Hypertensive Heart Disease: Definition
Hypertensive heart disease (HHD) is the spectrum of cardiac structural and functional abnormalities that develop as a consequence of chronic uncontrolled hypertension, ranging from asymptomatic left ventricular hypertrophy to overt heart failure. 1, 2
Pathophysiological Spectrum
HHD encompasses a progressive continuum of cardiac changes resulting from sustained pressure overload:
- Initial compensatory phase: Concentric left ventricular hypertrophy (LVH) develops to normalize systolic wall stress in response to chronic pressure overload 1, 3
- Intermediate structural changes: Diastolic dysfunction emerges alongside continued LVH, accompanied by alterations in gene expression, cardiomyocyte loss, defective vascular development, and myocardial fibrosis 1, 2
- Advanced disease: Progressive contractile dysfunction leads to either heart failure with preserved ejection fraction (HFpEF) when concentric remodeling predominates, or dilated cardiomyopathy with reduced ejection fraction when both pressure and volume overload occur 1, 3
Clinical Manifestations
The disease presents across a broad clinical spectrum:
- Asymptomatic stage: Isolated LVH detected on imaging without symptoms, representing the most common early manifestation 2
- Symptomatic heart failure: Either HFpEF (most common cardiac complication of hypertension) or heart failure with reduced ejection fraction in end-stage disease 1, 3
- Cardiac arrhythmias: Both supraventricular (particularly atrial fibrillation) and ventricular arrhythmias occur, especially in patients with LVH 2, 4, 5
- "Decapitated hypertension": Blood pressure paradoxically decreases as pump function deteriorates in advanced HF, potentially underestimating hypertension's contribution to the syndrome 3
Epidemiological Significance
HHD represents a major public health burden:
- Prevalence: In the Framingham Heart Study, hypertension accounted for 39% of heart failure cases in men and 59% in women 1
- Risk magnitude: LVH is an independent cardiovascular risk factor as potent as age or systolic blood pressure in predicting myocardial infarction, stroke, sudden death, or heart failure 1
- Population impact: Among patients hospitalized with heart failure, 75% had hypertension, with most having systolic blood pressures ≥140 mmHg 1
Key Clinical Pitfall
Heart failure symptoms are rare in hypertensive individuals whose blood pressure is well controlled and who have not sustained a myocardial infarction, emphasizing the critical importance of early and sustained blood pressure control to prevent progression to HHD 1