Phenotyping the Hypertensive Heart: Key Points

Tadic M, Cuspidi C, Marwick TH.
Phenotyping the Hypertensive Heart. Eur Heart J 2022;43:3794-3810.

The following are key points to remember from this review on hypertensive heart disease (HHD):

  1. Left ventricular hypertrophy (LVH) is noted in over 40% of hypertensive patients and left ventricular diastolic dysfunction (LVDD) is present in between 40-85%. Both can show improvement with treatment, with angiotensin-converting enzyme (ACE) inhibitors being more effective for this than beta-blockers or calcium channel blockers.
  2. Improvement in LVDD with treatment for hypertension with LVH is associated with reduced risk for heart failure (HF) hospitalization. Global longitudinal strain (GLS) is an independent prognostic marker for cardiovascular (CV) morbidity and mortality in hypertensive patients.
  3. The SPRINT trial showed reduction in CV morbidity and mortality proportional to extent of hypertension control. The STEP trial replicated this in the elderly.
  4. Echocardiography is the primary imaging modality in HHD with cardiac magnetic resonance imaging (MRI) being useful in detecting infiltrative cardiomyopathies or hypertrophic cardiomyopathy when extent of LVH is disproportional.
  5. Assessment of LV mass on echocardiography is reliant on high image quality and assumptions about LV geometry that may not hold true. Concentric remodeling is the first stage of HHD and is associated with incident stroke and coronary artery disease (CAD) rather than mortality.
  6. Eccentric hypertrophy can occur in some patients and is associated with increased CV risk. Additional LV dilatation adds to this risk associated with concentric and eccentric hypertrophy in HHD.
  7. LV ejection fraction (LVEF) is preserved in a large proportion of patients with HHD until end-stage disease, as both LVEDD and stroke volume decline mitigating the effect on EF.
  8. GLS and strain pattern can be used to differentiate between physiological and pathological LVH.
  9. Blood pressure, race, and age influence myocardial function in hypertensive patients irrespective of HHD. Systolic blood pressure at the time of imaging has the most important influence on systolic parameters.
  10. LVDD is predictive of HF with preserved EF (HFpEF) in HHD, and current guidelines recommend assessment of mitral inflow by pulsed Doppler as the first step when EF is preserved. Exercise-induced LVDD is associated with CV mortality and hospitalization risk.
  11. Increased left atrial (LA) volume is a marker of HHD and an independent predictor of adverse CV events and mortality. HHD patients show decrease in LA function.
  12. Interstitial myocardial fibrosis is the main histological feature of HHD. Cardiac MRI is the gold standard for evaluation of fibrosis using late gadolinium enhancement, extracellular volume, and T1 mapping.
  13. There is a temporal relationship between HHD without CAD and ventricular arrhythmias due to change in expression and distribution of ion channels. There is no reliable phenotyping for this risk. Similarly, patients with LVH are more prone to atrial fibrillation, which in turn is associated with an increased mortality risk.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Hypertension

Keywords: Angiotensin-Converting Enzyme Inhibitors, Arrhythmias, Cardiac, Atrial Fibrillation, Blood Pressure, Cardiomyopathy, Hypertrophic, Contrast Media, Coronary Artery Disease, Diagnostic Imaging, Dilatation, Echocardiography, Fibrosis, Gadolinium, Heart Failure, Hypertension, Hypertrophy, Left Ventricular, Magnetic Resonance Imaging, Morbidity, Secondary Prevention, Stroke Volume

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