The progression from hypertension to heart failure

Heart failure (HF) still presents a major health problem despite significant understanding of its underlying pathophysiology and recent therapeutic advances. Hypertension is a major risk factor for HF and plays a key role in the evolution of the disease. In an attempt to compensate for the increased peripheral resistance frequently noted in hypertension, the heart may hypertrophy, with the left ventricular enlargement accompanied by fibrosis and resulting in reduced contractility. Ultimately the hypertrophied or fibrosed myocardium is no longer able to maintain normal cardiac output and left ventricular failure occurs. Evidence shows that treating hypertension effectively can have a major beneficial impact on some, but not all, forms of adult cardiovascular disease. For example, the incidence of HF and stroke are clearly reduced; however, until recently, treating hypertension has had relatively little effect on coronary heart disease (CHD) events. The benefits of antihypertensive treatment are, however, clearly underestimated, possibly because many studies are too short and because more subtle benefits of treatment have been overlooked. Also, it must be realized that hypertension is a complex disorder and antihypertensive drugs do indeed differ regarding their effects on associated metabolic derangements often seen in hypertensive patients. Angiotensin converting enzyme (ACE) inhibitors have been shown to be highly efficacious and safe antihypertensive agents, and have additional favorable effects on metabolic parameters, renal functions, and cardiac hypertrophy. ACE inhibitors are now the mainstay of therapy in the patients with heart failure and it is now well recognized that earlier and more aggressive treatment of hypertension may reduce the incidence of HF. ACE inhibitors are an excellent choice as an antihypertensive agent; however, many physicians limit their use of ACE inhibitors due to concern about possible renal side-effects, which accompanied the early use of these agents at very high doses.