What are the diagnostic steps and treatment options for hypertensive heart disease?

Diagnosis of Hypertensive Heart Disease

Hypertensive heart disease is diagnosed through a systematic evaluation that begins with a 12-lead ECG to detect left ventricular hypertrophy (LVH), followed by echocardiography when the ECG is abnormal or cardiac symptoms are present, and includes assessment of renal function and cardiovascular risk factors to identify hypertension-mediated organ damage (HMOD). 1

Initial Diagnostic Workup

Mandatory Baseline Tests

All patients with hypertension require the following initial assessments to screen for hypertensive heart disease:

• 12-lead ECG to detect LVH using Sokolow-Lyon criteria (SV1+RV5-6 >38 mm) or Cornell voltage QRS duration product (>2440 mm*ms), atrial fibrillation, and ischemic heart disease 1
• Blood tests: Sodium, potassium, serum creatinine with estimated glomerular filtration rate (eGFR), and if available, lipid profile and fasting glucose 1
• Urine dipstick test with urinary albumin/creatinine ratio to assess for proteinuria (≥30 mg/g or ≥3 mg/mmol indicates moderate-to-severe kidney damage) 1

Physical Examination Findings

Focus the cardiac examination on specific signs of hypertensive heart disease:

• Cardiac assessment: Displaced or sustained apex beat (suggests LVH), extra heart sounds (S4 gallop indicates diastolic dysfunction, S3 suggests heart failure), irregular pulse (atrial fibrillation), basal crackles (pulmonary congestion) 1
• Vascular examination: Peripheral edema, carotid/abdominal/femoral bruits, radio-femoral delay 1
• Other systems: Elevated jugular venous pressure, increased BMI/waist circumference, enlarged kidneys 1

Advanced Diagnostic Testing

Echocardiography - The Gold Standard

Echocardiography is recommended in all hypertensive patients with abnormal ECG findings, cardiac murmurs, or symptoms such as chest pain, shortness of breath, or palpitations. 1

Echocardiography is more sensitive than ECG for detecting LVH and provides superior risk stratification. 1 It should assess:

• Left ventricular mass (LVM): LVH is defined as LVM indexed to body surface area >125 g/m² in men or >110 g/m² in women 1
• Geometric patterns: Concentric LVH (increased LVM with relative wall thickness >0.42) carries the highest cardiovascular risk, followed by eccentric LVH (increased LVM with relative wall thickness ≤0.42) and concentric remodeling (normal LVM with relative wall thickness >0.42) 1
• Diastolic dysfunction: Assessed using tissue Doppler-derived early diastolic velocity (e') and E/e' ratio; E/e' ≥13 indicates elevated LV filling pressures and increased cardiac risk independent of LVM 1
• Left atrial volume index (LAVi): LAVi ≥34 mL/m² independently predicts death, heart failure, atrial fibrillation, and ischemic stroke 1
• Systolic function: Ejection fraction and longitudinal strain to detect subclinical systolic dysfunction 1

The 2024 ESC guidelines suggest that echocardiography may be considered for all newly diagnosed hypertensive patients if resources allow, as subclinical diastolic dysfunction predicts incident cardiovascular disease over 5 years of follow-up. 1

Additional Imaging When Indicated

Consider these tests based on clinical suspicion and availability:

• Cardiac CT with coronary artery calcium (CAC) scoring: Improves risk stratification beyond conventional risk factors; presence of CAC reclassifies cardiovascular risk upward or downward 1
• Carotid ultrasound: Detects atherosclerotic plaques (wall thickness ≥1.5 mm) and stenosis, which improve risk prediction for cardiovascular events 1
• Pulse wave velocity (PWV): Measures arterial stiffness; carotid-femoral or brachial-ankle PWV can assess vascular HMOD 1
• Fundoscopy: Identifies retinal changes, hemorrhages, papilledema, arteriovenous nipping, and tortuosity indicating hypertensive retinopathy 1
• Brain CT/MRI: Detects ischemic or hemorrhagic brain injury from hypertension when neurological symptoms are present 1

Biomarkers for Advanced Assessment

Emerging biomarkers can enhance diagnosis of hypertensive heart disease:

• High-sensitivity cardiac troponin and NT-proBNP: Assess for HMOD and subclinical cardiac injury 1
• Brain natriuretic peptide (BNP): Shows promise as a screening biomarker in patients with heart failure symptoms 2
• Serum propeptide of procollagen type I: Provides noninvasive quantification of myocardial interstitial fibrosis, the lesion most critically involved in transition from subclinical disease to overt heart failure 3, 2

Cardiovascular Risk Stratification

Assessment of Additional Risk Factors

More than 50% of hypertensive patients have additional cardiovascular risk factors that proportionally increase risk of coronary, cerebrovascular, and renal disease. 1 Evaluate for:

• Metabolic factors: Diabetes (15-20% prevalence), dyslipidemia (elevated LDL-C and triglycerides in 30%), obesity (40%), hyperuricemia (25%), metabolic syndrome (40%) 1
• Lifestyle factors: Smoking, high alcohol intake, sedentary lifestyle 1
• Demographics: Age >65 years, male sex, heart rate >80 bpm, family history of premature CVD or hypertension 1
• Established CVD: Previous myocardial infarction, heart failure, stroke, peripheral artery disease, atrial fibrillation 1

Symptoms Requiring Urgent Evaluation

Specific symptoms suggest advanced hypertensive heart disease or complications:

• Cardiac symptoms: Chest pain (ischemia), shortness of breath (heart failure or diastolic dysfunction), palpitations (arrhythmias), peripheral edema (heart failure) 1
• Hypertensive emergency signs: Severe headaches, blurred vision, papilledema on fundoscopy, hemorrhages and exudates 1

Common Diagnostic Pitfalls

Critical Considerations

• ECG has limited sensitivity: While ECG should be performed in all hypertensive patients, it detects LVH in only a minority of cases compared to echocardiography, which is far more sensitive for risk prediction. 1 Do not rely solely on normal ECG to exclude hypertensive heart disease.

• Diastolic dysfunction precedes systolic dysfunction: Hypertensive heart disease initially manifests as diastolic dysfunction with preserved ejection fraction, which can cause heart failure symptoms even when systolic function appears normal. 1, 4 Always assess diastolic parameters on echocardiography.

• Myocardial fibrosis is the critical lesion: The transition from subclinical hypertensive heart disease to overt heart failure is driven by myocardial interstitial fibrosis. 3 Consider biomarkers like procollagen type I propeptide for early detection, especially in high-risk patients.

• Repeat measurements for CKD: If moderate-to-severe CKD (eGFR <60 mL/min/1.73 m² or albuminuria ≥30 mg/g) is diagnosed, repeat serum creatinine, eGFR, and urine albumin/creatinine ratio at least annually. 1

• Sex-specific thresholds matter: Use sex-specific thresholds for LVH diagnosis to avoid under-diagnosis in women, as cardiac size and function differ by sex. 1

When to Escalate Diagnostic Testing

Proceed to echocardiography immediately if:

• ECG shows LVH, ischemic changes, or atrial fibrillation 1
• Patient has cardiac symptoms (chest pain, dyspnea, palpitations) 1
• Cardiac murmurs are detected on examination 1
• Patient has established cardiovascular disease or multiple risk factors 1

Consider advanced imaging (cardiac CT, carotid ultrasound, PWV) when it will change management, particularly in patients with intermediate cardiovascular risk who may benefit from risk reclassification. 1