Cardiology > Hypertensive Vascular Disease 

Background

Hypertensive vascular disease refers to the pathological consequences of chronic elevated blood pressure on the vasculature, including both large and small arteries. Prolonged hypertension leads to arterial remodeling, increased vascular resistance, endothelial dysfunction, and target organ damage such as left ventricular hypertrophy, stroke, chronic kidney disease, and aortic dissection. 

II) Classification/Types

By Affected Vessel Size: 

• • Large vessel disease: Aortic aneurysm, aortic dissection, accelerated atherosclerosis 

• • Small vessel disease: Arteriolosclerosis, hyaline changes, and fibrinoid necrosis, particularly in the brain, kidney, and retina 

By Clinical Outcome: 

• • Benign hypertensive vascular disease: Gradual changes such as hyaline arteriolosclerosis, often subclinical for years 

• • Malignant hypertensive vascular disease: Rapidly progressive, with fibrinoid necrosis and hyperplastic arteriolosclerosis, associated with severe elevations in blood pressure and end-organ damage 

By Target Organ Involvement: 

• • Cerebrovascular disease (e.g., lacunar infarcts, intracerebral hemorrhage) 

• • Hypertensive heart disease 

• • Hypertensive nephropathy 

• • Hypertensive retinopathy 

III) Pathophysiology 

Chronic systemic hypertension causes shear stress and endothelial injury in blood vessels, triggering vascular smooth muscle hypertrophy and extracellular matrix deposition. This results in narrowed vessel lumens, increased afterload, and reduced perfusion to organs. Small arteries and arterioles develop hyaline or hyperplastic changes, leading to tissue ischemia and organ dysfunction. 

IV) Epidemiology

• • Sex: More common in men before age 60; prevalence equalizes after menopause 

• • Age: Increases with age; prevalence >70% in adults >65 years 

• • Geography: High prevalence in developed and developing countries alike 

• • Race/Ethnicity: African Americans have higher incidence and earlier onset 

• • Comorbidities: Often associated with diabetes, obesity, hyperlipidemia, and chronic kidney disease 

Etiology

I) Causes

• • Essential (primary) hypertension (90–95%) 

• • Secondary hypertension (5–10%) due to: 

• • Renal parenchymal disease 

• • Renovascular disease 

• • Primary hyperaldosteronism 

• • Pheochromocytoma 

• • Cushing’s syndrome 

• • Coarctation of the aorta 

• • Obstructive sleep apnea 

• • Drug-induced (NSAIDs, corticosteroids, sympathomimetics) 

II) Risk Factors

• • Age >55 

• • Family history of hypertension 

• • African American ethnicity 

• • Obesity 

• • Sedentary lifestyle 

• • High sodium intake 

• • Excess alcohol consumption 

• • Diabetes mellitus 

• • Chronic stress 

Clinical Presentation

I) History (Symptoms)

Often asymptomatic, but may present with: 

• • Headache (especially in the morning or occipital) 

• • Dizziness 

• • Palpitations 

• • Visual disturbances 

• • Chest pain or dyspnea (if cardiac involvement) 

• • Hematuria or nocturia (renal involvement) 

• • Neurological deficits (stroke or TIA) 

II) Physical Exam (Signs)

Vital Signs: 

• • Elevated blood pressure (typically ≥140/90 mmHg) 

• • Hypertensive urgency/crisis if ≥180/120 mmHg with or without symptoms 

Cardiac Exam: 

• • Displaced PMI (left ventricular hypertrophy) 

• • S4 heart sound 

• • Signs of heart failure in advanced disease 

Vascular Exam: 

• • Diminished peripheral pulses in aortic coarctation 

• • Bruits over renal arteries (renovascular disease) 

Ocular Exam: 

• • Arteriovenous nicking 

• • Cotton wool spots 

• • Flame hemorrhages 

• • Papilledema (in malignant hypertension) 

Differential Diagnosis (DDx)

• • White coat hypertension 

• • Pheochromocytoma 

• • Hyperthyroidism 

• • Anxiety disorders 

• • Substance use (cocaine, amphetamines) 

• • Secondary causes of hypertension (renal, endocrine, vascular) 

Diagnostic Tests

Initial Tests: 

• • Blood Pressure Monitoring: Ambulatory or home BP measurement for confirmation 

• • Basic Labs: 

• • CBC, BMP, fasting glucose 

• • Lipid profile 

• • Urinalysis (check for proteinuria or hematuria) 

• • ECG: Left ventricular hypertrophy, ischemic changes 

• • Echocardiogram: Evaluate LV hypertrophy, diastolic dysfunction 

• • Fundoscopy: Assess for hypertensive retinopathy 

• • Renal Ultrasound: Rule out renal artery stenosis 

• • Plasma Renin Activity & Aldosterone (if secondary hypertension suspected) 

• • 24-hour urine metanephrines (pheochromocytoma) 

Treatment

I) Medical Management

Lifestyle Modifications: 

• • DASH diet (low sodium, high potassium) 

• • Weight loss (goal BMI <25) 

• • Regular aerobic exercise 

• • Limit alcohol, stop smoking 

• • Reduce stress 

Antihypertensive Medications: 

• • First-line: Thiazide diuretics, ACE inhibitors, ARBs, calcium channel blockers 

• • Additional agents: Beta-blockers, aldosterone antagonists, hydralazine, clonidine 

• • Choice tailored to comorbidities (e.g., ACEi for CKD, BB for CAD) 

Urgent/Malignant Hypertension: 

• • IV antihypertensives (e.g., labetalol, nitroprusside) 

• • ICU monitoring for end-organ damage 

II) Interventional/Surgical

• • Renal artery stenting (in select cases of renovascular hypertension) 

• • Adrenalectomy (for aldosterone-secreting adenomas or pheochromocytomas) 

• • Coarctation repair (in congenital vascular abnormalities) 

Patient Education, Screening, Vaccines

• • Home BP Monitoring: Encourage regular tracking 

• • Adherence: Emphasize importance of medication and lifestyle compliance 

• • Complication Awareness: Educate on signs of stroke, MI, renal failure 

• • Vaccinations: 

• • Influenza annually 

• • Pneumococcal vaccine 

• • COVID-19 vaccination 

Consults

• • Cardiology: Resistant hypertension, LV hypertrophy, CAD 

• • Nephrology: Suspected renovascular hypertension, CKD 

• • Endocrinology: Adrenal causes, hyperthyroidism 

• • Ophthalmology: Hypertensive retinopathy 

• • Primary Care: Long-term monitoring and risk factor control 

Follow-Up

• • Initial Recheck: 2–4 weeks after starting or adjusting medication 

• • Stable Patients: BP check every 3–6 months 

• • Annual Workup: Lipid panel, glucose, renal function 

• • Repeat ECG or Echo: If symptomatic or to monitor for LVH 

• • Ambulatory BP Monitoring: If white coat or masked hypertension suspected