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 American Journal of Hypertension 

Volume 16, Issue 9, Supplement, September 2003, Pages 18 – 22

From hypertension to heart failure: breaking the chain of cardiovascular disease

Original contribution

From hypertension to heart failure: update on the management of systolic

and diastolic dysfunction

  John B Kostisa, , 

  a Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA

  http://dx.doi.org/10.1016/S0895-7061(03)00966-X, How to Cite or Link Using DOI 

  Permissions & Reprints 

 Abstract The aging of the population of the United States (US) will bring with it higher numbers of patients with

coronary heart disease and heart failure (HF). Because HF already imposes severe economic and

medical burdens on our health care system, it is imperative to optimize primary and secondary prevention

of cardiovascular (CV) disease.

In most cases, HF develops as a result of either long-standing hypertension or a myocardial infarction

(MI). Other than cardiac death, HF represents the last stage in the progression of CV disease, which

begins with CV risk factors such as hypertension, dyslipidemia, obesity, and smoking. These risk factors

lead to the development of left ventricular (LV) hypertrophy or an MI (or both), which lead to LV

dysfunction and, finally, to HF. The prognosis of HF is poor, the 5-year survival rate being approximately

25%. Heart failure may be due to either LV systolic or diastolic dysfunction, the latter having a normal

ejection fraction.

Because CV disease is progressive, interventions are possible at all stages along the CV continuum. β-

Blockers (βB) are recommended agents at several stages of CV disease. Large-scale trials have shown

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that βB significantly reduce risks for morbidity and mortality in patients with HF. Ongoing studies should

help to clarify further the optimal cardioprotective therapies in patients with HF.

Keywords

  Hypertension;

  heart failure;

  β-blockers;

  cardiovascular disease

Figures and tables from this article: 

FIG. 1. Progression from hypertension to heart failure.4 CHF = congestive heart failure; CV = cardiovascular; HF = heart

failure; LV = left ventricular; LVH = left ventricular hypertrophy; MI = myocardial infarction. (Reprinted with permission from

Vasan RS et al: The role of hypertension in the pathogenesis of heart failure. A clinical mechanistic overview. Arch Intern

Med 1996;156:1789 – 1796.)

Figure options

FIG. 2. Recommendations for management of heart failure by stage include the use of  β-blockers at all stages. ACE =

angiotensin-converting enzyme.10 

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Figure options

FIG. 3. In the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) study, treatment with carvedilol

reduced the relative risk of death by 35% (P = .0014), and the combined risk of death or hospitalization by 24% (P < .001),

compared with placebo, in 2289 patients with severe heart failure who were clinically euvolemic. RRR = relative risk

reduction.15 (Reprinted with permission from Packer M, et al: Effect of carvedilol on survival in severe chronic heart

failure. N Engl J Med 2001;344:1651 – 1658. Copyright © 2001. Massachusetts Medical Society. All rights reserved.)

Figure options

FIG. 4. The Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure (MERIT-HF) found that ER

metoprolol succinate achieved an RRR of 34% for all-cause mortality, compared with placebo (P = .0062), in 3991

patients with NYHA Class II to Class IV HF and an EF of  ≤40%, who were receiving standard therapy with diuretics and

angiotensin-converting enzyme inhibitors. EF = ejection fraction; ER = extended release; HF = heart failure; NYHA = New

York Heart Association; RRR = relative risk reduction.16 (Reprinted with permission from MERIT-HF Study Group: Effect

of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure

(MERIT-HF). Lancet 1999;353:2001 – 2007.)Figure options

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 FIG. 5. A substudy was conducted in patients enrolled in the Metoprolol CR/XL Randomized Intervention Trial in

Congestive Heart Failure (MERIT-HF) with severe HF (NYHA Class III/IV) and an EF of <25% (n=795). This trial found

that treatment with ER metoprolol succinate achieved a significant relative risk reduction of 39% in total mortality (P =

.009). EF = ejection fraction; ER = extended release; HF = heart failure; NYHA = New York Heart Association; RRR

relative risk reduction.21 (Reprinted with permission from Goldstein S, et al: Metoprolol controlled release/extended

release in patients with severe heart failure: analysis of the experience in the MERIT-HF Study. J Am Coll Cardiol

2001;38:932 – 938. Copyright © 2001. The American College of Cardiology Foundation. All rights reserved.)

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senin, 8 april 2013 22.10

May 22, 1996, Vol 275, No. 20 >

< Previous ArticleNext Article > 

ARTICLE | May 22, 1996 

The Progression From Hypertension to CongestiveHeart FailureDaniel Levy, MD; Martin G. Larson, ScD; Ramachandran S. Vasan, MD; William B. Kannel, MD, MPH; Kalon K. L.

Ho, MD, MSc

 JAMA. 1996;275(20):1557-1562. doi:10.1001/jama.1996.03530440037034.

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ArticleReferences

ABSTRACTABSTRACT | REFERENCES 

Objective. —To study the relative and population-attributable risks of hypertension for thedevelopment of congestive heart failure (CHF), to assess the time course of progression fromhypertension to CHF, and to identify risk factors that contribute to the development of overt heart failurein hypertensive subjects.

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Design. —Inception cohort study.Setting. —General community.Participants. —Original Framingham Heart Study and Framingham Offspring Study participants aged40 to 89 years and free of CHF. To reflect more contemporary experience, the starting point of this study 

 was January 1, 1970.Exposure Measures. —Hypertension (blood pressure of at least 140 mm Hg systolic or 90 mm Hg

diastolic or current use of medications for treatment of high blood pressure) and other potential CHF risk factors were assessed at periodic clinic examinations.Outcome Measure. —The development of CHF.Results. — A total of 5143 eligible subjects contributed 72422 person-years of observation. During up to20.1 years of follow-up (mean, 14.1 years), there were 392 new cases of heart failure; in 91% (357/392),hypertension antedated the development of heart failure. Adjusting for age and heart failure risk factorsin proportional hazards regression models, the hazard for developing heart failure in hypertensivecompared with normotensive subjects was about 2-fold in men and 3-fold in women. Multivariableanalyses revealed that hypertension had a high population-attributable risk for CHF, accounting for 39%of cases in men and 59% in women. Among hypertensive subjects, myocardial infarction, diabetes, left

 ventricular hypertrophy, and valvular heart disease were predictive of increased risk for CHF in bothsexes. Survival following the onset of hypertensive CHF was bleak; only 24% of men and 31% of womensurvived 5 years.Conclusions. —Hypertension was the most common risk factor for CHF, and it contributed a large

proportion of heart failure cases in this population-based sample. Preventive strategies directed towardearlier and more aggressive blood pressure control are likely to offer the greatest promise for reducing theincidence of CHF and its associated mortality.( JAMA. 1996;275:1557-1562)

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