Hypertension and Heart Failure

Hypertension and Heart Failure

V. VI. Unintentional progressive weight loss of greater than 10% of body weight over the preceding 6 months. Resting tachycardia greater than 100 bea...

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V. VI.

Unintentional progressive weight loss of greater than 10% of body weight over the preceding 6 months. Resting tachycardia greater than 100 beats/min in a patient with known severe COPD.1 Henry Yeager, Jr., MD, FCCP Washington, DC

Pulmonary and Critical Care Medicine, Georgetown University Medical Center, Washington, DC. Reprint requests: Dr. Yeager, Pulmonary/Critical Care Medicine, Georgetown University Medical Center, 3800 Reservoir Rd NW, Wasliington DC 20007

REFERENCES 1 Stuart B, Herbst L, Kinzbrunner B, et a!. Medical guidelines for determining prognosis in selected non-cancer diseases. Arlington, Va: National Hospice Organization, 1995 2 Anthonisen NR. Prognosis in chronic obstructive pulmonary disease: results from multicenter clinical trials. Am Rev Respir Dis 1989; 111:719-24 3 Rieves RD, Bass D, Carter RR, et al. Severe COPD and acute respiratory failure: correlates for survival at the time of tracheal intubation. Chest 1993; 104:854-60 4 American Thoracic Society. Ethical issues in COPD. Am J Respir Crit Care Med 1995; 152:S77-S116 5 Gilligan T, Raffin T A. End-of-life discussions with patients: timing and truth-telling. Chest 1996; 109:11-12 6 Sullivan KE, Hebert PC, Logan J, et al. What do physicians tell patients with end-stage COPD about intubation and mechanical ventilation? Chest 1996; 109:258-64 7 Lynn J. Travels in the valley of the shadow. In: Spiro H, Curnen MGM, Peschel E, et a!., eds. Empathy and the practice of medicine. New Haven, Conn: Yale University Press, 1993; 40-53 8 Hospice Benefits. A Special Way of Caring for the Terminally Ill. Washington, DC: HCFA Publication No. 02154, March 1995

Hypertension and Heart Failure The Link Continues Franklin Roosevelt entered his fourth term WashenPresident of the United States in 1944, he

was dying of congestive heart failure (CHF). He had severe uncontrolled hypertension, and no therapy was available to significantly modify its course. The Framingham study began in 1948, 3 years after Roosevelt's death from a cerebral hemorrhage. Early data from that study demonstrated that hypertension was the major risk factor in the development of CHF.l Since then, randomized clinical trials in hypertensive patients have demonstrated that treatment results in a marked reduction in the development of heart failure. 2 •5 With wide availability of effective, well-tolerated antihypertensive therapy, many believed that identification and treatment of hypertension had reduced, if not nearly eliminated,

it as a major risk factor for the development of CHF. The focus of cardiology for the last 10 years has been on the treatment of established CHF and on therapeutic approaches to prevent the progression from asymptomatic left ventricular dysfunction to overt heart failure . The Survival of Left Ventricular Dysfunction (SOLVD) trials 6 ·7 and the Survival and Ventricular Enlargement (SAVE) trial 8 have clearly shown the efficacy of angiotensin-converting enzyme (ACE) inhibitor therapy in patients with left ventricular systolic dysfunction. Many have viewed most modern-day left ventricular dysfunction as the longterm price we pay for reducing the mortality from acute myocardial infarction. The assumption that hypertension is no longer an important risk factor for the development of CHF was clearly dispelled this past year by Levy and colleagues9 from Framingham, Mass. These investigators evaluated the role of hypertension as a risk factor for CHF in the "modern era." Using a start date of January 1, 1970 (a time when good antihypertensive therapy was widely available), 5,143 subjects (age 40 to 89) from the original Framingham cohort, and subjects from the Framingham Offspring Study were enrolled. All subjects were free of CHF as detennined by the standard Framingham major and minor criteria system. Followed for an average of 14.1 years, 392 new cases of CHF were identified in this cohort. Hypertension predated the onset of CHF in 91% of these cases. Hypertension increased the hazard ratio for the development of CHF in men to 2.07 and in women to 3.35. Mter adjusting for other risk factors (coronary artery disease, diabetes mellitus, left ventricular hypertrophy, and valvular heart diseases), hypertension carried the greatest population-attributable risk for the development of CHF of all the risk factors considered. Hypertension was the attributable risk for the development of CHF in 39% of men and 59% of women. While higher blood pressure carried greater risk for CHF, even subjects with stage 1 hypertension had a substantially increased risk of developing CHF. While it's no great surprise to any of us in the heart failure field, it is also important to note that the survival associated with the development of overt heart failure was dismal. In the Levy et al Framingham study, 9 the hypertensive men who developed heart failure had a median survival of only 1.37 years, and in women the median survival was 2.48 years. At 5 years after identification of ove1t heart failure 76% of the men and 69% of the women had died. Why does hypertension remain a risk factor for CHF? We know from a number of large treatment studies (Veteran's Administration Cooperative Study Group on Antihypertensive Agents, 2 •3 Systolic Hypertension in the Elderly Program [SHEP], 4 and Swedish Trial in CHEST/112/1/JULY,1997


Old Patients With Hypertension [STOP-Hypertension] )5 that the treatment of hypertension is successful in preventing or reducing the development of CHF. Despite good therapy, hypertension is still the leading risk for CHF. So what is the problem? We are left with the worrisome possibility that despite the availability of adequate therapeutic options, many hypertensive patients do not receive optimal therapy. Data from serial surveys of control of hypertension in the nation indicate considerable improvement in the percentage of hypertensives with blood pressure less than 140 and less than 90; from 11% in 1976 to 1980, to 21% in 1988 to 1991, but only one half of the hypertensives are receiving medication. 10 With medication, hypertension in 50% of men and 58% of women is controlled, but control rates decrease with age in men and women of all races. For example, in non-Hispanic white women 18 to 49 years of age, hypertension is controlled in 68%, but in AfricanAmerican women over the age of 70, controlled hypertension is present in only 33%.1 1 There are similar data in men. One of the Department of Health and Human Services "Healthy People Year 2000" goals is to have the blood pressure in 50% of all hypertensives <140 systolic and <90 diastolic. 12 We have a long way to go. Despite the progress made in drug therapy dming the last 50 years, CHF is clearly a growth industry. CHF is the leading diagnostic related group for Medicare hospital admission and the only cardiovascular disease which is increasing in prevalence. CHF is a disorder which nearly doubles in frequency with each increasing decade of life. As our population ages, the prevalence of CHF grows. As we progress toward the next millennium, we should recognize that unlike the time of Franklin Roosevelt, we now have the tools available to change the natural history of hypertension, and with it, the epidemiology of CHF. Our lack of success thus far is not a result of inadequate therapy but rather inadequate delivery of adequate therapy. These provocative data from Framingham remind us that we cannot and must not be complacent vvith our treatment of hypertension. Brooks S. Edwards, MD Sheldon G. Sheps, MD, FCCP Rochester, Minnesota


Dr. Edwards is with the Division of Cardiovascular Diseases, and Dr. Sheps is \vith the Division of Hypertension, Department of Internal Medicine, Mayo Clinic.

REFERENCES 1 Kannel WB, Castelli WP, McNamara PM, et al. Role of blood pressure in the development of congestive heart failure: the Framingham Study. N Eng! J Med 1972; 287:781-87 2 Veterans Administration Cooperative Study Group on Antihypertensive Agents. Effects of treatment on morbidity in hypertension: results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA 1967; 202:1028-34 3 Veterans Administration Cooperative Study Group on Antihypertensive Agents. Effects of treatment on morbidity in hypertension: II. Results in patients \vith diastolic blood pressure averaging 90 through 114 mm Hg. JAMA 1970; 213:1143-51 4 The Systolic Hypertension in the Elderly Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991; 265:3255-64 5 Dahlof B, Lindholm LH, Hansson L, et a!. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). Lancet 1991; 338:1281-85 6 The SOLVD Inestigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Eng! J Med 1991; 325:293302 7 The SOLVD Investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Eng! J Med 1992; 327:685-91 8 Pfeffer MA and the SAVE Investigators. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. N Eng! J Med 1992; 327:669-77 9 Levy D, Larson MG, Vasan RS, et al. The progression from hypertension to congestive heart failure. JAMA 1996; 275: 1557-62 10 Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. The fifth report. Arch Intern Med 1993; 154:153-83 11 Burt VL, Cutler JA, Higgins M, et a!. Trends in the prevalence, awareness, treatment and control of hypertension in the adult US population. Hypertension 1995; 26:60-9 12 Healthy People 2000 Midcourse Review and 1995 Revisions. Washington, DC: US Department of Health and Human Services/Public Health Service