Prevention and Treatment of Heart Failure in Hypertension Guidelines
This chapter focuses on the prevention of heart failure by antihypertensive treatment and treatment of people with hypertension and an established heart failure. On the former issue, the chapter emphasizes that blood pressure-lowering interventions majorl
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Giuseppe Mancia
25.1 Introduction The notion that hypertension is a major risk factor for heart failure [1, 2] goes back to several decades. Yet, guidelines on the management of high blood pressure (BP) have for a long time devoted only a limited space and attention to the hypertension– heart failure relationship. This has been the case because early trials on the relationship between antihypertensive treatment and outcome mainly focused on myocardial infarction and stroke, i.e. events that can be precisely diagnosed. In contrast, heart failure did not offer a similar diagnostic precision because in its incipient phase symptoms and signs can be shared by other conditions, e.g. respiratory diseases, insufficiency of lower limbs veins, obesity and poor exercise performance, which made heart failure closer to “soft” than to “hard” end points as myocardial infarction and stroke were defined. Furthermore, diagnosis of incipient heart failure was also subjected to the confounding effect of antihypertensive agents, e.g. (1) an overdiagnosis in patients under calcium channel blockers due to the association of these drugs with ankle oedema and (2) an underdetection in patients treated with diuretics because of the masking effect of these drugs on heart failure symptoms and signs. Some of the above inconveniences persist today. Nevertheless, in the last 20 years, heart failure, as diagnosed in the hospital setting, has become a regular component of the assessment of the protective effect of antihypertensive treatment, almost invariably as a major secondary end point and not unfrequently also as a composite of the primary end point. This has considerably increased knowledge of the effect of blood pressure (BP)-lowering treatment on this important outcome.
G. Mancia (*) University of Milano-Bicocca, Milan, Italy Policlinico di Monza, Milan, Italy e-mail: [email protected] © Springer Nature Switzerland AG 2019 M. Dorobantu et al. (eds.), Hypertension and Heart Failure, Updates in Hypertension and Cardiovascular Protection, https://doi.org/10.1007/978-3-319-93320-7_25
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G. Mancia
This chapter will summarize current evidence on the ability of BP-lowering interventions to reduce new-onset heart failure. It will also review the position of the European guidelines on how to treat patients with heart failure, an aspect of antihypertensive treatment that has lately been addressed also by other guidelines.
25.2 A ntihypertensive Treatment and Prevention of Heart Failure 25.2.1 Prevention of Heart Failure A large number of randomized clinical trials have shown that reducing an elevated BP by antihypertensive drugs is associated with a reduction in the risk of developing heart failure and that the magnitude of this beneficial effect is comparable to or greater than the one which is universally regarded as the paradigma of the beneficial effects of BP-lowering treatment, i.e. reduction of stroke. In a recent very large meta-analysis, for example, Ettehad et al. [3] have shown that for a 10 mmHg reduction of syst
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