Difference Between Hypertension and Hypertensive Heart Disease
Hypertension is simply elevated blood pressure (≥140/90 mmHg), while hypertensive heart disease represents the structural and functional cardiac damage that results from chronic, uncontrolled hypertension—specifically including left ventricular hypertrophy, myocardial fibrosis, diastolic dysfunction, and ultimately heart failure. 1, 2
Hypertension: The Blood Pressure Elevation
Hypertension is defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg, based on evidence that treatment at these values reduces cardiovascular events. 1
The condition represents a hemodynamic abnormality—elevated pressure in the arterial system—without necessarily implying organ damage has occurred yet. 1
Hypertension is graded by severity: Grade 1 (140-159/90-99 mmHg), Grade 2 (160-179/100-109 mmHg), and Grade 3 (≥180/≥110 mmHg). 1
In older adults, isolated systolic hypertension (≥140 mmHg systolic with <90 mmHg diastolic) accounts for >90% of hypertension after age 70, reflecting arterial stiffening from elastin fragmentation and collagen deposition. 2
Hypertensive Heart Disease: The Cardiac Consequences
Hypertensive heart disease encompasses the spectrum of structural and functional cardiac abnormalities that develop as direct consequences of chronic pressure overload from sustained hypertension. 2, 3, 4
Concentric left ventricular hypertrophy is the hallmark adaptation, where the ventricle thickens to normalize systolic wall stress in response to chronic pressure overload. 2, 5
The hypertrophied myocardium exhibits altered gene expression, cardiomyocyte loss, defective vascular development, and progressive myocardial fibrosis between muscle cells. 2, 6
Medium and small coronary artery remodeling occurs alongside epicardial atherosclerosis, diminishing coronary flow reserve even without obstructive coronary disease. 2
Elevated myocardial oxygen demand from increased wall tension and hypertrophy, combined with reduced coronary flow reserve, creates a supply-demand mismatch predisposing to ischemia. 2
The Clinical Progression: From Pressure to Pathology
Early hypertensive heart disease manifests as diastolic heart failure with preserved ejection fraction due to impaired active relaxation and increased passive chamber stiffness from fibrosis. 5, 7
Reduced ventricular distensibility in the hypertrophied heart makes patients highly prone to acute pulmonary edema with modest volume shifts—a condition called "flash pulmonary edema." 2, 8
Late-stage disease transitions to systolic heart failure with reduced ejection fraction, dilated left ventricular chamber, and overt heart failure symptoms. 5, 7
This progression represents a continuum from compensated hypertrophy to decompensated heart failure if hypertension remains inadequately treated. 7
Key Distinguishing Features
Hypertension alone:
- Elevated blood pressure readings on measurement 1
- May be asymptomatic or cause headaches, but no structural cardiac changes 1
- Reversible with blood pressure control before organ damage occurs 1
Hypertensive heart disease:
- Detectable left ventricular hypertrophy on ECG (Sokolow-Lyon index ≥35 mm or Cornell index >28 mm for men, >20 mm for women) or echocardiography (LVMI >115 g/m² for men, >95 g/m² for women) 1
- Symptoms of heart failure: dyspnea, exercise intolerance, fluid retention 5, 7
- Elevated cardiac biomarkers and imaging evidence of myocardial fibrosis 6
- Structural changes may be partially reversible with aggressive blood pressure control, but established fibrosis is often irreversible 4, 6
Critical Clinical Implications
Antihypertensive therapy reduces the incidence of left ventricular hypertrophy by approximately 35% and the development of heart failure by approximately 52% when initiated before structural changes become established. 2
Once hypertensive heart disease develops, the target blood pressure becomes more stringent (<130/80 mmHg) compared to uncomplicated hypertension, particularly in patients with diabetes or chronic kidney disease. 1
Thiazide-like diuretics (chlorthalidone or indapamide) combined with ACE inhibitors or angiotensin receptor blockers are first-line for preventing heart failure in hypertensive patients, showing superior efficacy for heart failure prevention. 2
Common Pitfalls to Avoid
Do not assume preserved ejection fraction means absence of heart failure—diastolic dysfunction with elevated filling pressures causes genuine heart failure symptoms requiring treatment in hypertensive heart disease. 5
Avoid excessively low diastolic blood pressure (<60 mmHg) in older adults with wide pulse pressure and coronary disease, as this may worsen myocardial ischemia by lowering coronary perfusion pressure. 2, 8
Recognize "decapitated hypertension," where blood pressure may fall as heart failure develops, potentially leading to underestimation of hypertension's role in the heart failure syndrome. 2
Prevention of hypertensive heart disease hinges on early, sustained blood pressure control to prevent left ventricular hypertrophy and diastolic dysfunction before irreversible structural changes occur. 2, 4