What is hypertensive heart disease

Hypertensive heart disease refers to heart problems that occur because of high blood pressure that is present over a long time. High blood pressure also called hypertension, means the pressure inside the blood vessels (called arteries) is too high. As the heart pumps against this pressure, it must work harder. Over time, this causes the heart muscle to thicken. Patients with longstanding hypertension are at increased risk for developing left ventricular hypertrophy (LVH) and diastolic dysfunction ¹.

Because there are often no symptoms with high blood pressure, people can have the problem without knowing it. Symptoms most often do not occur until after many years of poor blood pressure control, when damage to the heart has occurred.

In general, the heart problems associated with high blood pressure relate to the heart’s arteries and muscles.

The types of hypertensive heart disease include:

• Narrowing of the arteries: Coronary arteries transport blood to your heart muscle. When high blood pressure causes the blood vessels to become narrow, blood flow to the heart can slow or stop. This condition is known as coronary heart disease also called coronary artery disease. Coronary heart disease makes it difficult for your heart to function and supply the rest of your organs with blood. It can put you at risk for heart attack from a blood clot that gets stuck in one of the narrowed arteries and cuts off blood flow to your heart.
• Thickening and enlargement of the heart: High blood pressure makes it difficult for your heart to pump blood. Like other muscles in your body, regular hard work causes your heart muscles to thicken and grow. This alters the way the heart functions. These changes usually happen in the main pumping chamber of the heart, the left ventricle. The condition is known as left ventricular hypertrophy (LVH). Sometimes, the heart muscle can be so thick that it does not get enough oxygen. This can cause angina (chest pain).

Coronary heart disease can cause left ventricular hypertrophy (LVH) and vice versa. When you have coronary heart disease, your heart must work harder. If left ventricular hypertrophy (LVH) enlarges your heart, it can compress the coronary arteries.

Without treatment of high blood pressure, symptoms of heart failure may develop.

High blood pressure also leads to thickening of the blood vessel walls. When combined with cholesterol deposits in the blood vessels, the risk of heart attack and stroke increases.

Hypertensive heart disease is the leading cause of heart attack, stroke, heart failure and sudden death from high blood pressure. According to the Framingham Study, hypertension accounts for about one quarter of heart failure cases ². In the elderly population, as many as 68% of heart failure cases are attributed to hypertension ³. Community-based studies have demonstrated that hypertension may contribute to the development of heart failure in as many as 50-60% of patients. In patients with hypertension, the risk of heart failure is increased by 2-fold in men and by 3-fold in women.

Hypertensive heart disease causes

There are two types of high blood pressure.

Primary (essential) hypertension

For most adults, there’s no identifiable cause of high blood pressure. This type of high blood pressure, called primary (essential) hypertension, tends to develop gradually over many years. Primary (essential) hypertension accounts for 90% of cases of hypertension in adults.

Secondary hypertension

Some people have high blood pressure caused by an underlying condition. This type of high blood pressure, called secondary hypertension, tends to appear suddenly and cause higher blood pressure than does primary hypertension. Various conditions and medications can lead to secondary hypertension, including:

• Obstructive sleep apnea
• Kidney problems
• Adrenal gland tumors
• Thyroid problems
• Certain defects you’re born with (congenital) in blood vessels
• Certain medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain relievers and some prescription drugs
• Illegal drugs, such as cocaine and amphetamines

Risk factors for hypertensive heart disease

High blood pressure has many risk factors, including:

• Age. The risk of high blood pressure increases as you age. Until about age 64, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65.
• Race. High blood pressure is particularly common among people of African heritage, often developing at an earlier age than it does in whites. Serious complications, such as stroke, heart attack and kidney failure, also are more common in people of African heritage.
• Family history. High blood pressure tends to run in families.
• Being overweight or obese. The more you weigh the more blood you need to supply oxygen and nutrients to your tissues. As the volume of blood circulated through your blood vessels increases, so does the pressure on your artery walls.
• Not being physically active. People who are inactive tend to have higher heart rates. The higher your heart rate, the harder your heart must work with each contraction and the stronger the force on your arteries. Lack of physical activity also increases the risk of being overweight.
• Using tobacco. Not only does smoking or chewing tobacco immediately raise your blood pressure temporarily, but the chemicals in tobacco can damage the lining of your artery walls. This can cause your arteries to narrow and increase your risk of heart disease. Secondhand smoke also can increase your heart disease risk.
• Too much salt (sodium) in your diet. Too much sodium in your diet can cause your body to retain fluid, which increases blood pressure.
• Too little potassium in your diet. Potassium helps balance the amount of sodium in your cells. If you don’t get enough potassium in your diet or retain enough potassium, you may accumulate too much sodium in your blood.
• Drinking too much alcohol. Over time, heavy drinking can damage your heart. Having more than one drink a day for women and more than two drinks a day for men may affect your blood pressure. If you drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women and two drinks a day for men. One drink equals 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.
• Stress. High levels of stress can lead to a temporary increase in blood pressure. If you try to relax by eating more, using tobacco or drinking alcohol, you may only increase problems with high blood pressure.
• Certain chronic conditions. Certain chronic conditions also may increase your risk of high blood pressure, such as kidney disease, diabetes and sleep apnea.

Sometimes pregnancy contributes to high blood pressure, as well.

Although high blood pressure is most common in adults, children may be at risk, too. For some children, high blood pressure is caused by problems with the kidneys or heart. But for a growing number of kids, poor lifestyle habits, such as an unhealthy diet, obesity and lack of exercise, contribute to high blood pressure.

Hypertensive heart disease prevention

Diagnosing high blood pressure early can help prevent heart disease, stroke, eye problems, and chronic kidney disease.

All adults over the age of 18 should have their blood pressure checked every year. More frequent measurement may be needed for those with a history of high blood pressure readings or those with risk factors for high blood pressure.

Hypertensive heart disease symptoms

Most people with high blood pressure have no signs or symptoms, even if blood pressure readings reach dangerously high levels.

A few people with high blood pressure may have headaches, shortness of breath or nosebleeds, but these signs and symptoms aren’t specific and usually don’t occur until high blood pressure has reached a severe or life-threatening stage.

The excessive pressure on your artery walls caused by high blood pressure can damage your blood vessels, as well as organs in your body. The higher your blood pressure and the longer it goes uncontrolled, the greater the damage.

Uncontrolled high blood pressure can lead to complications including:

• Heart attack or stroke. High blood pressure can cause hardening and thickening of the arteries (atherosclerosis), which can lead to a heart attack, stroke or other complications.
• Aneurysm. Increased blood pressure can cause your blood vessels to weaken and bulge, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.
• Heart failure. To pump blood against the higher pressure in your vessels, the heart has to work harder. This causes the walls of the heart’s pumping chamber to thicken (left ventricular hypertrophy). Eventually, the thickened muscle may have a hard time pumping enough blood to meet your body’s needs, which can lead to heart failure.
• Weakened and narrowed blood vessels in your kidneys. This can prevent these organs from functioning normally.
• Thickened, narrowed or torn blood vessels in the eyes. This can result in vision loss.
• Metabolic syndrome. This syndrome is a cluster of disorders of your body’s metabolism, including increased waist circumference; high triglycerides; low high-density lipoprotein (HDL) cholesterol, the “good” cholesterol; high blood pressure and high insulin levels. These conditions make you more likely to develop diabetes, heart disease and stroke.
• Trouble with memory or understanding. Uncontrolled high blood pressure may also affect your ability to think, remember and learn. Trouble with memory or understanding concepts is more common in people with high blood pressure.
• Dementia. Narrowed or blocked arteries can limit blood flow to the brain, leading to a certain type of dementia (vascular dementia). A stroke that interrupts blood flow to the brain also can cause vascular dementia.

Hypertensive heart disease diagnosis

To measure your blood pressure, your doctor or a specialist will usually place an inflatable arm cuff around your arm and measure your blood pressure using a pressure-measuring gauge.

A blood pressure reading, given in millimeters of mercury (mm Hg), has two numbers. The first, or upper, number measures the pressure in your arteries when your heart beats (systolic pressure). The second, or lower, number measures the pressure in your arteries between beats (diastolic pressure).

Blood pressure measurements fall into four general categories:

• Normal blood pressure. Your blood pressure is normal if it’s below 120/80 mm Hg.
• Elevated blood pressure. Elevated blood pressure is a systolic pressure ranging from 120 to 129 mm Hg and a diastolic pressure below 80 mm Hg. Elevated blood pressure tends to get worse over time unless steps are taken to control blood pressure.
• Stage 1 hypertension. Stage 1 hypertension is a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg.
• Stage 2 hypertension. More severe hypertension, stage 2 hypertension is a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.

Figure 1. Blood pressure levels

Both numbers in a blood pressure reading are important. But after age 50, the systolic reading is even more significant. Isolated systolic hypertension is a condition in which the diastolic pressure is normal (less than 80 mm Hg) but systolic pressure is high (greater than or equal to 130 mm Hg). This is a common type of high blood pressure among people older than 65.

Your doctor will likely take two to three blood pressure readings each at three or more separate appointments before diagnosing you with high blood pressure. This is because blood pressure normally varies throughout the day, and it may be elevated during visits to the doctor (white coat hypertension).

Your blood pressure generally should be measured in both arms to determine if there is a difference. It’s important to use an appropriate-sized arm cuff.

Your doctor may ask you to record your blood pressure at home to provide additional information and confirm if you have high blood pressure.

Your doctor may recommend a 24-hour blood pressure monitoring test called ambulatory blood pressure monitoring to confirm if you have high blood pressure. The device used for this test measures your blood pressure at regular intervals over a 24-hour period and provides a more accurate picture of blood pressure changes over an average day and night. However, these devices aren’t available in all medical centers, and they may not be reimbursed.

If you have any type of high blood pressure, your doctor will review your medical history and conduct a physical examination.

Your doctor may also recommend routine tests, such as a urine test (urinalysis), blood tests, a cholesterol test and an electrocardiogram — a test that measures your heart’s electrical activity. Your doctor may also recommend additional tests, such as an echocardiogram, to check for more signs of heart disease.

Taking your blood pressure at home

An important way to check if your blood pressure treatment is working, to confirm if you have high blood pressure, or to diagnose worsening high blood pressure, is to monitor your blood pressure at home.

Home blood pressure monitors are widely available and inexpensive, and you don’t need a prescription to buy one. Home blood pressure monitoring isn’t a substitute for visits to your doctor, and home blood pressure monitors may have some limitations.

Make sure to use a validated device, and check that the cuff fits. Bring the monitor with you to your doctor’s office to check its accuracy once a year. Talk to your doctor about how to get started with checking your blood pressure at home.

Devices that measure your blood pressure at your wrist or finger aren’t recommended by the American Heart Association.

Hypertensive heart disease treatment

If your blood pressure is high, you need to lower it and keep it under control.

Changing your lifestyle can go a long way toward controlling high blood pressure. Your doctor may recommend you make lifestyle changes including:

• Eating a heart-healthy diet with less salt
• Getting regular physical activity
• Maintaining a healthy weight or losing weight if you’re overweight or obese
• Limiting the amount of alcohol you drink

But sometimes lifestyle changes aren’t enough. In addition to diet and exercise, your doctor may recommend medication to lower your blood pressure.

Your blood pressure treatment goal depends on how healthy you are.

Your blood pressure treatment goal should be less than 130/80 mm Hg if:

• You’re a healthy adult age 65 or older
• You’re a healthy adult younger than age 65 with a 10 percent or higher risk of developing cardiovascular disease in the next 10 years
• You have chronic kidney disease, diabetes or coronary artery disease

Although 120/80 mm Hg or lower is the ideal blood pressure goal, doctors are unsure if you need treatment (medications) to reach that level.

If you’re age 65 or older, and use of medications produces lower systolic blood pressure (such as less than 130 mm Hg), your medications won’t need to be changed unless they cause negative effects to your health or quality of life.

The category of medication your doctor prescribes depends on your blood pressure measurements and your other medical problems. It’s helpful if you work together with a team of medical professionals experienced in providing treatment for high blood pressure to develop an individualized treatment plan.

Medications to treat high blood pressure

• Thiazide diuretics. Diuretics, sometimes called water pills, are medications that act on your kidneys to help your body eliminate sodium and water, reducing blood volume. Thiazide diuretics are often the first, but not the only, choice in high blood pressure medications. Thiazide diuretics include chlorthalidone, hydrochlorothiazide (Microzide) and others. If you’re not taking a diuretic and your blood pressure remains high, talk to your doctor about adding one or replacing a drug you currently take with a diuretic. Diuretics or calcium channel blockers may work better for people of African heritage and older people than do angiotensin-converting enzyme (ACE) inhibitors alone. A common side effect of diuretics is increased urination.
• Angiotensin-converting enzyme (ACE) inhibitors. These medications — such as lisinopril (Zestril), benazepril (Lotensin), captopril (Capoten) and others — help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels. People with chronic kidney disease may benefit from having an ACE inhibitor as one of their medications.
• Angiotensin 2 receptor blockers (ARBs). These medications help relax blood vessels by blocking the action, not the formation, of a natural chemical that narrows blood vessels. Angiotensin 2 receptor blockers include candesartan (Atacand), losartan (Cozaar) and others. People with chronic kidney disease may benefit from having an angiotensin 2 receptor blocker as one of their medications.
• Calcium channel blockers. These medications — including amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others) and others — help relax the muscles of your blood vessels. Some slow your heart rate. Calcium channel blockers may work better for older people and people of African heritage than do ACE inhibitors alone. Grapefruit juice interacts with some calcium channel blockers, increasing blood levels of the medication and putting you at higher risk of side effects. Talk to your doctor or pharmacist if you’re concerned about interactions.

Additional medications sometimes used to treat high blood pressure

If you’re having trouble reaching your blood pressure goal with combinations of the above medications, your doctor may prescribe:

• Alpha blockers. These medications reduce nerve impulses to blood vessels, reducing the effects of natural chemicals that narrow blood vessels. Alpha blockers include doxazosin (Cardura), prazosin (Minipress) and others.
• Alpha-beta blockers. In addition to reducing nerve impulses to blood vessels, alpha-beta blockers slow the heartbeat to reduce the amount of blood that must be pumped through the vessels. Alpha-beta blockers include carvedilol (Coreg) and labetalol (Trandate).
• Beta blockers. These medications reduce the workload on your heart and open your blood vessels, causing your heart to beat slower and with less force. Beta blockers include acebutolol (Sectral), atenolol (Tenormin) and others. Beta blockers aren’t usually recommended as the only medication you’re prescribed, but they may be effective when combined with other blood pressure medications.
• Aldosterone antagonists. Examples are spironolactone (Aldactone) and eplerenone (Inspra). These drugs block the effect of a natural chemical that can lead to salt and fluid retention, which can contribute to high blood pressure.
• Renin inhibitors. Aliskiren (Tekturna) slows down the production of renin, an enzyme produced by your kidneys that starts a chain of chemical steps that increases blood pressure. Aliskiren works by reducing the ability of renin to begin this process. Due to a risk of serious complications, including stroke, you shouldn’t take aliskiren with ACE inhibitors or ARBs.
• Vasodilators. These medications, including hydralazine and minoxidil, work directly on the muscles in the walls of your arteries, preventing the muscles from tightening and your arteries from narrowing.
• Central-acting agents. These medications prevent your brain from signaling your nervous system to increase your heart rate and narrow your blood vessels. Examples include clonidine (Catapres, Kapvay), guanfacine (Intuniv, Tenex) and methyldopa.

To reduce the number of daily medication doses you need, your doctor may prescribe a combination of low-dose medications rather than larger doses of one single drug. In fact, two or more blood pressure drugs often are more effective than one. Sometimes finding the most effective medication or combination of drugs is a matter of trial and error.

Resistant hypertension: When your blood pressure is difficult to control

If your blood pressure remains stubbornly high despite taking at least three different types of high blood pressure drugs, one of which usually should be a diuretic, you may have resistant hypertension.

People who have controlled high blood pressure but are taking four different types of medications at the same time to achieve that control also are considered to have resistant hypertension. The possibility of a secondary cause of the high blood pressure generally should be reconsidered.

Having resistant hypertension doesn’t mean your blood pressure will never get lower. In fact, if you and your doctor can identify what’s behind your persistently high blood pressure, there’s a good chance you can meet your goal with the help of treatment that’s more effective.

Your doctor or hypertension specialist may:

• Evaluate potential causes of your condition and determine if those can be treated
• Review medications you’re taking for other conditions and recommend you not take any that worsen your blood pressure
• Recommend that you monitor your blood pressure at home to see if you may have higher blood pressure in the doctor’s office (white coat hypertension)
• Suggest healthy lifestyle changes, such as eating a healthy diet with less salt, maintaining a healthy weight and limiting how much alcohol you drink
• Make changes to your high blood pressure medications to come up with the most effective combination and doses
• Consider adding an aldosterone antagonist such as spironolactone (Aldactone), which may lead to control of resistant hypertension

Some experimental therapies such as catheter-based radiofrequency ablation of renal sympathetic nerves (renal denervation) and electrical stimulation of carotid sinus baroreceptors are being studied.

If you don’t take your high blood pressure medications exactly as directed, your blood pressure can pay the price. If you skip doses because you can’t afford the medications, because you have side effects or because you simply forget to take your medications, talk to your doctor about solutions. Don’t change your treatment without your doctor’s guidance.

Lifestyle and home remedies

Lifestyle changes can help you control and prevent high blood pressure, even if you’re taking blood pressure medication. Here’s what you can do:

• Eat healthy foods. Eat a heart-healthy diet. Try the Dietary Approaches to Stop Hypertension (DASH) diet, which emphasizes fruits, vegetables, whole grains, poultry, fish and low-fat dairy foods. Get plenty of potassium, which can help prevent and control high blood pressure. Eat less saturated fat and trans fat.
• Decrease the salt in your diet. Aim to limit sodium to less than 2,300 milligrams (mg) a day or less. However, a lower sodium intake — 1,500 mg a day or less — is ideal for most adults. While you can reduce the amount of salt you eat by putting down the saltshaker, you generally should also pay attention to the amount of salt that’s in the processed foods you eat, such as canned soups or frozen dinners.
• Maintain a healthy weight. Keeping a healthy weight, or losing weight if you’re overweight or obese, can help you control your high blood pressure and lower your risk of related health problems. In general, you may reduce your blood pressure by about 1 mm Hg with each kilogram (about 2.2 pounds) of weight you lose.
• Increase physical activity. Regular physical activity can help lower your blood pressure, manage stress, reduce your risk of several health problems and keep your weight under control. Aim for at least 150 minutes a week of moderate aerobic activity or 75 minutes a week of vigorous aerobic activity, or a combination of moderate and vigorous activity. For example, try brisk walking for about 30 minutes most days of the week. Or try interval training, in which you alternate short bursts of intense activity with short recovery periods of lighter activity. Aim to do muscle-strengthening exercises at least two days a week.
• Limit alcohol. Even if you’re healthy, alcohol can raise your blood pressure. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women, and up to two drinks a day for men. One drink equals 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.
• Don’t smoke. Tobacco can injure blood vessel walls and speed up the process of buildup of plaque in the arteries. If you smoke, ask your doctor to help you quit.
• Manage stress. Reduce stress as much as possible. Practice healthy coping techniques, such as muscle relaxation, deep breathing or meditation. Getting regular physical activity and plenty of sleep can help, too.
• Monitor your blood pressure at home. Home blood pressure monitoring can help you keep closer tabs on your blood pressure, show if medication is working, and even alert you and your doctor to potential complications. Home blood pressure monitoring isn’t a substitute for visits to your doctor, and home blood pressure monitors may have some limitations. Even if you get normal readings, don’t stop or change your medications or alter your diet without talking to your doctor first. If your blood pressure is under control, check with your doctor about how often you need to check it.
• Practice relaxation or slow, deep breathing. Practice taking deep, slow breaths to help relax. There are some devices available that promote slow, deep breathing. According to the American Heart Association, device-guided breathing may be a reasonable nondrug option for lowering blood pressure, especially when anxiety accompanies high blood pressure or standard treatments aren’t well-tolerated.
• Control blood pressure during pregnancy. If you’re a woman with high blood pressure, discuss with your doctor how to control your blood pressure during pregnancy.

Alternative medicine

Although diet and exercise are the most appropriate tactics to lower your blood pressure, some supplements also may help lower it. However, more research is needed to determine the potential benefits. These include:

• Fiber, such as blond psyllium and wheat bran
• Minerals, such as magnesium, calcium and potassium
• Folic acid
• Supplements or products that increase nitric oxide or widen blood vessels (vasodilators), such as cocoa, coenzyme Q10, L-arginine or garlic
• Omega-3 fatty acids, found in fatty fish, high-dose fish oil supplements or flaxseed

Some research is studying whether vitamin D can reduce blood pressure, but more research is needed.

While it’s best to include these supplements in your diet as foods, you can also take supplement pills or capsules. Talk to your doctor before adding any of these supplements to your blood pressure treatment. Some supplements can interact with medications, causing harmful side effects, such as an increased bleeding risk that could be fatal.

You can also practice relaxation techniques, such as deep breathing or meditation, to help you relax and reduce your stress level. These practices may temporarily reduce your blood pressure.

1. Therapeutic approaches to diastolic dysfunction. Janardhanan R, Desai AS, Solomon SD. Curr Hypertens Rep. 2009 Aug; 11(4):283-91.[↩]
2. Kannel WB, Cobb J. Left ventricular hypertrophy and mortality–results from the Framingham Study. Cardiology. 1992. 81(4-5):291-8.[↩]
3. Yamasaki N, Kitaoka H, Matsumura Y, et al. Heart failure in the elderly. Intern Med. 2003 May. 42(5):383-8.[↩]