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THE OVERWORKED HEART

HIPERTENSIVE HEART DISEASE

Dr. Felix NunuraConsultant Cardiologist

Heart Institute of the Caribbean

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75 years-old male patient, Moderate HTN, abnormal ECG, exertional dyspnea

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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

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Is there a benefit to myocardial hypertrophy?

FROM HYPER-TENSION TO HEART-TENSION

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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”

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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′).

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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,

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Factors promoting LVHHypertension• Systolic > Diastolic Hypertension

Neurohumoral factors (growth stimulation)• Angiotensine II, Aldosterone• Norepinephrine, Insulin

Genetic Influences

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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

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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.

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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.

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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%

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Myocardial Remodeling assessment : Echocardiography

Janardhanan R., Kramer C., Imaging in hypertensive heart disease. Expert Rev. Cardiovasc. Ther. 2011; 9(2), 199–209

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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

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Myocardial Remodeling assessment : Cardiac Magnetic Resonance

Janardhanan R., Kramer C., Imaging in hypertensive heart disease. Expert Rev. Cardiovasc. Ther. 2011; 9(2), 199–209

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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.

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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

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Reduced Aortic Distensibility (cine CMR) in Diastolic HF patients

Subha V. Raman, The Hypertensive heart. J Am Coll Cardiol. 2010;55(2):91-96.

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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

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Normal Doppler Mitral flow

Little C William: Circulation 2009: 120;802-809

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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The overworked Heart