What are the risks of uncontrolled hypertension in a patient with laryngitis who may have underlying cardiovascular disease?

Risks of Uncontrolled Hypertension

Uncontrolled hypertension approximately doubles the risk of cardiovascular disease events, including stroke, myocardial infarction, heart failure, and cardiovascular death, with the risk increasing continuously starting at blood pressure levels as low as 115/75 mm Hg. 1, 2, 3

Cardiovascular Disease Risk

The relationship between elevated blood pressure and cardiovascular events is continuous and graded—each 10 mm Hg rise in mean arterial blood pressure independently increases the risk of concentric left ventricular hypertrophy, new-onset heart failure, and ischemic heart disease. 4

• Adults with stage 1 hypertension (BP 130-139/80-89 mm Hg) have approximately a 2-fold increase in cardiovascular disease risk compared with adults with normal blood pressure 1
• The absolute risk increase per mmHg is greater at higher blood pressures, meaning even modest reductions of severe hypertension provide substantial benefit 2, 3
• Elevated systolic or diastolic pressure causes increased cardiovascular risk across all populations 2, 3

Specific Organ System Complications

Stroke Risk

The largest and most consistent cardiovascular outcome associated with uncontrolled hypertension is stroke, with blood pressure reduction providing the greatest relative risk reduction for cerebrovascular events. 2, 3, 5

• Reductions in myocardial infarction and cardiovascular mortality are also seen regularly with blood pressure control 2, 3
• Catastrophic events such as stroke typically occur after long periods of uncontrolled hypertension 5

Heart Failure Development

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. 4

• Hypertensive patients have a 2-fold higher hazard ratio for developing heart failure in men and 3-fold higher in women compared to normotensive patients 4
• Optimal blood pressure control decreases the risk of new heart failure by approximately 50% 4
• Progressive concentric left ventricular hypertrophy develops with sustained elevated blood pressure 4

Renal Complications

Uncontrolled hypertension leads to chronic kidney disease, end-stage renal disease, and progressive renal dysfunction. 6, 5

• Microalbuminuria develops early in the course of hypertensive cardiovascular disease 5
• Hypertension is the single most important predictor of coronary artery disease in uremic patients, even more so than cigarette smoking and hypertriglyceridemia 4

Additional Target Organ Damage

Hypertension-mediated organ damage (HMOD) indicates long-standing elevated blood pressure and confers incremental prognostic information regarding cardiovascular disease risk in all blood pressure categories. 4

• Organs adversely affected include the heart, brain, kidneys, eyes, and vessels, which undergo structural and functional changes 4
• Unless treated, HMOD progresses from asymptomatic to symptomatic, ultimately resulting in overt cardiovascular disease events 4
• Subtle target-organ damage such as left-ventricular hypertrophy, microalbuminuria, and cognitive dysfunction occurs early 5
• Dementia and cognitive decline develop after long periods of uncontrolled hypertension 5

Resistant Hypertension: Highest Risk Population

Patients with resistant hypertension (uncontrolled BP on ≥3 medications or controlled BP on ≥4 medications) have a 47% higher risk of cardiovascular disease mortality compared to non-resistant hypertension. 7

• Resistant hypertension affects approximately 7.6 million Americans 7
• The prognosis is particularly impaired as these patients typically present with long-standing poorly controlled hypertension and commonly have associated cardiovascular risk factors such as diabetes, obstructive sleep apnea, left ventricular hypertrophy, and chronic kidney disease 1
• Even controlled resistant hypertension (BP <140/90 mm Hg on ≥4 medications) carries a 66% increased risk of cardiovascular death 7
• Clinical trials suggest resistant hypertension involves 20% to 30% of treated hypertensive patients 1

Risk Amplification with Comorbidities

Individuals with high underlying cardiovascular risk—including those with established atherosclerotic disease, diabetes mellitus, chronic kidney disease, or multiple cardiovascular risk factors—have the greatest absolute risk of new cardiovascular events attributable to uncontrolled hypertension. 1

• More than 50% of hypertensive patients have additional cardiovascular risk factors that proportionally increase their risk of coronary, cerebrovascular, and renal disease 8
• The absolute benefit of blood pressure reduction is greater in patients at higher risk independent of their hypertension (such as those with diabetes or hyperlipidemia) 2, 3
• Hypertension commonly clusters with other cardiovascular risk factors including aging, obesity, insulin resistance, diabetes, and hyperlipidemia 5

Clinical Context for Laryngitis with Underlying Cardiovascular Disease

In a patient with laryngitis who may have underlying cardiovascular disease, uncontrolled hypertension poses immediate and long-term risks that warrant careful blood pressure management during acute illness. 1

• The cardiovascular risk is undoubtedly increased in patients with a history of long-standing, severe hypertension complicated by multiple other cardiovascular risk factors 1
• Patients with established cardiovascular disease require blood pressure targets of at least <140/90 mm Hg, with consideration for more aggressive targets of <130/80 mm Hg in high-risk patients 1
• Acute illness can precipitate cardiovascular events in patients with poorly controlled hypertension and underlying cardiovascular disease 1