65–74 and Sex category (Female)
 Drug treatment strategy for hypertension and HFrEF.

Do not use non-dihydropyridine CCBs (e.g. verapamil or diltiazem)

a Consider an angiotensin receptor/neprilysin inhibitor instead of ACEi or ARB per ESC Heart
Failure Guidelines.

b Diuretic refers to thiazide/thiazide-like diuretic. Consider a loop diuretic as an alternative in

patients with oedema.

c MRA (spironolactone or eplerenone).

 Therapeutic
algorithm for
a patient with
symptomatic HFrEF
 Blood pressure paradox in patients with heart failure

A higher SBP in patients with HF is associated with a paradoxically

protective effect on survival.
Several studies, have shown that in most HF populations, high and,
not as one would expect, low SBP is associated with improved
outcomes

The relationship between systolic blood pressure and cardiovascular disease events in
patients with heart failure

In patients with HFrEF, a low BP reflects not only a lower LV

systolic contractility but also a lower cardiac output.
Indeed, BP is low because the heart is unable to contract
normally (decapitated hypertension).
Therefore, a higher BP is associated with a decreased mortality
because, in patients with HF, BP may be an indirect measure of
LV function.
Flash pulmonary
oedema and bilateral
renal artery stenosis:
The Pickering Syndrome

Three main
pathophysiological
mechanisms
contribute to the
development of
flash pulmonary
edema:
1) defective
pressure
natriuresis with
sodium and fluid
retention;
2) Increased LVEDP
associated with
LVH and stiffening;
and 3) failure of
the pulmonary
capillary blood–gas
barrier.
Flozins
What you need to know ?
 Arterial Hypertension in Patients with Heart Failure

 HTN carries the highest population-attributable risk for HF together with CAD
, and as a comorbidity is present in most patients with HF.

 There is inter individual variability in the progression from HTN to HF in both

the geometry of LV growth and the level of EF.

 The assessment of the hypertensive failing heart must combine imaging and
biochemical markers of the structural and function alterations of the
myocardium.

 The prevalence of HF calls for prevention efforts, and arterial HTN is a prime
target for such interventions.

 Because arterial HTN may complicate HF , adding further morbidity and

mortality risk, its management influences the prognosis of patients with HF.
 Suggested
Empirical
Antihypertensive
Strategy in HF
Patients With
Persisting
Hypertension