The correct answer is: B. As heart failure becomes worse, hypertensive HF patients develop normal or even low systolic blood pressure because of decreasing left ventricular systolic function.2
Decapitated hypertension is used to describe the decrease in blood pressure resulting from reduced pump function in HF. A decline in blood pressure reflects a failing left ventricle. It also complicates management. Medications that clinically improve the patient’s condition—angiotensin modifying agents, ACEIs or ARBs, diuretics, and beta blockers—may need to be stopped because they lower blood pressure too much in the presence of poor systolic function. Furthermore, the lower the pretreatment blood pressure in HF patients, the higher the risk for a major negative clinical event (hospitalization or death.)2,3
Although stroke is a very real complication of untreated hypertension, the heart is a target organ that is vulnerable to serious, potentially fatal injury. The correlation from Framingham—approximately 90% of newly diagnosed HF patients came to heart complications after a history of hypertension—should give the medical and lay community pause.
The heart does not stand alone as a target of hypertension. In the next installment we will see how the kidney responds to the widespread pathology created by hypertension.
1. Levy D, Larson MG, Vasan RA, et al. The progression from hypertension to congestive heart failure. JAMA 1996; 275:1557-1562.
2. Messerli FH, Rimoldi SF, Bangalore S. The transition from hypertension to heart failure: contemporary update. JACC. 2017; Article in Press.
3. Rouleau JL, Roecker EB, Tendera M, et al. Influence of pretreatment systolic pressure on the effect of carvedilol in patients with severe chronic heart failure: The Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) Study. J. Am. Coll. Cardiol. 2004; 43:1423-1429.