Hypertensive heart disease and failure
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1 Hypertensive heart disease and failure Prof. Dr. Alan Fraser Cardiff University
2 The heart in hypertension Pathophysiology of LV adaptation Regional development of hypertrophy Stress testing - inducible outflow tract obstruction - diastolic stress testing - long-axis functional reserve
3 Non-uniform systolic stress in LV wall Radius of curvature greater in septum Heng MK et al, Am Heart J 1985; 110: 84
4 Asymmetrical development of LVH in hypertension 74 untreated mild / moderate HTN vs. 34 controls Baltabaeva A European et al, Society Eur of Cardiology J Echocardiogr copyright -All right reserved 2008; 9: 501-8
5 Global and radial LV function in hypertrophy (n = 80) EF % Vs cm/s all n.s. HCM AHT Athletes Normals HCM AHT Athletes Controls Septum LVPW Vinereanu D et al, AJC 2001; 88: 53
6 Long-axis dysfunction in hypertension Vs cm/s Ve cm/s * * * * * L M A I Av * * * * * p<0.05 * HT and L M A I Av LVH Normal subjects Vinereanu D et al, Am J Cardiol 2001; 88: 53
7 Progression of LV dysfunction in hypertension LV ejection velocities fraction & deformation Radial function Longitudinal function CHF Natural history
8 Radial / circumferential left ventricular function is increased in essential hypertension Vs Midanteroseptal segment in PSAX 102 pts & 33 controls Przewlocka-Kosmala M et al, J Hum Hypertension 2006; 20:
9 Left ventricular torsion in hypertension By severity of diastolic dysfunction In hypertension, + / - diastolic dysfunction 116 patients with normal EF and diastolic dysfunction vs 32 controls Park SJ et al, JASE 2008
10 Longitudinal functional reserve Healthy control subject, aged 72 Rest (HR 56/min) Exercise (HR 101/min) 8 cm/s 15 cm/s 7 cm/s 11 cm/s ΔVs 7 cm/s ΔVe 4 cm/s courtesy of Y Tan and J Sanderson
11 Longitudinal functional reserve Dyspnoeic patient with normal EF, aged 77 Rest (HR 64/min) Exercise (HR 87/min) 6 cm/s 7 cm/s 6 cm/s 7 cm/s ΔVs 1 cm/s ΔVe 1 cm/s Supine exercise / offline analysis courtesy of Y Tan and J Sanderson
12 Longitudinal functional reserve in HFNEF 31 Patients 36 Controls Age (years) 71 ±8 70 ±7 BMI (kg/m 2 ) 29.7±4.5* 24.6±3.9 VO 2 max (ml/min/kg) 17.3±3.1* 30.9±5.9 LV EF (%) 62.4± ±7.7 LV Mass Index (g/m 2 ) 80.1± ±21.3 LA Volume Index (ml/m 2 ) 27.6± ±8.2 E/A 0.81± ±0.26 DT at rest (ms) 247±52 259±45 Diastolic LFR Index (cm/s) 1.8±1.5* 3.2±2.7 Systolic LFR Index (cm/s) 1.1±1.4* 2.1±1.3 Y Tan and J Sanderson, JACC 2009; 54: 36-46
13 Patients with heart failure & normal ejection fraction have increased LV end-diastolic diameter The Cardiovascular Health Study 499 controls, 2184 hypertensive, 167 HFNEF patients 5.2 vs 4.8 cm Maurer MS et al, J Am Coll Cardiol 2007; 49:
14 The heart in hypertension Clinical cases Untreated hypertension 1. Asymptomatic LV dysfunction 2. Dyspnoea & chest tightness on exertion 3. Acute pulmonary oedema Treated hypertension 4. Dyspnoea on exertion
15 1 Eccentric LVH in 60 year-old lady at screening central arterial stiffness not sigmoid septum, mutation- negative sigmoidal HCM, or discrete upper septal hypertrophy
16 2 Dobutamine stress in untreated hypertension
17 136 mmhg Peak stress Recovery
18 Provokable intracavitary gradients in Tako Tsubo 63 mmhg 80 mmhg 64 mmhg 70 mmhg Merli European E et Society al, of Cardiology Eur copyright J Echocardiogr -All right reserved 2006; 7: 53-61
19 3 F aged 38, new diagnosis HTN, 215/120 mmhg
20 Subclinical diastolic and systolic dysfunction E/Ve ~12 Valsalva manoeuvre APLAX
21 4 M, aged 80, hypertensive (BP 175/66 mmhg), NYHA 2b Septal thickness 1.6 cm Posterior wall thickness 1.5 cm LV diastole 5.5 cm, systole 3.6 cm Fractional shortening 35%
22 Diastolic function in hypertensive heart failure E velocity 0.75 m/s Isovolumic relaxation E deceleration time 300 ms time 150 ms
23 Lateral E 4 cm/s E/Ve = =21.4 Medial E 3 cm/s
24 75% of Ve (E ) 3.5 cm/s = 2.6, at age 80 yrs? Ve (mean) -2 cm/s AGE y MYDISE study database AGE JASE 2004;17:132 JASE 2003; 16:906
25 Evidence of diastolic dysfunction? E/E > > E/E > 8 NTproBNP > 220 NTproBNP > 220 E/E > 8 Heart failure with normal ejection fraction Paulus W et al, Eur Heart J 2007
26 Hypertensive heart disease and failure Systolic loading most affects the septum Interstitial fibrosis impairs long-axis function Radial function increases, EF maintained Long-axis systolic & diastolic function decline from subclinical dysfunction to disease Tests of functional reserve invaluable HFNEF is regional systolic dysfunction
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