Can Long-Standing Hypertension Cause Heart Failure?
Yes, long-standing hypertension is one of the most powerful and modifiable risk factors for developing heart failure, with 91% of heart failure patients having antecedent hypertension. 1
Epidemiological Evidence
The relationship between chronic hypertension and heart failure development is firmly established:
In the Framingham cohort, 91% of patients who developed heart failure had hypertension preceding the diagnosis, demonstrating that hypertension was a contributing cause in the vast majority of cases. 1
The hazard ratios for developing heart failure in hypertensive patients compared to normotensive patients were 2-fold higher in men and 3-fold higher in women. 1
Long-standing arterial hypertension is associated with increased cardiovascular deaths, and hypertension is the single most important predictor of coronary artery disease in uremic patients, even more so than cigarette smoking and hypertriglyceridemia. 1
Pathophysiological Mechanisms
The transition from hypertension to heart failure follows a predictable sequence:
Sustained pressure overload from chronic hypertension leads to cardiac remodeling consisting of diastolic dysfunction and concentric left ventricular hypertrophy. 2
When pressure overload is sustained, diastolic dysfunction progresses, filling of the concentrically remodeled left ventricle decreases, and heart failure with preserved ejection fraction (HFpEF) ensues. 2
The end stage of hypertensive heart disease results from combined pressure and volume overload, consisting of dilated cardiomyopathy with both diastolic dysfunction and reduced ejection fraction (HFrEF). 2
Each 10 mm Hg rise in mean arterial blood pressure is independently associated with a progressive increase of concentric left ventricular hypertrophy, development of de novo cardiac failure, and de novo ischemic heart disease. 1
Hypertension-Mediated Organ Damage
Long-standing elevated blood pressure causes structural and functional changes:
Evidence of hypertension-mediated organ damage (HMOD) usually indicates long-standing elevated blood pressure and confers incremental prognostic information regarding cardiovascular disease risk in all blood pressure categories. 1
Unless treated, HMOD can progress from asymptomatic to symptomatic, ultimately resulting in overt cardiovascular disease events. 1
Organs adversely affected include the heart, brain, kidneys, eyes, and vessels, which undergo structural and functional changes. 1
Prevention Through Blood Pressure Control
The evidence for prevention is compelling:
A meta-analysis of long-term hypertension treatment trials and large controlled studies have uniformly demonstrated that optimal blood pressure control decreases the risk of new heart failure by approximately 50%. 1
Patients with hypertension are at high risk for developing heart failure (stage A), and their blood pressure should be controlled in accordance with contemporary guidelines to lower the risk of heart failure. 1
Adequate blood pressure control can reduce cardiovascular events, including the development of heart failure. 3
Clinical Pitfalls
A critical phenomenon to recognize:
"Decapitated hypertension" is a term used to describe the decrease in blood pressure resulting from reduced pump function in heart failure, meaning that previously hypertensive patients may present with normal or low blood pressure once heart failure develops. 2
The relationship between blood pressure and cardiovascular events in dialysis patients may show a "U-shaped" curve, with excess mortality risk in patients with the lowest and highest levels of blood pressure. 1