Treatment of hypertensive patients with heart failure

Jamil Mayet

Department of Cardiology and

The Peart-Rose Clinic

St Mary’s Hospital, NHLI

Imperial College, London, UK

Age-adjusted risk of congestive heart failure by hypertensive status

0

20

40

60

80

100

Ann

ual i

ncid

ence

/ 10

,000

Women Men

NormotensiveBorderlineHypertensive <140/90

>160/90

Kannel WB.Framingham

The progression from hypertension to congestive heart failure

• 5143 subjects in Framingham study• 392 new cases of clinical CCF after mean

follow up of 20 years • In 91% hypertension antedated CCF• MI present in 52% of hypertensive men and

34% of hypertensive women with CCF• Median survival after CCF diagnosis in ht

1.37 years in men and 2.48 in women

Levy et al. JAMA 1996;275:1557-62

Age-adjusted BP parameters and CHF risk

0

0.5

1

1.5

2

2.5

SBP (mmHg) DBP (mmHg) PP (mmHg)<120 120-

139140-159

>159 <70 70-79

80-89

>89 <54 54-67

>67

Hazard

Ratio

Chae et al. JAMA1999;281:634-9

Treatments that improve CCF and lower BP

• Non-pharmacological (salt restriction, exercise)

• ACE inhibitors (SOLVD, CONSENSUS)

• Beta blockers (CIBIS 2, MERIT-HF)

• Diuretics

Age-adjusted BP parameters and CHF risk

0

0.5

1

1.5

2

2.5

SBP (mmHg) DBP (mmHg) PP (mmHg)<120 120-

139140-159

>159 <70 70-79

80-89

>89 <54 54-67

>67

Hazard

Ratio

Chae et al. JAMA199;281:634-9

Arterial stiffening in hypertension

• Increased PW velocity with early wave reflection

• Increased central systolic pressure and lower diastolic pressure

• Discrepancy between central and peripheral pressures lessened

• Therefore peripheral BP underestimates central effects

Reducing arterial stiffness as a therapeutic goal

• Later wave reflection reduces peak central pressure which is caused by summation of systolic wave and reflected wave

• In periphery peak pressure is not a summation wave and so there is less of a decrease

• Reducing stiffness causes preferential decrease in central compared with peripheral pressures

Non-pharmacological approaches to reducing arterial stiffness

• Increased arterial stiffness in obese subjects with improvement following weight reduction

• Moderate aerobic exercise increases arterial compliance

• Subjects with high salt intake have better arterial distensibility than those with low intake.

• Improvement following salt restriction

Stiffnessimpact

LVregression

Outcomedata

-blockers ?+ + No

ACE-inhibitors +++ +++ No

-blockers + + Yes

-blockers ‘extra’ ++ ?? No

Ca++ antagonists +++ ++ Yes

thiazides + +/++ Yes +

Relation between vascular and LV impacts of antihypertensives

Diastolic heart failure

• Symptoms/signs of heart failure with normal or mildly impaired LV systolic function

• Prevalence depends on clinical definition of heart failure

• May be up to 30% of cases with heart failure

• Diastolic dysfunction in hypertensives is very common, particularly in those with LVH

Pathophysiology of diastolic dysfunction

• Impaired relaxation– Energy dependent and sensitive to ischaemia

• Coronary artery disease

• Microvascular ischaemia (arteriolar rarefaction, arteriole wall thickening, perivascular fibrosis, endothelial dysfunction, relative myocyte hypertrophy)

• Decreased compliance– Increase in myocardial collagen

Treatment of diastolic dysfunction

• Treat underlying cause eg coronary intervention

• Most patients are elderly and hypertensive +/- LVH– Beta blockers may improve filling by reducing heart rate

and prolonging diastole; also may reduce myocardial O2 demand and regress LVH

– Ca antagonists, particularly rate limiting, may have similar effects

• BUT VERY LITTLE FUNCTIONAL DATA

Treatment of diastolic dysfunction

• Beta blockers and Ca antagonists unlikely to be effective when restrictive physiology with raised LA pressure

• Drugs that reduce fibrosis and reduce LA pressure likely to be effective– ACEI, AII antagonists, spironolactone, diuretics

• BUT VERY LITTLE FUNCTIONAL DATA

Treatment of diastolic dysfunction

• Echo guided strategy– Impaired relaxation

• Verapamil

• Beta-blockers

– Restriction with increased LA pressure• ACEI

• AII blockers

• Diuretics (spironolactone)