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05/02/2023 F.N. Dec/2012 1
THE OVERWORKED HEART
HIPERTENSIVE HEART DISEASE
Dr. Felix NunuraConsultant Cardiologist
Heart Institute of the Caribbean
05/02/2023 F.N. Dec/2012 2
75 years-old male patient, Moderate HTN, abnormal ECG, exertional dyspnea
05/02/2023 F.N. Dec/2012 3
The overworked heart
Uncontrolled High Blood Pressure causes the Heart Muscle to Overwork itself in order to pump blood under high pressure toughout the body
05/02/2023 F.N. Dec/2012 4
Is there a benefit to myocardial hypertrophy?
FROM HYPER-TENSION TO HEART-TENSION
05/02/2023 F.N. Dec/2012 5
Hypertension remains a major public health problem
“One in three adults
worldwide, according to the report, has raised blood pressure – a condition that causes around half of all deaths from stroke and heart disease. One in 10 adults has diabetes”
05/02/2023 F.N. Dec/2012 6
Date of download: 12/1/2012
Copyright © The American College of Cardiology. All rights reserved.
Ethnicity and Left Ventricular Diastolic Function in Hypertension: An ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial) Substudy
J Am Coll Cardiol. 2008;52(12):1015-1021. doi:10.1016/j.jacc.2008.04.065
Relationship of Age Group and Ethnicity to Diastolic Function, as Measured by E′ and the E/E′ RatioThe magnitude of the ethnic difference in these markers of diastolic function in comparison with that of each decade of aging is demonstrated. Diastolic function was assessed using the tissue Doppler early diastolic velocity (E′) and the ratio of this and the transmitral early filling velocity (E/E′).
05/02/2023 F.N. Dec/2012 7
From Hyper-tension to Heart-tension
Peripheral BP vs. Central Aortic BP
Chronically increasedworkoad on the left ventricle: pressure-overload
Increased wall thickness to normalize myocardial wall stress
Adapted from : Phil Chowienczyk and Ajay Shah, Hypertension.
2012;60:10-11,
05/02/2023 F.N. Dec/2012 8
Factors promoting LVHHypertension• Systolic > Diastolic Hypertension
Neurohumoral factors (growth stimulation)• Angiotensine II, Aldosterone• Norepinephrine, Insulin
Genetic Influences
05/02/2023 F.N. Dec/2012 9
Classic pathway in the progression from Hypertension to Heart Tension
Hypertension
Pressure overload
Increase in LV Mass LVH
Concentric LVH
Eccentric LVH Heart Failure
HF with Preserved
LVEF
HF with reduced
LVEF
Adapted from :Kamran Diaz, Yasmin Subhi , Hypertensive Heart Disease, Medscape Reference, Jan 2012
05/02/2023 F.N. Dec/2012 10
Structural Remodeling : the LV Geometry
Normal Relative Wall Thickness ( < 0.42)
Increased Relative Wall Thickness ( > 0.42)
NormalLV Mass Index g/m2
< 0.95 ♀< 115 ♂
Normal Concentric Remodelling
IncreasedLV Mass Index g/m2
0.95 ♀115 ♂
Eccentric Hypertrophy Concentric Hypertrophy
JPEG image
Adapted from : J Am Soc Echocardiogr 2005;18:1440-1463.
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The hypertensive heart
Structural Remodeling
Micro and Macrovascular
disease (aortopathy)
Myocardial Fibrosis
Left Atrial myopathy
Adapted from : Subha V. Raman, The Hypertensive heart. J Am Coll Cardiol. 2010;55(2):91-96.
05/02/2023 F.N. Dec/2012 12
Beyond the myocardial remodelling : The many aspects of Hypertensive Heart Disease (HHD)
Subha V. Raman, The Hypertensive heart. J Am Coll Cardiol. 2010;55(2):91-96.
05/02/2023 F.N. Dec/2012 13
This ECG from a 62-year-old woman shows left ventricular hypertrophy by the Cornell voltage criteria, the Cornell product criteria, the Sokolow-Lyon voltage
criteria, and the Romhilt-Estes point score system.
BAUML M A , UNDERWOOD D A Cleveland Clinic Journal of Medicine 2010;77:381-387
©2010 by Cleveland Clinic
Assessment of myocardial remodelling assessment: ECG
Cornell voltage criteria: SV3 + RaVL ≥ 2.0 mV (28 mm) in men SV3 + RaVL ≥ 2.8 mV (20 mm) in women Cornell voltage— median sensitivity 15%, median specificity 96%
05/02/2023 F.N. Dec/2012 14
Myocardial Remodeling assessment : Echocardiography
Janardhanan R., Kramer C., Imaging in hypertensive heart disease. Expert Rev. Cardiovasc. Ther. 2011; 9(2), 199–209
05/02/2023 F.N. Dec/2012 15
Myocardial area: estimating LV mass (2D Echo)
Lang R. Bierigh M., Devereux R. Recommendations for chamber quantification . Eur J Echocardiography 2006; 7:79-108
Lang R. Bierigh M., Devereux R. Recommendations for chamber quantification . Eur J Echocardiography 2006; 7:79-108
05/02/2023 F.N. Dec/2012 16
Myocardial Remodeling assessment : Cardiac Magnetic Resonance
Janardhanan R., Kramer C., Imaging in hypertensive heart disease. Expert Rev. Cardiovasc. Ther. 2011; 9(2), 199–209
05/02/2023 F.N. Dec/2012 17
Cardiac Magnetic Resonance –late galodinium enhancement (LGE)-T1 Mapping for Myocardial
Fibrosis Quantification
Subha V. Raman, The Hypertensive heart. J Am Coll Cardiol. 2010;55(2):91-96.
05/02/2023 F.N. Dec/2012 18
Cardiovascular adaptations to arterial stiffening that occur with aging
Aronow W., Fleg J., Pepine C. ACCF/AHA 2011 Expert Consensus Document on Hypertension
in the elderly JACC 2011; 57 ( 20
05/02/2023 F.N. Dec/2012 19
Reduced Aortic Distensibility (cine CMR) in Diastolic HF patients
Subha V. Raman, The Hypertensive heart. J Am Coll Cardiol. 2010;55(2):91-96.
05/02/2023 F.N. Dec/2012 20
From Pressure overload to Diastolic Heart Failure
Adapted from: CHHABI SATPATHY , RUBY SATPATHY Am Fam Physician. 2006 Mar 1;73(5):841-846.
Diastolic DysfunctionDiastolic Heart Failure
Pressure overloadIschemia
Abnormal Relaxation
Abnormal LV early filling
Normal exercise tolerance
Diastolic abnormalities
Hypertrophy/Myocardial Infarction
Abnormal Relaxation Increased Stiffness
Elevated LV filling pressure
Elevated Pulmonary Pressure during
exercise
Elevated Left atrial pressure and sizeAtrial Fibrillation
Decreased cardiac output
Reduced exercise toleranceAnd signs of Congestive
Heart Failure
05/02/2023 F.N. Dec/2012 21
Normal Doppler Mitral flow
Little C William: Circulation 2009: 120;802-809
05/02/2023 F.N. Dec/2012 22
Diastolic dysfunction can be found in 25% of asymptomatic hypertensives without LV hypertrophy
but in 90% of those having LV hypertrophy.
Little C William: Circulation 2009: 120;802-809
05/02/2023 F.N. Dec/2012 23
Tissue Doppler (TD) in Hypertensive patients
Naguegh S., EAE/ASE Recommendations for the evaluationof the left ventricular diastolic function by Echocardiography. Europan Journal of Echocardiography 2009; 10:165-193
05/02/2023 F.N. Dec/2012 24
Tissue Doppler Imaging : reduced early diastolic mitral
annular velocity (Ea) , suggestive of diastolic dysfunction
Janardhanan R., Kramer C., Imaging in hypertensive heart
disease. Expert Rev. Cardiovasc. Ther. 2011; 9(2), 199–209
05/02/2023 F.N. Dec/2012 25
Assessment of reduced Diastolic Reserve: Exercise Doppler recording of Mitral inflow and
TDI
Naguegh S., EAE/ASE Recommendations for the evaluationof the left ventricular diastolic function by Echocardiography. Europan Journal of Echocardiography 2009; 10:165-193
05/02/2023 F.N. Dec/2012 26
Beyond the myocardial remodelling : The many aspects of
Hypertensive Heart Disease (HHD)
LEFT ATRIAL MYOPHATHY
Subha V. Raman, The Hypertensive heart. J Am Coll Cardiol. 2010;55(2):91-96.
05/02/2023 27F.N. Dec/2012
Figure 1. Example of LA strain curves.
Kurt M et al. Circ Cardiovasc Imaging 2009;2:10-15
Copyright © American Heart Association
Left Atrial Strain during Atrial Systole
05/02/2023 F.N. Dec/2012 28
Pathways in the progression from hypertension to Heart Failure (HF)
Hypertension
ConcentricLVH
Symptomatic HF with preserved
EF
Hypertension
Dilated cardiac failure
Symptomatic HF with low EF
MI NoMI
MI
No MI
Adapted from: Drazner M, The progression of hypertensive heart disease, Circulation 20011; 123:327-334
05/02/2023 F.N. Dec/2012 29
Challenges to the classic paradigm of the progression of Hypertensive Heart Disease
In animals models of pressure overload , concentric LVH can be
blocked, and dilated cardiac failure does not develop
In humans, concentric LVH does not commonly progress to dilated cardiac failure in the absence of
myocardial infarction
Some hypertensive subjects develop dilated cardiac failure
without antecedent of concentric LVH or Myocardial Infarction
Adapted from: Drazner M, The progression of hypertensive heart disease, Circulation 20011; 123:327-334
05/02/2023 F.N. Dec/2012 30
The overworked HeartLVH is a maladaptive response to chronic pressure overload
Major Risk Factor in patients with Hypertension (atrial fibrillation, CAD, Diastolic HF, Systolic HF, sudden death.
Choice of antihypertensive agents may be important when treating a patient with hipertensive LV hypertrophy
ACE inhibitors, ARB, carvelidol , Aldosterone receptor blockers , aliskiren, statins, renal sympathetic denervation, facillitate regresion of LVH
With regression of LVH, diastolic function and coronary flow reserve improve, and cardiovascular risks decreases.
Adapted from: Kathori R., Couri D. Left ventricular hypertrophy: a major risk factor in patients with hypertension. International Journal of
Hypertension April, 2011
05/02/2023 31F.N. Dec/2012
The overworked Heart
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