Dr Rutecki is with the Cleveland Clinic National Consultation Service.
The spectrum of hypertensive heart disease is broad. Try these 2 questions to help sharpen your focus on points along the disease continuum.
The spectrum of hypertensive heart disease is broad, with various manifestations potentially culminating in heart failure (HF) and death. Abnormalities associated with disease progression include left ventricular hypertrophy, systolic and diastolic dysfunction, and their clinical manifestations. Try these 2 questions to help bring points on the spectrum into sharper focus.
Which of the following statements regarding hypertension and heart failure are TRUE:
A. Data from the Framingham Heart Study (n=5,143) demonstrated that hypertension preceded the development of HF in more than 90% of all newly diagnosed HF patients (20-year follow-up).
B. At 80 years of age, the lifetime risk for HF in the Framingham cohort was approximately 20% and that risk was doubled for patients with a blood pressure of 160/100 mm Hg compared to those with a reading of 140/90 mm Hg.
C. The risk for HF is the same in men and women with hypertension.
The correct answers: A and B are true1,2; C is false
The risk for developing heart failure is doubled in men with hypertension, but tripled in women.2
There are 4 stages in the progression of hypertensive heart damage2:
1 - isolated left ventricular diastolic dysfunction without hypertrophy.
2 - diastolic dysfunction with concentric left ventricular hypertrophy.
3 - clinical heart failure with preserved systolic function. Finally,
4 - dilated cardiomyopathy with HF and reduced ejection fraction.
Which of the following is the best definition for the term “decapitated hypertension”?
A. Blood pressure in hypertensive patients that is below target.
B. As heart failure becomes worse, hypertensive HF patients develop normal or even low systolic blood pressure because of decreasing left ventricular systolic function.
C. A blood pressure that can only be controlled on 4 antihypertensive agents.
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.