The Role of Drug Therapy in Lowering Mortality and Morbidity: From Established Heart Failure to High-Risk Hypertension
Hypertension, untreated or insufficiently treated, is the most important cause of left ventricular hypertrophy, coronary heart disease, myocardial infarction, arrhythmias, and eventually cardiac failure whether left ventricular ejection fraction is reduce
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Nisha Mistry, Sverre E. Kjeldsen, and Arne Westheim
16.1 Introduction Hypertension, untreated or insufficiently treated, is the most important cause of the development of left ventricular hypertrophy, coronary heart disease, myocardial infarction, arrhythmias, and eventually cardiac failure [1] (Fig. 16.1). Traditionally we divide heart failure into patients with reduced ejection fraction (HFrEF) and patients with preserved EF (HFpEF). In patients with HFrEF, angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs), beta-blockers (β-blockers), and aldosterone antagonists now termed mineralocorticoid receptor antagonists (MRAs) are all well-established treatment with reduction of morbidity and mortality. Use of diuretics is important to reduce symptoms. In patients with HFpEF, no treatment has specifically been shown to reduce morbidity and mortality. However, the agents used in the treatment of HFpEF, including diuretics and various calcium antagonists, may also be indicated in the treatment of patients with HFpEF due to comorbidities as hypertension, left ventricular hypertrophy, atrial fibrillation, and coronary artery disease. Optimally, heart failure, like all other hypertensive complications, should be prevented by medical treatment, and in this aspect all the classes of antihypertensive drugs are effective. The various drug classes that may be choices for treatment or prevention of heart failure are summarized in Table 16.1 together with their mechanisms of action.
N. Mistry · S. E. Kjeldsen (*) · A. Westheim University of Oslo, Institute for Clinical Medicine, Oslo, Norway Department of Cardiology, Oslo University Hospital, Ullevaal, Oslo, Norway e-mail: [email protected]; [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_16
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Obesity Diabetes
Diastolic dysfunction LVH
BP
Atrial Fibrillation Myocardial ischemia
HEART FAILURE
Systolic dysfunction
Fig. 16.1 Schematic illustration of how high blood pressure (BP) may lead to heart failure through development of left ventricular hypertrophy (LVH), myocardial ischemia, and/or arrhythmia like atrial fibrillation. Approximately half of the patients develop heart failure with preserved ejection fraction (HFpEF, diastolic dysfunction), and approximately half of the patients develop heart failure with reduced ejection fraction (HFrEF, systolic dysfunction). Structural and functional differences between HFpEF and HFrEF as well as diagnostic methods with echocardiography are explained elsewhere [55] Table 16.1 Mechanisms for how different drug classes can improve the heart’s function in HFpEF ACE inhibitors and angiotensin receptor blockers (ARBs): Reduces or inhibits adverse effects of angiotensin II, reduces peripheral vascular resistance and arterial blood pressure, promotes regression of cardiac hypertrophy and adverse r
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