hypertensive heart disease



OVERVIEW

Definition

Hypertensive heart disease is a heart condition caused by high blood pressure. The main cardiac changes caused by long-term hypertension are left ventricular hypertrophy and dilatation.

If not treated promptly and effectively, cardiac muscle diastolic and systolic dysfunction will gradually develop, and eventually heart failure (decline in heart function) will occur.

Morbidity

Left ventricular hypertrophy may occur in more than 30% of cases of hypertension, and the incidence is positively correlated with the severity of hypertension.

Etiology

Causes

When the heart pumps blood throughout the body, it needs to overcome the resistance of the blood vessels. Prolonged poor control of hypertension increases the pressure load on the ejection of blood from the heart. In order to overcome the resistance to ejection of blood and to increase the contractile force of the heart muscle, the septum and the free wall of the left ventricle thicken in a compensatory manner.

Common factors leading to poor blood pressure control

Failure to take blood pressure lowering medications correctly. Discontinuation of medication just after the blood pressure has returned to normal level.

Eating a salty, oily diet.

Mental tension, irritability, impatience.

Overwork, always stay up late or have insomnia.

Smoking and drinking.

Overweight.

Secondary causes of hypertension not corrected, such as nocturnal sleep apnea.

Symptoms

Early hypertensive heart disease usually has no special symptoms, with the development of the disease can occur heart failure. Generally the first manifestation of the left heart failure, the further development of the condition can occur right heart failure, and ultimately the formation of total heart failure.

Left heart failure

Dyspnea

Exertional dyspnea: Dyspnea occurs when doing activities or physical labor, and can be relieved after stopping activities and resting.

Nocturnal paroxysmal dyspnea: sudden onset of dyspnea during sleep at night, gradually relieved after sitting up.

Sit-up breathing: Dyspnea occurs when lying down and is gradually relieved by sitting up; dyspnea may reappear after lying down again.

Acute pulmonary edema (cardiogenic asthma): a more severe state. A distinctive rumbling sound (similar to a whistle) may be produced during breathing. In the most severe cases, there may be a grayish color, blue lips, profuse sweating, and irritability, along with frequent coughing and coughing up pink frothy sputum.

Cough, sputum, hemoptysis

Cough with sputum, often at night, relieved or alleviated by sitting up or standing up, white frothy sputum.

In severe cases, coughing is frequent, with pink frothy sputum.

In more severe cases, hemoptysis (blood in the sputum) may occur.

Other

Weakness, fatigue, chest tightness, shortness of breath, which worsens after a little activity, dizziness, palpitations, and oliguria.

Right heart failure

Digestive tract symptoms

Presenting as bloating, loss of appetite, nausea, vomiting, etc.

Dyspnea

Manifested as dyspnea after activity, with some relief from before.

Edema

Occurs in both lower limbs at the same time, often feels swollen and heavy in the legs, and a more obvious depression will appear after pressing the lower limbs, and it is not easy to recover. The edema starts as simple foot and ankle edema, and gradually develops to the whole lower limbs and even the lower abdomen.

Total heart failure

Symptoms of left heart failure and right heart failure may occur.

Most of the symptoms are severe, and dyspnea is likely to be less severe than in the early stages.

Complications

Pre-phase contractions (premature beats)

Palpitations, shortness of breath, chest tightness, weakness and dizziness may occur.

Atrial fibrillation

Most of them have no obvious symptoms. Those who have symptoms most commonly have palpitations, and may also have chest pain, dyspnea, limb weakness, dizziness, and blackouts (sudden darkness in front of the eyes).

The palpitations can be paroxysmal, which may be paroxysmal atrial fibrillation, but once it becomes persistent atrial fibrillation, the palpitations become less pronounced.

Consultation

Recommendations

Hypertensive heart disease is mainly diagnosed and treated in cardiovascular medicine.

Long-term poor control of blood pressure, dyspnea, cough, sputum, hemoptysis, oliguria, edema, and cyanosis of the skin and mucous membranes are symptoms for which it is recommended to go to the hospital.

If the following symptoms occur, you need to go to the emergency department immediately.

Symptoms of dyspnea and shortness of breath that worsen after activity, or shortness of breath that occurs at rest.

Sudden onset of shortness of breath during sleep at night, waking up with suffocation, inability to lie down, needing to put up a pillow or sit up.

Feeling palpitations, a fast or slow heartbeat, or an irregular pulse, and feeling dizzy or having a sense of fear.

Repeat patients follow the doctor’s instructions to see the doctor on time.

Preparation for Consultation

Registration

Before the outpatient consultation, you need to register at the hospital or through official channels (such as the hospital’s official website, official app, 114 platform, etc.).

Emergency admissions can be made directly by registering. Pre-hospital emergency admissions generally do not need to register in advance, and can be made up in the course of treatment.

Preparation of documents

Prepare your medical card, social security card (medical insurance card) and other documents.

Bring your previous medical records, medical history, and test reports such as echocardiograms and markers of myocardial injury.

If you are taking medication, prepare a list of medications. Take your regular medication on the day of your visit and do not stop taking it.

What questions the doctor may ask

When did these symptoms appear? Did they occur for the first time or multiple times?

Under what circumstances did the symptoms lessen or worsen?

Was there any coughing up of phlegm? What does the phlegm look like?

Do you wake up at night with suffocation?

Do you have high blood pressure? How is your blood pressure controlled?

Have you had any other heart disease before? Have you been treated? How effective is the treatment?

Have you had any other illnesses?

Questions you can ask your doctor

What tests are needed?

What causes these symptoms?

How is it treated?

Can it be cured?

What do I need to pay attention to in my daily life?

Diagnosis

Diagnostic basis

Medical history

History of hypertension.

Poor long-term blood pressure control.

Clinical manifestations

Symptoms

Prolonged poor control of blood pressure, dyspnea, cough, sputum, hemoptysis, oliguria, edema, and bruising of skin and mucous membranes.

Physical signs

There may be jugular venous rage, increased pulse rate, irregular pulse beat, elevated blood pressure, and increased respiratory rate.

Auscultation of the lungs may show wet rales (sounds similar to small blisters bursting).

Auscultation may reveal an increased apical beat and a widening of the heart border to the lower left. Auscultation may show abnormal sounds.

Pressure-concave edema of the lower extremities.

Laboratory Tests

B-type natriuretic peptide (BNP) and amino-terminal brain natriuretic peptide precursor (NT-proBNP)

Can be used in the diagnosis of heart failure and to assess the severity of the condition as well as to evaluate the efficacy of treatment.

Elevated BNP and NT-proBNP can be seen.

Routine blood tests

To check white blood cell count, red blood cell count and hemoglobin concentration.

May clarify the presence of infection, anemia, etc.

Blood biochemistry

Check liver and kidney function, blood sugar, blood lipid, electrolytes.

It can clarify whether there is hyperlipidemia, diabetes mellitus, renal insufficiency and other conditions.

Note: Fasting is required before the examination, i.e., fasting for 8 hours, and a small amount of water can be consumed; no fasting is required for emergency examination.

Urine routine

Check the specific gravity of urine, red blood cells in urine, urine protein and so on.

It can clarify whether there is renal insufficiency and other conditions.

Precautions: Clean mid-stage urine should be retained during the examination, i.e., a portion of the urine should be discharged first, and then a urine cup should be used to catch the urine, and then the remaining urine should be discharged.

Imaging

Echocardiography

To check the structure and function of the heart, which can clarify the severity of the disease, etc.

Uniform thickening of the interventricular septum and left ventricular free wall and left ventricular hypertrophy.

Precautions

Expose the chest as requested by the doctor before the examination.

A coupling agent will be applied to the skin at the examination site.

Maintain the position as required by the doctor and avoid moving around during the examination.

The coupling agent can be removed with tissue paper after the examination.

Chest X-ray

The size, shape, and structure of the heart can be visualized.

Enlargement of the left ventricle can be seen.

Precautions: Remove jewelry or metal objects, such as necklaces, from the examination area and take off clothing made of metal before the examination.

Cardiac Magnetic Resonance (CMR)

Examines the structure and function of the heart, and the presence of myocardial fibrosis.

It can clarify the cause of the disease or rule out other diseases.

Precautions

Remove items containing metallic materials, as well as electronic products, magnetic cards, etc. before the examination.

If there are steel nails, plates, implantable pacemakers, etc. in the body, the doctor should be informed in advance.

Ambulatory Blood Pressure Monitoring

Measurement of blood pressure for 24 hours. It can clarify the changes in blood pressure and the relationship between blood pressure changes and time and daily behavior.

It can provide a basis for diagnosis and formulation of treatment programs.

Precautions

During the examination, tie the cuff and carry the instrument according to the doctor’s requirements.

If the cuff falls off during the examination, it should be tied in time according to the doctor’s requirements, and avoid damaging the instrument by bumping it when moving around. If the instrument is malfunctioning, it should be adjusted by the doctor at the hospital.

During the examination, you can carry on your normal daily life without increasing or decreasing your exercise, and you cannot take a bath.

Electrocardiogram

By recording the waveform changes of the heart’s electrical activity, we can understand the occurrence and conduction of the heart’s electrical activity.

It can clarify the presence of myocardial ischemia, arrhythmia, etc.

Precautions

Avoid strenuous exercise and emotional excitement, and remove any electronic devices or bracelets from your body before the examination.

Expose the skin of the anterior chest, bilateral wrists and ankles during the examination, position yourself according to the doctor’s requirements, maintain even breathing, and avoid movement.

Differential Diagnosis

Mitral valve insufficiency

Symptoms such as palpitations, weakness and shortness of breath on exertion may be present. It can be identified by echocardiography.

Aortic valve insufficiency

Mainly caused by rheumatic fever and degenerative calcification of the aortic valve in the elderly. It manifests as weakness, palpitations, shortness of breath after exertion, and in severe cases, angina pectoris, sedentary breathing, paroxysmal dyspnea, and syncope. It can be identified by echocardiography.

Aortic valve stenosis

It may be caused by rheumatic heart disease, congenital stenosis of the aortic valve, or calcification of the aortic valve in old age, which mainly manifests as dyspnea, angina pectoris, and syncope, and systolic jet murmur can be heard in the second intercostal space at the right edge of the sternum. It can be identified by echocardiography.

Treatment

Emergency treatment

In the following emergencies, call an ambulance by dialing “120” immediately and take appropriate treatment.

If the patient is lying down and has difficulty in breathing, he should sit up and lower his legs, and at the same time, pay attention to soothing his emotions, and inhale oxygen if possible.

When unconsciousness occurs, keep the patient lying on his side on the floor or bed to avoid asphyxiation caused by oral secretions and vomit.

In case of respiratory arrest (unresponsive and not breathing), CPR should be performed immediately, with chest compressions and artificial respiration in the ratio of 30:2, or only chest compressions, and defibrillation using an AED (automated external defibrillator) as soon as possible.

General treatment

Improve diet

Low-salt, low-fat diet, control of pickled foods, stimulating foods and fried foods.

Abstain from alcohol.

Improve lifestyle habits

Avoid exertion.

Regular work and rest, ensure enough sleep and avoid staying up late.

Exercise in moderation and avoid sedentary lifestyle.

Quit smoking and avoid second-hand smoke.

Weight control

If you are obese or overweight, control your weight reasonably.

Maintain a good mood

Regulate your mood on a daily basis. Avoid bad moods such as tension, anxiety, anger and depression.

Oxygen intake

Follow the doctor’s requirements for oxygen intake, do not adjust the oxygen flow by yourself.

Medication

The root cause of hypertensive heart disease is long-term poor control of blood pressure, drug therapy to control blood pressure; if heart failure has occurred, should actively control heart failure.

Diuretics

Correct fluid retention and relieve symptoms by promoting the discharge of sodium ions with urine.

Commonly used drugs include thiazide diuretics (hydrochlorothiazide), labeled diuretics (furosemide), and potassium-preserving diuretics (spironolactone).

Adverse reactions include affecting the metabolism of blood lipids, blood glucose, blood uric acid, causing electrolyte disorders such as hypokalemia and hyponatremia.

Potassium-preserving diuretics can cause hyperkalemia, try to avoid combining with ACEI or ARB, and are contraindicated in renal insufficiency.

Angiotensin converting enzyme inhibitor (ACEI)

By inhibiting angiotensin-converting enzyme, reduce the production of angiotensin II, to achieve the purpose of lowering blood pressure.

Commonly used drugs include captopril, enalapril, benazepril, perindopril, lynopril and so on.

Adverse reactions include pharyngeal itching, irritating dry cough, dysgeusia, edema, and so on.

Angiotensin II receptor antagonists (ARB)

By blocking the angiotensin II receptor subtype, inhibit the corresponding vasoconstriction, reduce the burden on the heart and improve the symptoms.

Commonly used drugs include chlorosartan, valsartan, irbesartan, timosartan, candesartan, and so on.

Adverse reactions are less frequent, and may include headache, dizziness, cough, diarrhea, and fatigue.

Beta-blockers

Improve symptoms, slow disease progression, improve post-treatment status, and reduce the risk of death by antagonizing sympathetic overactivation, decreasing myocardial contractility, and slowing heart rate.

Commonly used drugs include metoprolol, atenolol, bisoprolol and carvedilol.

Adverse effects include bradycardia, fatigue, and chills in the extremities.

Angiotensin receptor-enkephalinase inhibitor (ARNI)

Can inhibit vasoconstriction, reduce myocardial remodeling, decrease cardiac burden and improve cardiac function.

Commonly used drugs such as sacubitril valsartan.

Adverse effects include hypotension, impaired renal function, hyperkalemia, and angioedema.

Control of atrial fibrillation

Controlling ventricular rate, reversing and maintaining sinus rhythm, and preventing thromboembolism are the principles of treatment for atrial fibrillation.

Commonly used drugs verapamil, digitalis, verapamil, warfarin and so on.

Surgery

When there is heart enlargement and heart failure, and it is difficult to control and improve the symptoms with medication, further surgical treatment can be taken.

Heart Transplantation

Heart transplantation requires a suitable organ supplier, but the probability of success is low.

Other treatments must be maintained until a heart suitable for transplantation is obtained.

Complications such as graft failure and rejection may occur after transplantation and should be prevented and treated as required by the doctor.

It is currently difficult to perform widely due to factors such as donor source and rejection.

Cardiac resynchronization therapy

When cardiac dyssynchrony exists, implantation of a triple-chamber pacemaker is used to correct the dyssynchrony and improve heart failure.

Implantable Cardioverter Defibrillator (ICD)

The device is implanted in the heart through interventional therapy. When an abnormal heart rhythm occurs, the device automatically discharges to normalize the heart rhythm.

It can reduce the risk of serious arrhythmias such as ventricular fibrillation and prolong life.

Prognosis

Cure

Hypertension cannot be cured and it is more difficult to reverse cardiac rational changes. With active treatment, the condition can be effectively controlled and symptoms relieved, but symptoms may recur.

Hazard

If blood pressure is not well controlled for a long period of time, it can lead to other cardiac complications, such as pre-stage contraction, atrial fibrillation and other cardiac arrhythmias.

When the condition is serious, myocardial infarction can also occur, which is life-threatening.

Daily

Daily Management

Dietary management

Low salt diet

Daily salt intake should be less than 5 grams (equivalent to about 25 ml of soy sauce).

Avoid pickled food, such as pickles, fermented bean curd, dashi, bacon, preserved meat and red sausage.

Reduce fast food, such as instant noodles and instant rice.

Ensure balanced nutrition

Limit total calories and diet should be eight-minute full.

Ensure adequate protein, unsaturated fat, vitamins, minerals and dietary fiber.

Meat is preferred to poultry and fish, about one poker box size amount per day.

Skimmed milk 300 ml per day.

One palmful of nuts daily.

Fresh low-sugar fruits, such as kiwi, strawberries, pears, grapefruit, etc., 1~2 per day.

Fresh vegetables 400 to 500 grams (raw weight) daily.

Reduce the intake of carbohydrates appropriately by choosing cereals and potatoes instead of refined rice and noodles.

Control the amount of cooking oil, which should be less than 25 grams per day (about 2.5 white porcelain soup spoons)

Ensure water intake as directed by your doctor

Avoid other inappropriate diets

Avoid stimulating beverages such as strong tea and coffee.

Avoid foods high in saturated fat such as fatty meats and fried foods.

Abstain from alcohol.

Lifestyle Management

Work and rest management

Ensure adequate sleep.

Try to avoid heavy physical labor such as lifting heavy objects, long or prolonged riding or driving. Or choose the intensity of labor according to your doctor’s requirements.

Exercise management

Exercise in moderation, such as jogging, tai chi and swimming. Or follow the doctor’s instruction to plan the time of exercise and choose the exercise program.

Avoid excessive exercise.

If you feel sick during exercise, stop exercising immediately.

Quit bad habits

Quit smoking and stay away from second-hand smoke.

Avoid staying up late.

Emotion management

Avoid stress, anxiety, anger, depression and other negative emotions.

Relieve them by chatting with friends and relatives, listening to soft music, reading books and watching soothing TV programs.

In serious cases, you can go to a formal psychological counseling agency for psychological counseling and treatment.

Avoid environmental stimuli

Avoid cold and heat.

Keep warm when going out in winter.

In summer, pay attention to prevent heatstroke, and the temperature of indoor air-conditioning should not be too low.

Avoid prolonged exposure to excessive cold or heat.

Weight and Waistline Management

Keep BMI at 18 to 23.9.

Waist circumference should not exceed 90 cm for men and 85 cm for women.

Regular Blood Pressure Measurement

Self-measurement of blood pressure can be done at home using a sphygmomanometer. Upper arm electronic sphygmomanometers from regular manufacturers are available.

Try to measure at the same time and in a quiet state, for example, at 7:00 a.m. every day, after urinating, and in a sitting position.

Avoid drinking coffee, alcoholic beverages, strong tea, etc. and empty your bladder (urinate) before measurement.

Avoid strenuous activities before measurement. If there is activity, rest for at least 5 minutes before taking the measurement.

Avoid rolling up the sleeves too tightly during the measurement by removing the clothing on the side of the measurement.

The lower side of the cuff should be 2 horizontal fingers (about 2.5 cm) from the middle of the elbow socket during measurement, and the cuff should be tight enough to accommodate 1 finger.

Avoid moving your body during the measurement and keep quiet.

The interval between measurements should be 1 to 2 minutes, and the cuff should be untied and relaxed between measurements. Avoid continuous measurements.

Adherence to medication

Take medication according to the doctor’s requirements, avoid reducing, adding or changing medication on your own.

If you feel uncomfortable or feel that the treatment effect is not good during the process of taking medication, you should consult a doctor in time and adjust the medication according to the doctor’s instruction.

Do not blindly believe in unproven remedies such as local remedies, secret recipes and biased remedies.

Prevention

Reasonable use of medication according to the doctor’s requirements, and active control of blood pressure.

Improve diet: Ensure balanced nutrition, avoid high salt food and alcohol abuse.

Exercise in moderation: Maintain good exercise habits and avoid sedentary behavior.

Maintain a good mood: avoid stress, anxiety and other bad emotions.

Quit bad habits: Quit smoking and stay away from “second-hand smoke”.

Control your weight and waistline: Keep your weight and waistline within normal limits.

Regular medical checkups: Have regular medical checkups, especially blood pressure, electrocardiogram, echocardiogram, etc., for early detection and early intervention to avoid or detect complications in time.