- THE RISK OF LVH INCREASES TWO FOLDS BY ASSOCIATED OBESITY.
- CHR. & SEVERE HYPERTENSION CAN CAUSE AORTIC ROOT DILATATION LEADING TO SIGNIFICANT AORTIC REGURGITATION.
- COMMON CARDIAC ARRHYTHMIAS SEEN IN HYPERTENSION ARE ATRIAL FIBRILLATION, VENTRICULAR ECTOPIC & VENTRICULAR TACHYCARDIA.
* - TREATMENT OF PRIMARY CAUSE MAY TREAT IT FOR ALL TIME.
Medical Care: The medical care of patients with hypertensive heart disease falls under 2 categories-treatment of the elevated BP and prevention and treatment of hypertensive heart disease. The BP goal should be less than 140/90 mm Hg in patients without diabetes or chronic kidney disease and less than 130/90 mm Hg in those with either of these diseases. Various treatment strategies include dietary modifications, regular aerobic exercise, weight loss, and pharmacotherapy directed toward hypertension, heart failure secondary to diastolic and systolic LV dysfunction, coronary artery disease, and arrhythmias.
" Dietary modifications
o Specific diet recommendations include a diet low in sodium, high in potassium (in patients with normal renal function), rich in fresh fruits and vegetables, low in cholesterol, and low in alcohol consumption.
o A low-sodium diet, alone or in combination with pharmacotherapy, has been shown by numerous studies to reduce BP in patients with hypertension, with a more prominent response in a subset of patients with hypertension-mainly African Americans-with low renin levels. Restriction of sodium in these patients does not lead to compensatory stimulation of the renin-angiotensin system and thus has a potent antihypertensive effect. The recommended daily sodium intake is 50-100 mmol, equivalent to 3-6 g of salt per day, which leads to an average 2-8 mm of Hg reduction in BP.
o In various epidemiological studies, a high-potassium diet has been associated with lowering of the BP. The mechanism of this action is not clear. Intravenous infusion of potassium has been shown to cause vasodilatation, which is believed to be mediated by nitric oxide in the vascular wall. Foods rich in potassium, such as fresh fruit and vegetables, should be recommended for patients with normal renal function.
o A diet rich in fresh fruits and vegetables, known as the DASH diet, has been shown to significantly lower the BP (8-14 mm Hg) in patients with hypertension regardless of them maintaining a constant sodium content in their diet. This diet should be advised in patients with hypertension.
o A low-cholesterol diet is part of secondary prophylaxis in patients with coronary artery disease. It is also a part of the primary prophylaxis of coronary artery disease in patients at high risk for this disease.
o Heavy alcohol consumption has been associated with high BP and an increase in LV mass. Moderation in alcohol consumption is advised; no more than 1-2 drinks per day is recommended.
" Regular aerobic exercise
o Regular dynamic isotonic exercise, such as walking, running, swimming, or cycling, has been shown to decrease BP and improve cardiovascular well-being. Regular isotonic exercise has additional favorable cardiovascular effects, including improved endothelial function, peripheral vasodilatation, reduced resting heart rate, improved heart rate variability, and reduced plasma levels of catecholamines.
o Regular 30-minute sessions of aerobic exercise 3-4 times a week should be advised. Average reduction in BP with regular aerobic exercise such as walking at least 30 minutes most days of the week is 4-9 mm of Hg. Isometric and strenuous exercise should be avoided.
" Weight reduction
o Obesity has been linked to hypertension and LVH in various epidemiological studies, with as many as 50% of obese patients having some degree of hypertension and as many as 60-70% of patients with hypertension being obese. Abdominal adiposity, clinically measured as waist-to-hip ratio and more accurately assessed by abdominal CT scan, is a more sensitive risk factor for hypertension. Studies have shown that weight reduction is one of the most effective ways to reduce BP. A 5-20 mm Hg BP reduction occurs with each 10 kg of weight loss.
o Gradual weight reduction (1 kg/wk) should be advised. Pharmacological interventions to reduce weight should be used with great caution because diet pills, especially those available over the counter, frequently contain sympathomimetics. These can raise BP, worsen angina or symptoms of heart failure, and exacerbate tendencies for cardiac arrhythmias.
" Pharmacotherapy
o Treatment of hypertension and hypertensive heart disease can involve the following classes of antihypertensive medications: thiazide diuretics, beta-blockers and combined alpha- and beta-blockers, calcium channel blockers, ACE inhibitors, angiotensin receptor blockers, and direct vasodilators such as hydralazine. Most patients require 2 or more antihypertensive drugs to achieve the BP goal, and, when the BP is more than 20/10 mm Hg above the goal, consider initiating treatment with 2 drugs, either as separate prescriptions or in fixed-dose combinations.
o Thiazide diuretics are the drugs of first choice in most patients with uncomplicated hypertension, as outlined by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
o Drugs from other classes can be used in the presence of compelling indications.
" Calcium channel blockers are effective for systolic hypertension in elderly patients.
" ACE inhibitors are the first choice in patients with diabetes and/or LV dysfunction.
" Angiotensin receptor blockers are a reasonable alternative, especially for patients with adverse effects with ACE inhibitors.
" Beta-blockers are the drugs of first choice in patients with heart failure due to systolic LV dysfunction, patients with ischemic heart disease with or without a history of myocardial infarction, and in patients with thyrotoxicosis.
" Peripheral alpha-channel blockers should be avoided in patients with hypertension in view of recent findings of their adverse effect on cardiovascular morbidity and mortality rates.
" Central alpha-antagonists have no evidence-based support and have more adverse effects.
o Intravenous drugs used in patients with a hypertensive emergency include nitroprusside, labetalol, hydralazine, enalapril, and beta-blockers (avoided in patients with acutely decompensated heart failure).
" Treatment of LVH
o LVH, a marker of increased risk of cardiovascular morbidity and mortality, should be treated aggressively. Whether regression in LVH leads to improvement in cardiovascular mortality and morbidity rates is not clear, although limited data support this hypothesis.
o All the medications already listed for the treatment of hypertension have been shown to reduce LVH. Limited meta-analysis data suggest a slight advantage to ACE inhibitors.
" Treatment of LV diastolic dysfunction
o Certain classes of antihypertensives-ACE inhibitors, beta-blockers, and nondihydropyridine calcium channel blockers-have been shown (although not consistently) to improve echocardiographic parameters in symptomatic and asymptomatic diastolic dysfunction and the symptomatology of heart failure.
o Use diuretics and nitrates with caution in patients with heart failure due to diastolic dysfunction. These drugs may cause severe hypotension by inappropriately decreasing the preload, which is required for adequate LV filling pressures. If diuretics are indicated, delicate titration is necessary.
o Hydralazine has been shown to cause severe hypotension in patients with heart failure due to diastolic dysfunction.
o By increasing the intracellular calcium level, digoxin can worsen LV stiffness. However, a large randomized trial has not shown any increase in mortality rate.
" Treatment of LV systolic dysfunction
o Diuretics (predominantly loop diuretics) are used in the treatment of LV systolic dysfunction.
o ACE inhibitors are used for preload and afterload reduction and prevention of pulmonary or systemic congestion. They have been shown to decrease morbidity and mortality rates in patients with heart failure due to systolic dysfunction. The aim should be to use the target dose or the maximum tolerable doses. ACE inhibitors are also indicated in patients with asymptomatic LV dilatation and dysfunction.
o Beta-blockers (cardioselective or mixed alpha and beta), such as carvedilol, metoprolol XL, and bisoprolol, have been shown to improve LV function and decrease rates of mortality and morbidity from heart failure. Recent trials have also shown improvement in outcomes for patients in NYHA class IV heart failure with carvedilol administration. These drugs should be started when the patient has no signs of fluid overload and is in compensated heart failure. Therapy should be initiated with low doses, increasing the dose of the beta-blocker very slowly and closely monitoring the patient for signs of worsening heart failure.
o Low-dose spironolactone has been shown to decrease the rates of morbidity and mortality in patients in NYHA class III or IV heart failure who are already taking ACE inhibitors.
" Treatment of cardiac arrhythmias
o Treatment depends upon the specific arrhythmia and the underlying LV function.
o Anticoagulation should be considered in patients with atrial fibrillation.
Surgical Care: Surgical treatment may be necessary for definitive treatment in selected cases of secondary causes for hypertension.
Diet: Specific diet recommendations include a diet low in sodium, high in potassium, rich in fresh fruits and vegetables, low in cholesterol, and low in alcohol intake.
Activity: Regular 30-minute sessions of aerobic exercise 3-4 times a week should be advised. Isometric and strenuous exercise should be avoided.
DRUG TREATMENT :
1. THIAZIDES & RELATED DIURETICS :
- HYDROCHLORTHIAZIDE
- CHLORTHALIDONE
2. ALPHA / BETA ADRENERGIC BLOCKING DRUGS :
- CARVEDILOL
3. BETA ADRENERGIC BLOCKING DRUGS :
- BISOPROLOL
- ATENOLOL
- METOPROLOL
4. ACE INHIBITORS :
- CAPTOPRIL
- FOSINOPRIL
- RAMIPRIL
5. ANGIOTENSIN II RECEPTOR BLOCKERS :
- LOSARTAN
- VALSARTAN
- CANDESARTAN
- IRBESARTAN
- EPROSARTAN
- OLMESARTAN
6. CALCIUM CHANNEL BLOCKERS, NONDIHYDROPYRIDINES :
- DILTIAZEM
- VERAPAMIL
7. CALCIUM CHANNEL BLOCKERS, DIHYDROPYRADINES :
- AMLODIPNE
- FELODIPINE
- NIFEDIPINE
8. PERIPHERAL VASODILATOR:
- HYDRALAZINE
9. ALDOSTERONE ANTAGONIST :
- SPIRONOLACTONE