Cardiology > Hypertensive Heart Disease   

Background 

 Hypertensive heart disease (HHD) refers to a spectrum of structural and functional cardiac abnormalities caused by prolonged, uncontrolled hypertension. It includes left ventricular hypertrophy (LVH), heart failure with preserved or reduced ejection fraction (HFpEF or HFrEF), ischemic heart disease, and arrhythmias such as atrial fibrillation. 

II) Classification/Types

By Manifestation: 

• • Left Ventricular Hypertrophy (LVH) 

• • Diastolic Dysfunction and HFpEF 

• • Systolic Dysfunction and HFrEF 

• • Ischemic Heart Disease 

• • Arrhythmias (especially atrial fibrillation) 

By Stage (ACC/AHA Heart Failure Classification): 

• • Stage A: At risk for heart failure (e.g., hypertension, diabetes) 

• • Stage B: Structural heart disease (e.g., LVH) without symptoms 

• • Stage C: Structural disease with prior/current symptoms of heart failure 

• • Stage D: Refractory heart failure requiring specialized interventions 

III) Pathophysiology 

 Chronic elevation of systemic blood pressure leads to increased afterload, causing the left ventricle to hypertrophy to maintain cardiac output. Over time, this results in impaired diastolic filling, increased myocardial oxygen demand, interstitial fibrosis, and eventual systolic dysfunction. LVH also predisposes to arrhythmias and ischemia. 

IV) Epidemiology

• • Highly prevalent among hypertensive patients—affects ~20–30% of adults with chronic hypertension 

• • Increased risk in African American populations 

• • Strongly associated with poor BP control and long-standing hypertension 

• • Major contributor to cardiovascular morbidity and mortality worldwide 

Etiology 

I) Causes

• • Long-standing, poorly controlled hypertension 

• • Secondary hypertension (e.g., renal disease, primary aldosteronism) 

• • Coexisting atherosclerotic disease 

• • Genetic predisposition to hypertrophy or heart failure 

II) Risk Factors

• • Hypertension (primary risk factor) 

• • Advanced age 

• • Male sex 

• • Obesity 

• • Diabetes mellitus 

• • Chronic kidney disease 

• • Smoking and dyslipidemia 

Clinical Presentation 

I) History (Symptoms)

• • Early stages may be asymptomatic 

• • Dyspnea on exertion or orthopnea (HF) 

• • Fatigue, decreased exercise tolerance 

• • Palpitations (atrial fibrillation) 

• • Chest pain (hypertrophy-induced ischemia) 

• • Nocturnal cough or paroxysmal nocturnal dyspnea 

II) Physical Exam (Signs)

• • Elevated blood pressure 

• • Displaced, sustained apical impulse (LVH) 

• • S4 heart sound (diastolic dysfunction) 

• • S3 heart sound, rales, elevated JVP, peripheral edema (heart failure) 

• • Irregularly irregular rhythm (atrial fibrillation) 

Differential Diagnosis (DDx) 

• • Coronary artery disease (CAD) 

• • Primary cardiomyopathies (e.g., hypertrophic, dilated) 

• • Valvular heart disease 

• • Infiltrative cardiomyopathy (e.g., amyloidosis) 

• • Constrictive pericarditis 

• • Pulmonary hypertension/Cor pulmonale 

Diagnostic Tests 

Initial Work-Up 

• • Blood pressure measurement (confirm chronicity) 

• • ECG: LVH, atrial enlargement, arrhythmias 

• • Chest X-ray: Cardiomegaly, pulmonary congestion 

• • Echocardiogram: Gold standard for assessing LVH, EF, wall motion 

• • BNP/NT-proBNP: Heart failure biomarker 

• • Cardiac MRI: Advanced imaging of myocardial structure and fibrosis 

• • Stress testing: If ischemia suspected 

• • Labs: CMP, CBC, TSH, lipid profile, HbA1c 

Treatment 

I) Initial Approach

• • Optimize blood pressure control (goal: <130/80 mm Hg) 

• • Assess for heart failure and ischemia 

• • Address modifiable risk factors: smoking, diet, exercise 

• • Evaluate and treat underlying causes 

II) Medications

III) Devices & Advanced Therapies 

• • ICD or CRT in advanced heart failure with reduced EF 

• • Ablation for refractory atrial fibrillation 

• • Cardiac transplant (end-stage) 

Patient Education, Screening, Vaccines 

Education 

• • Adherence to antihypertensives and lifestyle changes 

• • Low-sodium, heart-healthy diet 

• • Regular exercise, smoking cessation 

• • Recognizing symptoms of heart failure 

Screening 

• • Annual BP measurement 

• • Echocardiography for LVH if high risk 

• • Screen for associated conditions: diabetes, dyslipidemia 

Vaccinations 

• • Influenza, pneumococcal, and COVID-19 vaccines 

• • Especially important in HF or CKD 

Consults/Referrals 

• • Cardiology: Confirmed HHD, symptomatic heart failure, or arrhythmias 

• • Electrophysiology: Recurrent atrial fibrillation or need for pacing 

• • Nephrology: CKD or resistant hypertension 

• • Nutritionist: Dietary counseling 

• • Physical therapy/cardiac rehab for deconditioning 

Follow-Up 

Short-Term 

• • Monitor BP, volume status, symptom control 

• • Adjust medications based on BP and EF 

Long-Term 

• • Lifelong management of hypertension 

• • Periodic imaging (e.g., echocardiogram) 

• • Monitor for complications: AF, HF, ischemia 

• • Address psychosocial factors and adherence 

Prognosis 

• • Favorable with early diagnosis and tight BP control 

• • Poor outcomes associated with persistent LVH, HF, or arrhythmias 

• • Major cause of cardiovascular morbidity and mortality if untreated