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Hypertension and Heart Failure Hypertension and Heart Failure Jeremy Slivnick, MDa, Brent C. Lampert, DOb,* KEYWORDS Hypertension Heart failure LVH HFpEF HFrEF Heart failure drug therapy KEY POINTS Hypertension leads to heart failure through pathologic left ventricular hypertrophy (LVH) and dia- stolic dysfunction. A subset of these patients ultimately develops systolic heart failure owing to ischemia, genetic polymorphisms, or other insults to the cardiac myocytes. LVH represents the inciting event in the development of heart failure owing to hypertension. Early screening and intervention are keys to preventing hypertensive heart failure. Even after the onset of LVH, prompt initiation of therapy may still lead to reversal of remodeling. Once heart failure develops, the outlook declines significantly. Treatment should be in accordance with current guidelines for heart failure. INTRODUCTION PATHOPHYSIOLOGY Hypertension is the leading risk factor for numerous In the most widely accepted model of hyperten- cardiovascular diseases, including stroke, coronary sive heart failure, chronic pressure overload leads artery disease, atrial fibrillation, and peripheral to the development of left ventricular hypertrophy vascular disease. In particular, hypertension con- (LVH). Progressive hypertrophy and fibrotic tributes significantly to the incidence of heart fail- changes in the heart lead to progressive diastolic ure, a condition responsible for 1 in 9 annual dysfunction ultimately leading to elevated left- deaths in the United States and approximately sided filling pressures and diastolic heart failure. $30.7 billion in annual health care costs.1,2 Hyper- Eventually, a subset of patients progresses to sys- tension is highly prevalent in the heart failure popu- tolic dysfunction in the presence of chronic volume lation. In the Framingham study, 91% of patients and pressure overload.6 with new heart failure had underlying hyperten- Multiple mechanisms appear to contribute to this sion.3 History of hypertension has also been noted disease progression. Chronic pressure overload ap- in up to 70% of patients in the PARADIGM-HF trial.4 pears to lead to alterations in gene expression Hypertension appears to have a dose-dependent resulting in both myocyte hypertrophy and alter- impact on heart failure incidence.5 In all, hyperten- ations in the extracellular matrix. At the myocyte sion is the single greatest risk factor for heart failure level, increased microtubule density initially leads at a population level, owing to its high prevalence.3 to improved contractility and left ventricular mass.7 Hypertension is also a leading cause of myocardial In the later stages, derangements within the car- infarction, the second greatest risk factor. Hyper- diac myocyte lead to impaired relaxation and tensive heart disease is therefore a major concern increased stiffness. Abnormal calcium handling, to anyone caring for heart failure patients. microtubule disarray, and hyperphosphorylation of Disclosure Statement: The authors have nothing to disclose. Funding sources: No research funding was used in this research. Relevant disclosures: None. a Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA; b Heart Transplantation and Mechanical Circulatory Support, Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA * Corresponding author. E-mail address: [email protected] Heart Failure Clin - (2019) -–- https://doi.org/10.1016/j.hfc.2019.06.007 1551-7136/19/Ó 2019 Elsevier Inc. All rights reserved. heartfailure.theclinics.com 2 Slivnick & Lampert titin protein have been implicated in this pathologic Degree IV: Symptomatic heart failure with process.8,9 Increased collagen turnover owing to reduced ejection fraction enzymes called membranometalloproteases is also linked to increased fibrotic remodeling and These stages draw similarities from the Amer- ultimately the development of both diastolic and ican College of Cardiology/American Heart Asso- systolic dysfunction in hypertensive patients.10,11 ciation (ACC/AHA) stages in which those with The microvasculature may also play a role; stage A possess risk factors without overt disease; both microvascular resistance and reactivity are stage B patients have underlying structural heart impaired in hypertension and may contribute to disease, and stage C/D patients are those with the development of both systolic and diastolic heart overt, clinical heart failure. failure.12,13 LEFT VENTRICULAR HYPERTROPHY Increased neurohormonal stress also appears to play a powerful role in remodeling, and ultimately, Chronic pressure overload resulting in LVH appears 14 heart failure (Fig. 1). Elevated levels of renin to be the inciting event in the cascade ultimately and aldosterone have been implicated in the leading to hypertensive heart failure. Concentric 15,16 development of LVH and fibrotic remodeling. hypertrophy represents, at least initially, an attempt Polymorphisms in these pathways may be partially by the left ventricle to maintain wall stress in responsible for the variability in remodeling seen in response to elevated systemic pressures in accor- different patient populations. dance with Laplace’s law (Fig. 3). Classically, LVH was diagnosed by electrocardi- STAGES OF HYPERTENSIVE HEART FAILURE ography (ECG); however, although specific, ECG 18 Based on the pathophysiologic mechanisms criteria appear to lack sensitivity for this finding. described above, Messerli and colleagues6,17 pro- When more sensitive modalities such as cardiac MRI are used, the prevalence of LVH in the popu- posed the following stages in the evolution of 19 hypertensive heart disease (Fig. 2): lation ranges from 9% to 13%. The link between hypertension and the incidence Degree I: Hypertension without LVH of LVH is well established and has been demon- Degree II: Asymptomatic hypertension with strated using multiple imaging modalities, including LVH ECG, echocardiography, and cardiac MRI.20,21 Hy- Degree III: Symptomatic heart failure with pre- pertension appears to result in LVH in a dose- served ejection fraction (HFpEF) dependent fashion with even prehypertensive Fig. 1. Cellular pathways contributing to LVH in hypertensive heart disease. Both physical and neurohormonal stresses contribute to alterations in gene expression resulting in myocyte hypertrophy and pathologic remodel- ing. LV, left ventricular; MVO2, Myocar- dial oxygen consumption. (From Shenasa M, Shenasa H. Hypertension, left ventricular hypertrophy, and sud- den cardiac death. Int J Cardiol 2017;237:61; with permission.) Hypertension and Heart Failure 3 Fig. 2. Stages of hypertensive heart disease. (From Messerli FH, Rimoldi SF, Bangalore S. The Transition From Hypertension to Heart Failure: Contemporary Update. JACC Heart Fail 2017;5(8):546; with permission.) patients at risk for remodeling.21–23 This correlation mass.21,25 Race appears to play a significant appears to be much stronger when ambulatory or role. On average, blacks have significantly higher workplace blood pressure monitoring is used as left ventricular mass and are over twice as likely compared with physician’s office measurements.24 to develop LVH as their white counterparts.18,19 It should be noted that other factors besides These racial differences suggest the possible role blood pressure also modulate the development of genetics in the remodeling process. This is of LVH. Not all patients with hypertension develop supported by sibling studies from the Framing- LVH and not all LVH occur secondary to hyperten- ham cohort, which demonstrated a significant sion. In a review of major trials by Devereux and heritable component of hypertrophy in response colleagues,24 the prevalence of LVH among hyper- to hypertension.26 Last, classical cardiovascular tensive patients was only 23% to 48%. In addition, risk factors, such as diabetes, active smoking, LVH was seen in 0% to 10% of normal subjects. In and obesity, also significantly contribute to LVH regression models, hypertension only explained irrespective of blood pressure.21,27,28 Thus, this 50% to 68% of the variance in left ventricular process appears to be multifactorial in nature. FROM REMODELING TO HEART FAILURE Although initially adaptive, LVH in response to hy- pertension ultimately becomes pathologic. There are clear differences in the pattern of hypertrophy in patients with LVH owing to hypertension when compared with those with physiologic hypertrophy, such as in athletes. In a study by Galderisi and col- Fig. 3. Law of Laplace. leagues,29 patients with hypertensive hypertrophy 4 Slivnick & Lampert had significantly lower global longitudinal strain medical intervention has been shown to alter and greater degrees of diastolic dysfunction than mortality in HFpEF and very few medications age-matched competitive athletes despite lower appear to alter the disease process at all. This high- mean left ventricular mass. As discussed above, lights the importance of the early detection and impairments in active myocyte relaxation and treatment of hypertension and LVH before onset extracellular fibrosis appear to contribute to the of HFpEF. process. In addition, left ventricular mass inversely correlates with cardiac index in hypertensive pa- HEART FAILURE WITH REDUCED EJECTION tients, which also argues against a physiologic FRACTION benefit to this pattern of hypertrophy.24 Regardless of how it occurs, once LVH de- Eventually, a subset of patients with longstanding velops, the risk
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