Hypertensive Cardiovascular Disease

High blood pressure is commonly seen in most people these days. But do you know that it has a very close connection with cardiovascular diseases? Read on to learn about hypertensive cardiovascular disease.
By Ashwini Ambekar | Thursday, October 09, 2008

Hypertensive cardiovascular disease also known as hypertensive heart disease occurs due to the complication of hypertension or high blood pressure. In this condition the workload of the heart is increased manifold and with time this causes the heart muscles to thicken. The heart continues pumping blood against this increased pressure and over a period of time the left ventricle of the heart enlarges and this in turn causes the blood pumped by heart to reduce. If proper treatment is not taken at this stage then symptoms of congestive heart failure may be observed. High blood pressure or hypertension is among the top most factors associated with cardiovascular diseases. This can result in ischemic heart disease. High blood pressure is also a contributing factor to the eventual thickening of walls of blood vessels. This increases the possibility of heart attacks and strokes. Hypertensive cardiovascular disease is among the leading killers in present times. Around 7 people out of every 1000 suffer from this disease. Heredity is an important factor so far as people suffering from hypertension are concerned. Other factors include excessive consumption of salt and excessive stress. Symptoms It usually takes some time for the problem of high blood pressure to eventually lead to hypertensive cardiovascular disease and therefore high blood pressure is often called the silent killer. Eventually hypertensive heart disease can also lead to congestive heart failure. Some symptoms of hypertension and the eventual congestive heart failure include arrhythmias, shortness of breath, weakness and fatigue, swelling in lower extremities and greater frequency of urination during the night. Hypertensive cardiovascular disease may also result in ischemic heart condition and in this case there might be chest pain, sweating and dizziness, nausea and shortness of breath. Hypertrophic cardiomyopathy could also be a result of hypertensive heart disease. Tests Usually the first signal is elevated blood pressure together with a possibility of enlargement of the heart. Fluid within the lungs may also be found in preliminary examination by using the stethoscope and some

abnormal heart sounds may also be detected. ECG is ordinarily done and this may show abnormal results in those who have possible hypertensive cardiovascular disease. Evidence of ischemia which is the lack of oxygen in the heart muscle may also be detected. Some other tests ordinarily conducted may include a chest X ray, a CT scan of the chest, echocardiogram and coronary angiogram. Treatment The primary aim of any treatment in hypertensive cardiovascular disease is reduction of blood pressure and then eventual control of the heart disease. The line of treatment will ordinarily depend on the condition such as whether there is angina or acute myocardial infarction. The line of treatment may include beta blockers, angiotensin converting enzyme inhibitors (ACE), calcium channel blockers, diuretics etc depending upon particulars of each individual case. The blood pressure is consistently required to be checked and kept under control in this condition. Likewise people experiencing hypertensive cardiovascular disease have to make certain changes in their lifestyle and diet patters. These would ordinarily include weight loss where obesity is identified, moderate exercise as per directions of the medical professional and adjustments in the diet. These adjustments would include inake of healthy food including vegetables, fresh fruits and low fat dairy items. Smoking is also a contributing factor to hypertension and therefore these lifestyle changes would have to include the patient quitting smoking. Consumption of fish, whole grains are also recommended. In the long run the outcome largely depends on the possibility and extent of complications. In hypertensive cardiovascular disease the treatment will depend largely on the degree of enlargement of the left ventricle. However some medicines such as ACE inhibitors and others can reverse this enlargement and thereby help in improving the chances of survival in the patients in the long run.

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Atrial fibrillation (paroxysmal, chronic recurrent, or chronic persistent) is observed [9] frequently in patients with hypertension. In fact, elevated BP is the most common cause of atrial fibrillation in the Western hemisphere. In one study, nearly 50% of patients with atrial fibrillation had hypertension. Although the exact etiology is not known, LA structural abnormalities, associated coronary artery disease, and LVH have been suggested as possible contributing factors. The development of atrial fibrillation can cause decompensation of systolic and, more importantly, diastolic dysfunction, owing to loss of atrial kick, and it also increases the risk of thromboembolic complications, most notably stroke.

Physical signs of hypertensive heart disease depend on the predominant cardiac abnormality and the duration and severity of the hypertensive heart disease. Findings from the physical examination may be entirely normal in the very early stages of the disease, or the patient may have classic signs upon examination. In addition to generalized findings attributable directly to high BP, the physical examination may reveal clues to a potential etiology of hypertension, such as truncal obesity and striae in Cushing syndrome, renal artery bruit in renal artery stenosis, and abdominal mass in polycystic kidney disease.

Pulses
The arterial pulses are normal in the early stages of hypertensive heart disease. The cardiac rhythm is regular if the patient is in sinus rhythm; it is irregularly irregular if the patient is in atrial fibrillation. The heart rate is as follows:

Normal in patients in sinus rhythm Not normal in decompensated heart failure Tachycardic in patients with heart failure and in patients with atrial fibrillation and a rapid ventricular response The pulse volume is usually normal, but it is decreased in patients with LV dysfunction. Additional findings may include radial-femoral delay if the etiology of hypertension is coarctation of the aorta

Blood pressure
Systolic and/or diastolic BP is elevated (>140/90mm Hg). Mean BP and pulse pressure are also elevated generally. The BP in the upper extremities may be higher than that in the lower extremities in patients with coarctation of the aorta. BP may be normal at the time of evaluation if the patient is on adequate antihypertensive medications or if the patient has advanced LV dysfunction and the LV cannot generate enough stroke volume and cardiac output to produce an elevated BP.

Veins
In patients with heart failure, the jugular veins may be distended. The predominant waves depend on the severity of the heart failure and any other associated lesions.

Heart
The apical impulse is sustained and nondisplaced in patients without significant systolic LV dysfunction but with LVH. A presystolic S4 may be felt. Later in the course of disease, when significant systolic LV dysfunction supervenes, the apical impulse is displaced laterally, owing to LV dilatation. In the right ventricle, a lift is present late in the course of heart failure if significant pulmonary hypertension develops. S1 is normal in intensity and character. S2 at the right upper sternal border is loud because of an accentuated aortic component (A2); it can have a reverse or paradoxical split due either to increased afterload or to associated left bundle-branch block (LBBB). S4 is frequently palpable and audible, implying the presence of a stiffened, noncompliant ventricle due to chronic pressure overload and LVH. S3is not typically present initially, but it is audible in the presence of heart failure, either systolic or diastolic. An early decrescendo diastolic murmur of aortic insufficiency may be heard along the mid-parasternal to left parasternal area, especially in the presence of acutely elevated BP, frequently disappearing once the BP is better controlled. In addition, an early systolic to midsystolic murmur of aortic sclerosis is commonly audible. A holosystolic murmur of mitral regurgitation may be present in patients with advanced heart failure and a dilated mitral annulus.

Lungs
Findings upon chest examination may be normal or may include signs of pulmonary congestion, such as rales, decreased breath sounds, and dullness to percussion due to pleural effusion.

Abdomen
The abdominal examination may reveal a renal artery bruit in patients with hypertension secondary to renal artery stenosis, a pulsatile expansile mass of abdominal aortic aneurysm, and hepatomegaly and ascites due to CHF.

Extremities
Ankle edema may be present in patients with advanced heart failure.

Central nervous system and ophthalmologic system

Central nervous system (CNS) examination findings are usually unremarkable unless the patient has had previous cerebrovascular accidents with residual deficit. CNS changes may also be seen in patients who present with hypertensive emergency. Examination of the fundi may reveal evidence of hypertensive retinopathy, the severity of which depends on the duration and severity of the patient's hypertension, or earlier signs of hypertension, such as arteriovenous nicking.

Lifestyle Modifications
Emerging data support a target BP goal of less than 150/80mm Hg in patients older than 80 years as a means of reducing the risk of congestive heart failure by 64%.[14] Various treatment strategies include the following: Dietary modifications Regular aerobic exercise Weight loss[15] Pharmacotherapy directed toward hypertension, heart failure secondary to diastolic and systolic LV dysfunction, coronary artery disease, and arrhythmias

Dietary modifications
Studies have shown that diet and a healthy lifestyle alone or in combination with medical treatment can lower BP and decrease the symptoms of heart failure, as well as reverse LVH. A heart-healthy diet is part of the secondary prophylaxis in patients with coronary artery disease and of the primary prophylaxis in patients at high risk for this disease. Specific dietary 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.[16, 17, 18] In a large cohort study of women, the following 6 modifiable lifestyle and dietary factors for lowering the risk of hypertension were identified[19] : A body mass index (BMI) below 25kg/m2 Vigorous exercise for a daily mean period of 30 minutes A high score on the Dietary Approaches to Stop Hypertension (DASH) diet Modest alcohol intake (up to 10g/day) Nonnarcotic analgesic use less than once weekly Intake of 400mcg/day or more of supplemental folic acid 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 hypertensionmainly black individualswith 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. Data also indicate that sodium reduction, previously shown to lower BP, may also reduce the long-term risk of cardiovascular events. The recommended daily sodium intake is 50100mmol, equivalent to 3-6g of salt per day, which leads to an average 2-8mm Hg reduction in BP.[20] In various epidemiologic studies, a high-potassium diet has been associated with lowering of 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. Fresh fruits and vegetables rich in potassium, such as bananas, oranges, avocados, and tomatoes, should be recommended for patients with normal renal function. The DASH diet has been shown to significantly lower the BP (8-14mm Hg) in patients with hypertension regardless of whether or not they maintain a constant sodium content in their diet. The DASH diet is not only rich in important nutrients and fiber but also includes foods that contain far more potassium, calcium,

and magnesium than are found in the average American diet. This diet should be advised in patients with hypertension.[21, 22, 23, 24, 25] Heavy alcohol consumption has been associated with high BP and an increase in LV mass. [26] Moderation in alcohol consumption is advised; no more than 1-2 drinks daily is recommended.[27] Sinha et al concluded that high intakes of red or processed meat were associated with modest increases in total mortality, cancer mortality, and cardiovascular disease mortality.[28] The baseline population was a cohort of one-half million people aged 50-71 years from the National Institutes of Health (NIH)-AARP (formerly known as the American Association of Retired Persons) Diet and Health Study.[28]

Exercise
Regular dynamic isotonic (aerobic) exercise, such as walking, running, swimming, or cycling, has been shown to decrease BP and improve cardiovascular well-being.[29] It also 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. Regular aerobic exercise sessions of at least 30 minutes for most days of the week can produce an average reduction in BP of 4-9mm Hg. Isometric and strenuous exercise should be avoided.

Weight reduction
Studies have shown that weight reduction is one of the most effective ways to reduce BP. A 5-20mm Hg BP reduction occurs with each 10kg of weight loss.[30]Gradual weight reduction (1kg weekly) should be advised. Pharmacologic interventions to reduce weight should be used with great caution, because diet pills, especially those available over the counter, frequently contain sympathomimetics. These agents can raise BP, worsen angina or symptoms of heart failure, and exacerbate tendencies for cardiac arrhythmias. Medications that should be avoided include nonsteroid anti-inflammatory drugs (NSAIDs), sympathomimetics, and monoamine oxidase inhibitors (MAOIs), as these agents can elevate BP or interfere with antihypertensive therapy.

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