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PENYAKIT JANTUNG HIPERTENSI
Dr.Suhaemi,SpPD,Finasim
FDR’s Final Picture (April 11, 1945)
Mortality in Hypertension
50% from ischemic heart disease or heart failure
33% from cerebrovascular disease 10 to 15% from renal failure
Kaplan in Zipes, Libby, Bonow, and Braunwald. 2005
Hypertensive Heart Disease
Results in LVH to maintain normal wall stress
Initially impaired diastolic function
Normal systolic function
Hypertensive Heart Disease
End Organ Damage as a consequence of systemic hypertension.
Chronic systemic pressure overload
CV Complications of Untreated Hypertension (N=500)
20
5
10
15
20
25
30
35
40
45
50
18
128
16
50
RenalFailure
Stroke Enceph MI Angina CHF
MI, myocardial infarction; CHF, chronic heart failure.Perera GA J. Chron Dis. 1955;1:33-42.
Eventrate(%)
LVH, left ventricular hypertrophy; MI, myocardial infarction; CHF, chronic heart failure.Vasan RS and Levy D. Arch Intern Med. 1996;156:1789-1796.
Progression From Hypertensionto Heart Failure
Hypertension
Smoking
Dyslipidemia
Diabetes
Obesity
Diabetes
MI
LVH
CHF
Normal LV Structure
and Function
LV Remodeling
Subclinical LV Dysfunction
Overt Heart Failure
DiastolicDysfunction
Systolic Dysfunction
Population-attributable risk defined as: (100 x prevalence x [hazard ratio – 1])/(prevalence x [hazard ratio – 1] + 1)
Population-Attributable Risks for Development of CHF
CHF, chronic heart failure; AP, angina pectoris; DM, diabetes mellitus; LVH, left ventricular hypertrophy;VHD, valvular heart disease; HTN, hypertension; MI, myocardial infarction.Levy D et al. JAMA. 1996;275:1557-1562.
AP5%DM
6%LVH4%
VHD7%
MI34%
HTN 39%
Men Women
HTN 59%
DM12%
LVH5%
VHD
8%
AP5%
MI12%
UKPDSHypertension Study:
Benefits of 144/82 vs 154/87 Tight BP control, with either a β-blocker or an
ACEI, in type 2 diabetes decreases1: Death related to diabetes by - 32% Stroke by - 44% Microvascular disease by - 37% HF by - 56% Progression of retinopathy by - 34% Deterioration of visual acuity by - 47%
BP target <130/80 for patients with diabetes and in chronic renal disease, JNC 72 1. UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713. 2. National Institutes of Health, National Heart, Lung, and Blood Institute. JNC 7 Express. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, MD: National Institutes of Health; December 2003. NIH Publication No. 03-5233.
Effects of Hypertension on The Heart
Left Ventricular Hypertrophy Vascular Disease: -Atherosclerosis -Arteriosclerosis
Jessup and Brozena. NEJM. 2003
Aurigemma and Gaasch. NEJM. 2004
Kieran McGlade Nov 2001Department of General Practice QUB
The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.
Left Ventricular Hypertrophy
Independent Predictor of: Myocardial infarction Stroke Heart Failure Total Mortality Sudden Death
Consequences of LVH Although initially compensatory, LVH ultimately associated with
risk of cardiovascular events similar to history of prior myocardial infarction
Ischemia Decreased coronary reserve with increased LV mass
angina Greater risk of death following myocardial infarction
Heart Failure Depressed LV systolic and diastolic function
Arrhythmia Atrial fibrillation Ventricular arrhythmias
Nonuniform action potential prolongation Altered repolarization Specific vulnerability to torsades Ischemic ventricular arrhythmia
Dunn and Pfeffer. NEJM. 1999
Effects of Hypertension on The Heart
Left Ventricular Hypertrophy Vascular Disease: -Atherosclerosis -Arteriosclerosis
ATHERO- ARTERIO- SCLEROSIS SCLEROSIS
(Increased vascular stiffness Decreased vascular compliance)
Focal, Occlusive Inflammatory Endothelial
dysfunction Related to LDL
cholesterol oxidation “Inside-out” Sensitive to A II and
other substances
Diffuse, Dilatory Fibrotic (elastin
breakdown, collagen increase)
Adventitial and medial hypertrophy
Related to age and BP “Outside-in” Sensitive to A II and
other substances
Integrated Perspective on CV Risk Factors and Vascular Disease
CVDisease
Ross. N Engl J Med. 1999;340:115-126.
Oxidative Stress & Inflammation
Endothelial Dysfunction
Ross. N Engl J Med. 1999;340:115-126.
)
AGING AND ARTERIAL STIFFNESS PATHOPHYSIOLOGY
Young elastic vessels Old inelastic vessels
Adapted from Izzo JL. J Am Geriatr Soc. 1981;29:520-524.
SYSTOLE DIASTOLE DIASTOLESYSTOLE
STROKEVOLUME
RESISTANCEARTERIOLES
AORTA
PRESSURE(FLOW)
STROKEVOLUME
RESISTANCEARTERIOLES
AORTA
PRESSURE(FLOW)
(Increased systolic
Decreased diastolic
Hypertension: A Major Risk Factor for CHF
Time, decades
Vasan RS, Levy D. Arch Intern Med. 1996;156:1789-1796.
Death
ObesityDiabetes
SmokingDyslipidemia
Systolic Dysfunction
Diastolic Dysfunction
SubclinicalLeft Ventricular
Dysfunction
CHF
Overt HeartFailure
Time, months
Hypertension
LVH
MI
Left VentricularRemodeling
Adapted from Dzau V, et al. Am Heart J. 1991;2(4 pt 1):1244-1263.
Risk factors• Hyperlipidemia• Hypertension• Diabetes• Insulin resistance
AtherosclerosisLVH
CAD
Myocardial ischemia
Coronarythrombosis
Myocardialinfarction
Loss ofmuscle
Arrhythmia
Suddendeath
Remodeling
Ventriculardilatation
Heart failure
Death
From Risk Factors to Heart Failure: The Cardiovascular Continuum
A B
cD