What is Hypertensive Heart Disease?
Hypertensive heart disease is a condition caused by long-term high blood pressure which results in changes to the heart’s left ventricle, left atrium, and coronary arteries. The high blood pressure makes the heart work harder, leading to changes in the heart muscle. This can cause the left ventricle to become enlarged, a condition known as left ventricular hypertrophy, which can eventually lead to heart failure. Those with left ventricular hypertrophy are at a higher risk of health complications and have a significantly increased mortality rate. Treatments follow standard guidelines for managing high blood pressure, but the benefits of medication in reversing left ventricular hypertrophy remain uncertain.
The type of hypertensive heart disease is categorized based on whether heart failure is present or not, as heart failure requires a more intensive treatment plan. Hypertensive heart disease can result in either diastolic heart failure, systolic failure, or both. Patients with hypertensive heart disease are at more risk of experiencing severe complications like sudden heart failure, acute coronary syndrome, or unexpected cardiac death.
Chronic high blood pressure disrupts the endothelial system, or the inner lining of the blood vessels, increasing the risk of coronary artery disease and peripheral arterial disease. This makes it a significant risk factor for the development of atherosclerotic disease, a condition where plaque builds up inside the arteries. Ultimately, hypertensive heart disease accounts for all the direct and indirect consequences of prolonged high blood pressure, which include heart failure, irregular heart rhythms (especially atrial fibrillation), and heightened risk of coronary artery disease.
What Causes Hypertensive Heart Disease?
Hypertensive heart disease happens when a person has high blood pressure for a long time. The American Cardiology Association and American Heart Association guidelines from 2017 define high blood pressure as having a systolic (the top number) blood pressure higher than 120 or a diastolic (the bottom number) pressure higher than 80. If a person’s blood pressure increases by 20 for systolic and 10 for diastolic over a base blood pressure of 115/75, their risk of dying from a heart problem doubles.
Most people (90 to 95%) with high blood pressure have what’s called primary or essential hypertension. We don’t fully understand why this happens, but it probably involves a combination of a person’s genetics and their environment. Several risk factors might increase a person’s chance of developing high blood pressure. These include getting older, having a family history of high blood pressure, being overweight, eating too much salt (over 3g/day), not getting enough exercise, and drinking too much alcohol. Researchers have found that high blood pressure usually happens about 14.1 years before a person develops heart failure.
Heart failure happens when your heart can’t pump enough blood to meet your body’s needs. About a fourth of all heart failures are due to hypertensive heart disease. According to the Framingham Heart Study, having high blood pressure doubles a man’s chances of developing heart failure and triples a woman’s chances, taking into account other risk factors and age. The 2015 SPRINT trial showed that patients who had a lower target systolic blood pressure of 120mmHg were less likely to develop heart failure compared to patients with a target of 140mmHg (1.3% vs 2.1%). Properly managing high blood pressure was related to a 64% reduction in the chance of developing heart failure.
Risk Factors and Frequency for Hypertensive Heart Disease
Hypertension, also known as high blood pressure, is a common health problem affecting around 75 million adults in the US, which is one out of every three adults. However, only 54% of these individuals have their blood pressure under control. Globally, hypertension affects over a billion people, yet only one in five of these individuals manage their blood pressure effectively. Continued high blood pressure can lead to heart failure typically after about 14 years.
Many studies have shown a direct relationship between high blood pressure and an increased risk of heart disease, a risk that grows significantly as people age. It’s important to note that hypertension affects both men and women, although it is slightly more common in women.
- In the 45-54 age group, 36.1% of men and 33.2% of women have hypertension.
- For those aged 55-64, the rate is 57.6% in men and 55.5% in women.
- In the 65-74 age group, 63.6% of men and 65.8% of women have hypertension.
- If 75 or older, 73.4% of men and 81.2% of women have hypertension.
Women face a three times higher risk of developing heart failure due to hypertension compared to a two times risk in men. Women are also more likely to have uncontrolled blood pressure, and some blood pressure-lowering medications may not work as well in women.
Hypertension affects some ethnic groups more than others. For instance, the African American population has one of the world’s highest rates of hypertension, with 45.0% in men and 46.3% in women. By comparison, the rates in Caucasian and Hispanic populations are lower. Furthermore, African Americans tend to develop high blood pressure earlier, have a higher average pressure, and face greater difficulty treating it. All these factors pose a higher risk of death and greater health burdens.
- African American men: 45.0% have hypertension.
- African American women: 46.3% have hypertension.
- Caucasian men: 34.5% have hypertension.
- Caucasian women: 32.3% have hypertension.
- Hispanic men: 28.9% have hypertension.
- Hispanic women: 30.7% have hypertension.
Signs and Symptoms of Hypertensive Heart Disease
Hypertensive heart disease is a condition often not noticed until complications occur. People with this condition may not show symptoms, but there are several signs one should be aware of. Some might experience chest pain due to the heart requiring more oxygen or due to blockages in the arteries. Shortness of breath might also be a symptom, especially if the heart can’t perform its job properly. This condition also carries a risk of developing irregular heartbeats (atrial fibrillation), and some people may experience palpitations, dizziness, fainting or even sudden heart attacks.
People with high blood pressure are more likely to develop heart conditions, brain diseases, peripheral artery disease, aneurysms, or suffer from kidney disease. In addition to high blood pressure, certain lifestyle habits and health conditions can increase the risk of these diseases. These include high cholesterol, diabetes, alcohol and tobacco use, drug use, obesity, and conditions like kidney or lung disease. Diabetes is particularly common and is considered a high risk factor for developing heart or kidney diseases. A test called Hemoglobin A1C can be used to monitor how well diabetes is being managed. Uncontrolled symptoms or risk factors can lead to treatment-resistant hypertension, which is high blood pressure that can’t be improved with treatment.
During checkups for hypertensive heart disease, the doctor will usually listen to the heart and may notice certain sounds that indicate heart problems. These could indicate that the walls of the heart are too stiff or thin, which are both signs of heart disease. People at risk of diseases caused by artery hardening may have abnormal sounds in the neck arteries or weak pulses in the limbs. Also, checking blood pressure at each appointment is necessary, and tracking blood pressure at home is recommended.
Often overlooked, an eye examination can provide hints about the severity and duration of high blood pressure. It can reveal narrowing or hardening of the blood vessels in the retina, or bleeding, exudate (discharge), and swelling of the optic nerve. Hypertensive retinopathy, or damage to the retina caused by high blood pressure, can be assessed with a procedure called the Keith-Wagener-Barker classification.
- Grade 1 – Mild condition: slight abnormality in the blood vessels of the retina indicative of mild, symptomless hypertension
- Grade 2 – Moderate condition: noticeable narrowing or hardening with “nicking” or sclerosis present which often indicates more elevated but likely symptomless chronic hypertension
- Grade 3 – Severe condition: presents with bleeding and cotton wool spots – blood pressure is often significantly elevated and symptomatic, but damage to organs is minimal and mostly reversible
- Grade 4 – Very severe condition: additional signs include swelling of the optic nerve and retinal edema – blood pressure is continually elevated, and the patient will present symptoms like headache, change in vision, general discomfort, or difficulty in breathing. These patients need an urgent assessment and follow-up as they have a high risk of heart conditions. Anyone in Category 3 or 4 requires an immediate referral to an eye specialist to evaluate and treat retinal disease.
Testing for Hypertensive Heart Disease
When checking for hypertensive heart disease, doctors generally look for possible damage to the organs, other factors that could lead to heart disease, and reasons for high blood pressure that could be suggested by symptoms or a physical exam. Your doctor will likely screen for conditions like kidney disease, diabetes, high cholesterol, lung disease, and other related health conditions.
This is especially important in overweight men, who have a higher risk of developing sleep apnea, a condition that could interfere with sleep. A test called STOP-BANG may be used, which can help decide if a sleep apnea evaluation is necessary. Moreover, all patients are assessed using a 10-year heart disease risk calculator. This tool helps to estimate each patient’s risk of developing heart disease within the next decade and allows doctors to determine the level of treatment needed.
One of the tools doctors may use is an EKG (electrocardiogram), which gives a graphical representation of the heart’s electrical activity. It can show if the heart muscle is enlarged, if there’s a change in the direction of the electrical signal, or if there are issues with the electrical signals themselves. While EKGs are particularly good at confirming heart disease (75 to 95% specific), they are not as effective at ruling it out when the test is negative (25 to 61% sensitive).
To get a full picture, your doctor might also check for levels of sodium, potassium, calcium, and creatinine (which can indicate kidney function) in your blood, among other things. They may also perform a lipid panel (cholesterol test), a complete blood count (CBC), and a urinalysis test that includes a urine protein albumin ratio. If you have a heart condition called atrial fibrillation, your thyroid function might be checked as well.
An echocardiogram, which is a type of ultrasound scan of the heart, is not typically used for general testing of high blood pressure since the finding of left ventricular hypertrophy (or enlargement of the heart’s main pumping chamber) doesn’t really change how your doctor will manage your blood pressure. However, it may be performed in specific cases, such as in patients showing symptoms of heart failure, in younger patients under 18 years old, or in those with severe, long-term high blood pressure.
Treatment Options for Hypertensive Heart Disease
In 2017, the American Cardiology Association and American Heart Association updated their guidelines for blood pressure. They created four categories to classify blood pressure levels: normal, elevated, stage 1 hypertension (high blood pressure), and stage 2 hypertension.
Here’s what each category means:
- Normal blood pressure: Systolic (top number) is under 120 mm Hg and diastolic (bottom number) is less than 80 mm Hg.
- Elevated blood pressure: Systolic is between 120 and 129 mm Hg, but diastolic is less than 80 mm Hg.
- Stage 1 hypertension: Systolic ranges from 130 to 139 mm Hg, or diastolic is between 80 and 89 mm Hg.
- Stage 2 hypertension: Systolic is above 140 mm Hg or diastolic is 90 mm Hg or higher.
High blood pressure or hypertension is typically treated with medications that help to lower blood pressure. These include:
- Thiazide diuretics, particularly chlorthalidone. These medicines remove extra fluid from the body and are often the first choice for treating hypertension.
- Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). These are often the first line of treatment, especially for patients with diabetes or chronic kidney disease.
- Calcium channel blockers, which help relax and widen the blood vessels, are another first-line treatment option.
- Beta-blockers, which slow the heart rate and reduce the heart’s workload, but these are typically not used for treating high blood pressure alone. They are typically recommended for people with other heart conditions, like heart failure or ischemic heart disease.
- Vasodilators like hydralazine, which widen the blood vessels and are usually only added when other medications are not enough or if a patient has allergies or other reasons they can’t take the first-line medicines.
For getting hypertension under control, especially in patients with stage 2 hypertension, doctors often prescribe two or more blood pressure medications. However, they avoid using two drugs from the same class, like both an ACE inhibitor and an ARB. These patients are usually reassessed within thirty days to see how they’re responding to treatment.
A patient’s heart failure plan should be guided by their doctor’s recommendations. This is essential for ensuring a healthy heart while effectively treating high blood pressure.
What else can Hypertensive Heart Disease be?
Before diagnosing hypertensive heart disease, doctors need to ensure other causes of heart failure are not to blame. The most common cause of heart failure is ischemic cardiomyopathy, contributing to over half of all heart failure cases. So, when a patient has newly developed heart failure, doctors usually check the coronary blood flow first before diagnosing hypertensive heart disease.
The other conditions that need to be ruled out include:
- Ischemic cardiomyopathy or coronary artery disease
- Hypertrophic cardiomyopathy
- Cardiomyopathy due to other sources, such as drugs or infection
- Valve problems, like aortic stenosis
- Sleep apnea
What to expect with Hypertensive Heart Disease
Hypertensive heart disease is a long-term condition that greatly increases the risk of dying from heart-related complications. High blood pressure is a key risk factor for developing a range of heart conditions including hardening of the heart arteries, heart failure, irregular heartbeats, stroke, poor circulation in the limbs, aneurysm (when a blood vessel wall weakens and expands), and chronic kidney disease.
The overall outlook for those with hypertensive heart disease varies greatly and depends on many factors like the specific symptoms of the disease, any other existing heart conditions or risk factors, and any additional medical conditions the patient has. There are also tools available to work out whether a patient is at high or low risk of experiencing heart-related events.
Certain symptoms of hypertensive heart disease like heart failure or irregular heartbeats can greatly increase the risk of dying from heart-related causes. Patients suffering from a certain kind of heart failure, known as diastolic heart failure, face a similar level of danger as those whose hearts are not able to pump out enough blood, with the risk of dying in the 6 months following diagnosis being as high as 16%.
Possible Complications When Diagnosed with Hypertensive Heart Disease
Hypertensive heart disease is a condition linked to long-term high blood pressure. It’s a major factor that can increase the risk of serious heart diseases, so doctors monitor it closely to detect any problems early and prevent them from getting worse. When your blood pressure is high for a prolonged period, it can cause the left side of your heart to get bigger. This enlargement may eventually lead to heart failure.
Increased muscle mass in the heart can disrupt normal electrical pathways, increasing the risk of developing a condition called atrial fibrillation. This condition can lead to a stroke. Also, sudden changes in blood pressure might make you more susceptible to a condition called intracerebral hemorrhage, which is bleeding within the brain, or eye disease.
Long-term high blood pressure is a big risk factor for developing heart ailments including disease in the heart arteries, heart failure, problems with the heart valves, and atrial fibrillation. It can also increase the risk of stroke, chronic kidney disease, disease of the retina in the eye, and metabolic diseases. About half of all strokes and heart diseases related to blocked arteries are connected to long-term high blood pressure.
Health Risks of Long-term High Blood Pressure:
- Enlarged left side of the heart
- Heart failure
- Increased risk of developing atrial fibrillation
- Increased risk of stroke
- Susceptibility to bleeding within the brain
- Potential for eye disease
- Possibility of developing various heart diseases
- Risk of chronic kidney disease
- Risk of retinal disease
- Potential for metabolic diseases
Preventing Hypertensive Heart Disease
Hypertension, also known as high blood pressure, is a long-term health condition that builds up over many years. It’s vital for people with hypertension to understand the risks associated with not keeping their blood pressure levels in control. Many pharmacies and stores sell automatic blood pressure monitors that are affordable and easy to use. Doctors recommend that all patients with high blood pressure use these monitors to regularly check their levels at home.
Keeping a daily record of your blood pressure readings is particularly important if you have resistant hypertension, which means your blood pressure stays high despite treatment, or if you have several risk factors for heart disease. Regularly taking your own blood pressure helps you stay committed to maintaining healthy levels and allows you to play an active role in managing your condition.
Hypertension is the most commonly seen risk factor for heart disease that can be addressed and improved through lifestyle changes. It often occurs alongside other major risk factors. Effective management of hypertension involves spotting these risk factors and making changes to slow down the development of complications. One key part of this is looking at lifestyle habits, particularly those that can be changed.
Doctors recommend quitting smoking and reducing alcohol consumption, increasing physical activity to at least three times a week, and following a low-sodium diet where you consume less than 2 grams of salt a day. Adjusting these parts of your lifestyle, such as giving up smoking or losing weight, can provide far more benefits to your heart health than simply taking medication.
