HYPERTENSIVE HEART DISEASES Iruo, Azibataram A. 1427

CONTENT Introduction What is Hypertension? Types of Hypertension What are Hypertensive Heart diseases? Epidemiology Systemic hypertensive heart diseases Pulmonary hypertensive heart diseases Risk Factors Signs and Symptoms Diagnosis Prevention Treatment References

INTRODUCTION WHAT IS HYPERTENSION? Hypertension, also referred to as high blood pressure, is a condition in which the arteries have persistently elevated blood pressure. Every time the human heart beats, it pumps blood to the whole body through the arteries. Blood pressure is the force of blood pushing up against the blood vessel walls. The higher the pressure the harder the heart has to pump.

NORMAL BLOOD PRESSURE = 120/80mmHg PREHYPERTENSION = >120 to 130/>80 to 90mmHg HYPERTENSION = >140/90mmHg STAGE 1 HYPERTENSION = 140 to 159/90 to 99mmHg STAGE 2 HYPERTENSION = 160/120mmHg MALIGNANT HYPERTENSION = 200/120mmHg ACCELERATED HYPERTENSION ISOLATED SYSTOLIC HYPERTENSION LABILE HYPERTENSION WHITE COAT HYPERTENSION

TYPES OF HYPERTENSION Essential Hypertension: of unknown cause, idiopathic or primary hypertension. Involves about 95% of cases. Secondary Hypertension: Due to a previously diagnosed problem which could be renal, endocrine, cardiovascular or miscellaneous. Hypertension can lead to the damage of organs eg brain, heart, eyes or kidney.

What are Hypertensive Heart Diseases? Hypertensive heart disease includes a number of complications of systemic arterial hypertension or high blood pressure that affect the heart. They always involve myocyte hypertrophy as an adaptive response to pressure overload.

However there are limits to the myocardial adaptive responses and persistent hypertension can eventually culminate in dysfunction, cardiac dilation, congestive heart failure and even sudden cardiac death. Although hypertensive heart diseases most commonly affects the left side of the heart secondary to systemic hypertension, it can also cause right sided hypertensive changes – so called cor pulmonale.

EPIDEMIOLOGY Hypertension or high blood pressure affects at least 1 billion people worldwide. Hypertensive heart disease is only one of several diseases attributable to high blood pressure. Other diseases caused by high blood pressure include ischemic heart disease, stroke, peripheral arterial disease, aneurysms and kidney disease. Hypertension increases the risk of heart failure by two or three-fold and probably accounts for about 25% of all cases of heart failure. In addition, hypertension precedes heart failure in 90% of cases, and the majority of heart failure in the elderly may be attributable to hypertension.

Hypertensive heart disease was estimated to be responsible for 1.0 million deaths worldwide in 2004 (or approximately 1.7% of all deaths globally), and was ranked 13th in the leading global causes of death for all ages. There are more women than men with hypertension. The effectiveness of antihypertensive drugs differs between men and women and that treatment for heart failure may be less effective in women.

Studies in the USA indicate that a disproportionate number of African Americans have hypertension compared with non-Hispanic whites and Mexican Americans. Heart failure is more common in people of African American ethnicity with a higher mortality; and it develops at an earlier age. Recent data suggests that rates of hypertension are increasing more rapidly in African Americans than other ethnic groups. The excess of high blood pressure and its consequences in African Americans is likely to contribute to their shorter life expectancy compared with white Americans

SYSTEMIC (LEFT SIDED) HYPERTENSIVE HEART DISEASES The criteria for this diagnosis would be: A Left ventricular hypertrophy in the absence of other cardiovascular pathology e.g. valvular stenosis A history or pathologic evidence of hypertension. Systemic hypertension imposes pressure overload on the heart due to increased afterload and is associated with gross and morphological changes distinct from those caused by volume overload.

The essential feature of systemic hypertension is left ventricular hypertrophy (without dilation which is seen in long standing systemic hypertensive heart disease leading to CHF) Atrial dilation Increased width of myocytes Prominent nuclear enlargement with hyperchromasia (“box-car” nuclei) Intercellular fibrosis

PULMONARY HYPERTENSIVE HEART DISEASE Also called cor pulmonale. It consists if right ventricular hypertrophy and dilation-frequently accompanied by right heart failure-caused by pulmonary hypertension attributable to primary disorders of the lung parenchyma or pulmonary vasculature. Can be acute in onset (as in pulmonary embolism) or slow and insidious in onset as in chronic lung and pulmonary vascular disease.

In acute cor pulmonale; the right ventricle usually shows only dilation; if an embolism causes sudden death, the heart may even be of normal size. Chronic cor pulmonale is characterized by right ventricular (and often right atrial dilation) hypertrophy; the pulmonary arteries often contain artheromatous plaques and other lesions reflecting long standing hypertension. In extreme cases, the thickness of the right ventricular wall may be comparable with or even exceed that of the left ventricle.

Clinical Features Typically asymptomatic due to compensation and only suspected from elevated blood pressure on routine physical exams; or from ECG or echocardiographic findings of left ventricular hypertrophy. In some patients, the disease comes to attention with the onset of atrial fibrillation (secondary to atrial enlargement) and/or Congestive Heart Failure. Can lead to progressive ischaemic heart diseases (coronary artherosclerosis due to hypertension); progressive renal damage; cerebrovascular stroke; or progressive heart failure; with an increased risk of sudden cardiac death.

SIGNS AND SYMPTOMS In the absence of heart failure, hypertension with or without left ventricular hypertrophy is symptomless. But with heart failure, symptoms include; Fatigue Irregular pulse or palpitations Swelling of feet and ankles Weight gain Nausea Shortness of breath Difficulty sleeping flat in bed (orthopnea) Bloating and abdominal pain Greater need to urinate at night Altered mentation (in severe cases) An enlarged heart (cardiomegaly)

RISK FACTORS Age Ethnicity Family history Gender High blood pressure High cholesterol Tobacco exposure Obesity Physical inactivity Diabetes Unhealthy diets Excessive alcholism

DIAGNOSIS Transthoracic echocardiography (TTE) Echocardiography (ECG) Urinalysis blood glucose and hematocrit levels Serum potassium, creatinine and calcium measurements Lipid profile (HDL, LDL and TGs)

PREVENTION Because there are no symptoms with high blood pressure, people can have the condition without knowing it. Diagnosing high blood pressure early can help prevent heart disease, stroke, eye problems, and chronic kidney disease. The risk of cardiovascular disease and death can be reduced by lifestyle modifications, including dietary advice promotion of weight loss regular aerobic exercise moderation of alcohol intake cessation of smoking.

Drug treatment may also be needed to control the hypertension and reduce the risk of cardiovascular disease, manage the heart failure, or control cardiac arrhythmias. Patients with hypertensive heart disease should avoid taking over the counter non-steroidal anti-inflammatory drugs (NSAIDs), or cough suppressants, and decongestants containing sympathomimetics, unless otherwise advised by their physician as these can exacerbate hypertension and heart failure.

TREATMENT DASH diet which reduces blood pressure by 2-4mmHg Alcohol moderation reduces blood pressure by 2-4mmHg Weight reduction reduces bp by 5-20mmHg Physical activity reduces bp by 4-9mmHg; they could include walking, jogging, cycling, non-competitive swimmers. Sodium reduction reduces bp by 2-8mmHg Antihypertensive drugs like: Thiazide diuretics Calcium channel blockers Beta blockers (or combined alpha and beta blocker) ACE inhibitors Angiotensin receptor blockers

REFERENCES Pathoma Robbins Basic Pathology, 9 th Edition overview#a30 overview#a disease disease

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