Hypertensive Heart Disease

Hypertensive heart disease encompasses various complications of high blood pressure that impact the heart. While definitions vary in medical literature, the term is often used within the context of the International Classification of Diseases (ICD). The definition includes heart failure and other cardiac complications of hypertension when a causal relationship is indicated. In 2013, hypertensive heart disease resulted in 1.07 million deaths, up from 630,000 in 1990.

According to ICD-10, hypertensive heart disease (I11) and its subcategories—hypertensive heart disease with heart failure (I11.0) and without heart failure (I11.9)—are differentiated from chronic rheumatic heart diseases (I05-I09), other heart diseases (I30-I52), and ischaemic heart diseases (I20-I25). However, since high blood pressure is a risk factor for atherosclerosis and ischaemic heart disease, death rates from hypertensive heart disease provide an incomplete measure of the burden of disease due to high blood pressure.

Signs and Symptoms

The symptoms of hypertensive heart disease depend on whether heart failure is present. In the absence of heart failure, hypertension, with or without left ventricular hypertrophy, is typically symptomless.

Symptoms and signs of congestive heart failure include:

• Fatigue
• Irregular pulse or palpitations
• Swelling of feet and ankles
• Weight gain
• Nausea
• Shortness of breath
• Difficulty sleeping flat (orthopnea)
• Bloating and abdominal pain
• Increased urination at night
• Enlarged heart (cardiomegaly)
• Left ventricular hypertrophy and left ventricular remodelling
• Diminished coronary flow reserve and silent myocardial ischaemia
• Coronary heart disease and accelerated atherosclerosis
• Heart failure with normal left ventricular ejection fraction (HFNEF), often termed diastolic heart failure
• Atrial fibrillation and other cardiac arrhythmias or sudden cardiac death

Heart failure can develop insidiously or present acutely due to sudden pump failure of the heart, precipitated by myocardial ischaemia, marked increases in blood pressure, or cardiac arrhythmias.

Diagnosis

Stages of Elevated BP and Hypertension

Category	Systolic BP (mm Hg)	Diastolic BP (mm Hg)
Normal	< 120	< 80
Elevated	120–129	< 80
Stage I	130–139	80–89
Stage II	≥ 140	≥ 90

Differential Diagnosis

Conditions that share features with hypertensive heart disease include:

• Coronary artery disease or ischaemic heart diseases due to atherosclerosis
• Hypertrophic cardiomyopathy
• Left ventricular hypertrophy in athletes
• Congestive heart failure due to other causes
• Atrial fibrillation or other cardiac rhythm disorders due to other causes
• Sleep apnoea

Prevention

Early diagnosis of high blood pressure can prevent heart disease, stroke, eye problems, and chronic kidney disease. Lifestyle modifications such as dietary changes, weight loss, regular aerobic exercise, moderation of alcohol intake, and smoking cessation can reduce cardiovascular risk. Drug treatment may be necessary to control hypertension, manage heart failure, or control cardiac arrhythmias. Patients should avoid over-the-counter NSAIDs, cough suppressants, and decongestants containing sympathomimetics unless advised by a physician, as these can exacerbate hypertension and heart failure.

Blood Pressure Goals

According to JNC 7, BP goals should be:

• Less than 140/90 mm Hg in patients with uncomplicated hypertension
• Less than 130/85 mm Hg in patients with diabetes or renal disease with less than 1 g/24-hour proteinuria
• Less than 125/75 mm Hg in patients with renal disease and more than 1 g/24-hour proteinuria

Treatment

The medical care of patients with hypertensive heart disease involves:

• Treatment of hypertension
• Prevention and treatment of heart failure or other cardiovascular diseases

Epidemiology

Hypertension affects at least 26.4% of the world's population. Hypertensive heart disease is one of several diseases attributable to high blood pressure, including ischaemic heart disease, cancer, stroke, peripheral arterial disease, aneurysms, and kidney disease. Hypertension increases the risk of heart failure by two to three-fold and accounts for about 25% of all heart failure cases. It precedes heart failure in 90% of cases, with most heart failure in the elderly attributable to hypertension. Hypertensive heart disease was estimated to cause 1.0 million deaths globally in 2004, accounting for approximately 1.7% of all deaths.

Sex Differences

More women than men have hypertension, and although men develop hypertension earlier, it is less well controlled in women. Hypertension is a significant factor in heart attacks in women. Women have been under-represented in clinical trials for hypertension and heart failure, but evidence suggests that the effectiveness of antihypertensive drugs and heart failure treatments may vary between sexes.

Ethnic Differences

In the US, a disproportionate number of African Americans have hypertension compared to non-Hispanic whites and Mexican Americans. They also bear a greater burden of hypertensive heart disease, with higher rates of heart failure and mortality. Hypertension rates are increasing more rapidly in African Americans, contributing to their shorter life expectancy compared to white Americans.

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Self-assessment MCQs (single best answer)

What is hypertensive heart disease primarily associated with?

Which of the following is NOT a symptom of hypertensive heart disease with heart failure?

What is the systolic blood pressure range for Stage I hypertension according to the table provided?

Which of the following is a potential condition that shares features with hypertensive heart disease?

What is the blood pressure goal for patients with diabetes or renal disease with less than 1 g/24-hour proteinuria?

According to the ICD-10 classification, which code represents hypertensive heart disease?

What is the primary method for preventing hypertensive heart disease?

In what year did hypertensive heart disease result in 1.07 million deaths?

Which population group in the US has the highest burden of hypertensive heart disease?

What percentage of the world's population is affected by hypertension?