HYPERTENSION

The cause of hypertensive heart disease is chronic uncontrolled blood pressure (BP); however, the causes of elevated BP may be multifactorial.Essential (Primary) hypertension accounts for 90% of cases of hypertension in adults. Secondary causes of hypertension account for the remaining 10% of cases of chronically elevated BP. Uncontrolled and prolonged elevation of BP can lead to a variety of changes in the myocardial structure, coronary vasculature, and conduction system of the heart. These changes in turn can lead to the development of left ventricular hypertrophy (LVH), coronary artery disease (CAD), various conduction system diseases, and systolic and diastolic dysfunction of the myocardium, complications that manifest clinically as angina or myocardial infarction, cardiac arrhythmias (especially atrial fibrillation), and congestive heart failure (CHF).

Thus, hypertensive heart disease is a term applied generally to heart diseases, such as LVH, coronary artery disease, cardiac arrhythmias, and CHF, that are caused by the direct or indirect effects of elevated BP. Although these diseases generally develop in response to chronically elevated BP, marked and acute elevation of BP can lead to accentuation of an underlying predisposition to any of the symptoms traditionally associated with chronic hypertension.

Hypertension Classification:

Office blood pressure (BP) measurement

  • Normal BP: < 130 mmHg (systolic [SBP]) and < 85 mmHg (diastolic [DBP])
  • High-normal: 130-139 mmHg SBP and/or 85-89 mmHg DBP
  • Grade 1 hypertension: 140-159 mmHg SBP and/or 90-99 mmHg DBP
  • Grade 2 hypertension: ≥160 mmHg SBP and/or ≥100 mmHg DBP

Hypertension Criteria:

Office, ambulatory (ABPM), and home based (HBPM) (SBP/DBP [mmHg])

  • Office BP: ≥140 and/or ≥90 mmHg
  • ABPM: 24-Hour average of ≥130 and/or ≥80 mmHg; daytime/awake average of ≥135 and/or ≥85 mmHg; night time/sleep ≥120 and/or ≥70 mmHg
  • HBPM: ≥135 and/or ≥85 mmHg

Hypertension Diagnosis:

Office and out-of-office BP measurements and plans

  • At the first office visit, concurrently measure BP in both arms. If a >10 mmHg difference is consistent between the arms on repeated measurements, use the arm with the higher BP. If a >20 mmHg difference is found, consider further evaluation.
  • Office BP < 130/85 mmHg: Remeasure in 3 years (after 1 year if other risk factors exist)
  • Office BP 130-159/85-99 mmHg: Confirm with ABPM or HBPM measurement, or confirm with repeated office visits. If HBPM < 135/85 mmHg or 24-hour ABPM < 130/80 mmHg, remeasure after 1 year; If HBPM ≥135/85 mmHg or 24-hour ABPM ≥130/80 mmHg, then hypertension is diagnosed.
  • Office BP >160/100 mmHg: Confirm within a few days or weeks.

Diagnostic Studies:

Laboratory, electrocardiography (ECG), and imaging

  • Levels of sodium, potassium, serum creatinine, fasting glucose; estimated glomerular filtration rate; lipid profile
  • Urine dipstick
  • 12-Lead ECG to detect atrial fibrillation, left ventricular hypertrophy, ischemic heart disease
  • Other tests as needed if organ damage or secondary hypertension is suspected

Symptoms:

  • chest pain (angina)
  • tightness or pressure in the chest.
  • shortness of breath.
  • pain in the neck, back, arms, or shoulders.
  • persistent cough.
  • loss of appetite.
  • leg or ankle swelling.
  • Palpitations, syncope, sudden cardiac death

Diagnosis:

Clinical examination helps in getting clues for the diagnosis (Pulse, BP, cardiac examination, lungs, abdomen, extremities, CNS examination)

Best diagnostic tool is 24 hour ambulatory BP monitoring, other ways are to check home based or clinic measurements. If it is above the cut off with reasonable number of measurements help in diagnosis.Electrocardiography and Echocardiography can help in diagnosing BP once LVH sets in. Similarly, Fundoscopic examination also helps in diagnosis early.

Treatment:

Treatment for Hypertension

Grade 1 hypertension (140-159/90-99 mmHg)

  • Start lifestyle interventions (smoking cessation, exercise, weight loss, salt and alcohol reduction, healthy diet)
  • Initiate Tablets in high-risk patients (cardiovascular disease, chronic kidney disease, diabetes, or organ damage) and those with persistent high BP after 3-6 months of lifestyle intervention

Grade 2 hypertension (≥160/100 mmHg)

  • Immediately initiate medical therapy
  • Start lifestyle interventions.

BP control targets:

  • Aim for BP control within 3 months
  • Aim for at least a 20/10 mmHg BP reduction, ideally to < 140/90 mm Hg
  • Target BP < 130/80 mmHg if tolerated (but near 120/80 mmHg is always preferred)
  • Medical therapy (if BP uncontrolled after 3-6 months of lifestyle intervention)

Consider monotherapy in low-risk grade 1 hypertension and elderly (>80 years) or frail patients. A simplified regimen with once-daily dosing and single pill combinations is ideal.

  • Step 1: Use a dual low-dose drug combination (angiotensin-converting enzyme inhibitor [ACEI] or angiotensin-receptor blocker [ARB] +/- dihydropyridine-calcium channel blocker [DHP-CCB])
  • Step 2: Increase the regimen to the dual full-dose combination
  • Step 3 (triple combination): Add a thiazide or thiazide-like diuretic
  • Step 4 (resistant hypertension): Triple combination plus beta blocker, centrally acting agents, alpha blockers, spironolactone or eplerenone.
CONDITIONS & TREATMENTS