module 3 chapter 1a
DESCRIPTION
E-Hypertension Academy. Module 3 chapter 1a. Cardiovascular changes in Hypertension. Introduction. Clinical squeal of hypertension include heart failure, arrhythmias, and ischemic events, especially myocardial infarction and stroke. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/1.jpg)
![Page 2: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/2.jpg)
MODULE 3 CHAPTER 1AE-Hypertension Academy
![Page 3: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/3.jpg)
CARDIOVASCULAR CHANGES IN HYPERTENSION
![Page 4: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/4.jpg)
Introduction
• Clinical squeal of hypertension include heart failure, arrhythmias, and ischemic events, especially myocardial infarction and stroke.
• Recognizing the hypertensive heart has diagnostic as well as prognostic implications.
![Page 5: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/5.jpg)
Hypertensive heart disease (HHD) The Sequel
• Heart failure: reduced EF as well as Preserved EF• The link between HHD and atrial fibrillation, whose
likelihood increases by 40% to 50% in the presence of hypertension
• Ventricular arrhythmias occur more frequently in hypertensive patients , with QT dispersion increasing directly with left ventricular (LV) mass
• Increased susceptibility to ischemic heart disease rounds out the cardiovascular squeal of HHD, with a 6-fold higher risk of myocardial infarction in hypertensive patients than in normotensive individuals
![Page 6: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/6.jpg)
• Cardiomyocyte hypertrophy is but one of many structural alterations in HHD
• Fibroblasts undergo hyperplasia and conversion to myofibroblasts, along with hypertrophy of vascular smooth muscle cells.
• Noncellular elements central to myocardial remodeling in HHD include expansion of interstitial and perivascular collagen that make up the extracellular matrix.
• Changes in intramyocardial capillary density and arteriolar thickening compound ischemia in the hearts of patients with hypertension
Hypertensive heart disease (HHD) The structural remodeling
![Page 7: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/7.jpg)
• A common end point of many cellular and non cellular pathologic processes in HHD is myocardial fibrosis.
• Fibrosis quantification in endomyocardial samples obtained via transjugular biopsy showed significantly greater collagen volume fraction in patients with hypertension than in normotensive controls
Hypertensive heart disease (HHD) The myocardial fibrosis
![Page 8: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/8.jpg)
• Concentric left-ventricular hypertrophy, when a pressure load leads to growth in cardiomyocyte thickness
• Eccentric hypertrophy, when a volume load produces myocyte lengthening;
LVH
![Page 9: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/9.jpg)
![Page 10: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/10.jpg)
Picture from Atlas of the Heart Hurst JW et al eds. New York:Lippencot,1988.
• Left ventricular hypertrophy (LVH) is a condition wherein the cardiac muscle responds to increased resistance in the circulation by becoming enlarged
• Fibers of the hypertrophied heart muscle become thickened and shortened, and consequently less able to relax. The outcome of this process is a heart that is less able to meet the output demands of normal circulation.
LVH
![Page 11: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/11.jpg)
Reactive increase in left ventricular mass in response to an increased workload
Lorell, Carabello. Circulation 2000;102:470–479Verdecchia et al. J Am Coll Cardiol 2001;38:1829–1835
Concentric Hypertrophy due to Persistent pressure overload
Atherosclerosis
Concentric Hypertrophy due to Persistent pressure overload
Atherosclerosis
Eccentric hypertrophy due to Na + and H2O retention
Eccentric hypertrophy due to Na + and H2O retention
Myocyte elongation Normal ratio of wall thickness to
dimension
Myocyte elongation Normal ratio of wall thickness to
dimension
Cellular hypertrophyInduction of cellular proto- oncogenes
Increased ratio of wall thicknessto dimension
Cellular hypertrophyInduction of cellular proto- oncogenes
Increased ratio of wall thicknessto dimension
Left Ventricular Hypertrophy
![Page 12: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/12.jpg)
0
20
40
60
80
100
120
Stroke Heart failure Coronary disease
2-y
ea
r a
ge
-ad
jus
ted
in
cid
en
ce
(p
er
10
0 p
ati
en
ts)
Hypertension
Hypertension + LVH
LVH is an independent risk factor for stroke, heart failure
and Coronary Heart Disease
![Page 13: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/13.jpg)
• Echocardiography can be used to estimate both Left ventricular mass and volume
• Since the two-dimensional images contain cross-sectional data, volume may be estimated from the short and long axes in systole or diastole
LV MASS INDEX : 115gms/m2 in men 95 gms/m2 in womenESC 2013
![Page 14: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/14.jpg)
LVH – Measurement by Echo
• Calculation of LV Mass (LVM) is currently performed according to the American Society of Echocardiography formula
• Relative wall thickness (RWT) or the wall-to-radius ratio (2 x posterior wall thickness/end diastolic diameter) categorizes geometry (concentric or eccentric)
![Page 15: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/15.jpg)
Three types of LVH
• Concentric : RWT and LVM increased• Eccentric: RWT normal LVM increased• Concentric remodeling: RWT increased LVM
normal• Concentric LVH is the strongest predictor of
increased risk
![Page 16: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/16.jpg)
Left Atrium• As witness to chronically elevated LV filling pressures,
left atrial enlargement is a reliable marker of diastolic dysfunction in the absence of mitral valve disease
• The correlation between left atrial volume and brain natriuretic peptide levels further underscores its role as sentinel in heart failure with preserved ejection fraction
• LA volumes not only predict future HF especially HFPEF but also atrial fibrillation
• Normal LA volume index is less than 22ml/m2
![Page 17: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/17.jpg)
ESC 2013
![Page 18: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/18.jpg)
• Microvascular disease and endothelial dysfunction are apparent in hypertensive heart disease
• Progressive impairment of flow-mediated vasodilation happens as LV mass increased, consistent with the previously described ultra structural remodeling of myocardial micro vessels
• This explains increased frequency of hypertension in patients with chest pain, angiographically normal coronary arteries, and subendocardial ischemia on perfusion imaging
Hypertensive Heart Disease (HHD) Vascular and other changes
![Page 19: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/19.jpg)
Hypertensive heart disease (HHD) Vascular and other changes
• At the macrovascular level, increased arterial stiffness often seen in long-standing hypertension accelerates aortic pulse wave velocity .
• This, in turn, results in earlier return of the wave reflected at the iliac bifurcation in systole, increasing LV afterload and central pulse pressure.
• The concomitant fall in central diastolic blood pressure decreases coronary perfusion, further contributing to myocardial ischemia
![Page 20: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/20.jpg)
Pulse Wave Velocity
• Carotid-femoral PWV is the ‘gold standard’ for measuring aortic stiffness .
• Although the relationship between aortic stiffness and events is continuous, a threshold of >10 m/s has been suggested as a conservative estimate of significant alterations of aortic function in middle-aged hypertensive patients
![Page 21: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/21.jpg)
Ankle-Brachial Index (ABI)
• Ankle-brachial index (ABI) can be measured either with automated devices, or with a continuous-wave Doppler
• Unit and a BP Sphygmomanometer. • A low ABI (i.e. <0.9 signals PAD and, in general,
advanced atherosclerosis, has predictive value for CV events , and was associated with approximately twice the 10-year CV mortality and major coronary event rate, compared with the overall rate in each Framingham category
![Page 22: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/22.jpg)
Carotid Arteries
• Ultrasound examination of the carotid arteries with measurement of intima media thickness (IMT) and/or the presence of plaques has been shown to predict the occurrence of both stroke and myocardial infarction independently of traditional CV risk factors
• Carotid IMT >0.9mm has been taken as a conservative estimate of existing abnormalities
![Page 23: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/23.jpg)
Fundoscopy
• Grade III (retinal haemorrhages, microaneurysms, hard exudates, cotton wool spots) and grade IV retinopathy (grade III signs and papilloedema and/or macular oedema) are indicative of severe hypertensive retinopathy, with a high predictive value for mortality
![Page 24: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/24.jpg)
Kidney• The diagnosis of hypertension-induced renal damage is based on the
finding of a reduced renal function and/or the detection of elevated urinary excretion of albumin
• Once detected, CKD is classified according to eGFR, calculated by the abbreviated ‘modification of diet in renal disease’ (MDRD) formula [208], the Cockcroft-Gault formula or, more recently, through the Chronic Kidney Disease EPIdemiology Collaboration (CKD-EPI) formula
• When eGFR is below 60 mL/min/1.73m2, it predicts not only future kidney disease but also future CVD
• Therefore it is recommended, in all hypertensive patients, that eGFR be estimated and that a test for microalbuminuria be made on a spot urine sample
![Page 25: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/25.jpg)
Brain
• Hypertension, beyond its well known effect on the occurrence of clinical stroke, is also associated with the risk of asymptomatic brain damage noticed on cerebral MRI, in particular in elderly individuals
• White matter hyperintensities and silent infarcts are associated with an increased risk of stroke, cognitive decline and dementia
• In hypertensive patients without overt CVD, MRI showed that silent cerebrovascular lesions are even more prevalent (44%) than cardiac (21%) and renal (26%) subclinical damage and do frequently occur in the absence of other signs of organ damage
![Page 26: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/26.jpg)
ESC 2013
![Page 27: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/27.jpg)
Investigations (ESC 2013)
![Page 28: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/28.jpg)
Investigations (ESC 2013)
![Page 29: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/29.jpg)
ESC 2013
![Page 30: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/30.jpg)
Summary
![Page 31: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/31.jpg)
Conclusion
• Detection of earliest cardiovascular changes in asymptomatic hypertensives and appropiriate management will prevent future CVD and kidney disease.
![Page 32: Module 3 chapter 1a](https://reader037.vdocuments.mx/reader037/viewer/2022102818/56812a9b550346895d8e51c1/html5/thumbnails/32.jpg)
END OF MODULE 3 CHAPTER 1A