Regression of left ventricular hypertrophy by felodipine or a combination of felodipine and metoprolol

Hypertension in the elderly: age- and disease-related complications and therapeutic implications

Effective treatment of hypertension in the elderly requires an understanding of both the progressive course of the disease and the impact of aging on the cardiovascular system, including physiological, genetic, lifestyle, and environmental factors. Review of the literature that has attempted to define the impact of an "aging process" on cardiovascular structure and function reveals a diversity of findings and interpretations. However, in general, normotensive elderly subjects exhibit the heart and vascular characteristics of "muted" hypertension, including many features of younger hypertensive patients: cardiac hypertrophy, diminution in resting left ventricular early diastolic filling rate, increased arterial stiffness and aortic impedance, diminution in the baroreceptor reflex, a diminished response to catecholamines and diminished renal blood flow, and an increase in peripheral vascular resistance (PVR). Treatment of elderly hypertensives is more challenging because of the greater likelihood of the presence of concomitant diseases, most importantly, coronary and peripheral atherosclerosis, renal dysfunction, and diabetes mellitus. Isolated systolic hypertension (ISH), the most common form of hypertension in the elderly, has also been clearly shown to be an important predictor of cardiovascular morbidity and mortality, including coronary artery disease, congestive heart failure, and stroke. Treatment of ISH has been shown to lower systolic pressure safely and effectively in the elderly. By reducing PVR, and possibly the arterial stiffness, and thus the early reflected pulse waves, vasodilators, including calcium antagonists, may lower these three components of arterial impedance, and hence lower the arterial load on the heart. The cardiac hypertrophy and reduced left ventricular filling rate associated with hypertension in older individuals can also be ameliorated, to some extent, by calcium channel blockers.

Reduction of left ventricular hypertrophy: how beneficial?

Left ventricular hypertrophy (LVH) can no longer be considered a compensatory adaptation of the heart serving to normalize the increased wall stress in hypertension. Recent studies have indicated that LVH is a powerful pressure-independent risk factor for cardiovascular morbidity and mortality. The pathophysiologic sequelae of LVH are reduced ventricular filling and contractility, ventricular dysrhythmias, and diminished coronary reserve or myocardial ischemia. Left ventricular hypertrophy can be reduced by antihypertensive therapy, although not all drugs are equipotent in this regard. Recent studies have shown that such a reduction also improves the pathophysiologic sequelae of LVH, that is, ventricular filling, coronary reserve, and ventricular dysrhythmias, and maintains left ventricular pump function. Although the reversal of these pathophysiologic findings is encouraging, it remains unknown whether a reduction of LVH will ultimately reduce the excessive risk of sudden death, acute myocardial infarction, and congestive heart failure that has been associated with this disorder independent of arterial pressure.

Hypertension, left ventricular hypertrophy, ventricular ectopy, and sudden death

Left ventricular hypertrophy (LVH) is a common sequela of sustained arterial hypertension, although the correlation between spot blood pressure measurements and LV mass is not a close one. LVH has been shown to be a powerful blood pressure-independent risk factor for cardiovascular morbidity and mortality. LVH has been shown to trigger or to accelerate ventricular dysrhythmias, although the connection between ventricular dysrhythmias and sudden death is poorly documented. LVH can be reduced by specific antihypertensive therapy; however, not all drugs are equipotent in this regard. A reduction of LVH has been shown to be associated with a suppression of ventricular dysrythmias. Preliminary studies also indicate that the reduction of LVH may reduce its inherent excessive morbidity and mortality.

Does a reduction in left ventricular hypertrophy reduce cardiovascular morbidity and mortality?

Left ventricular hypertrophy is an important risk factor for sudden death and other cardiovascular morbidity and mortality irrespective of the level of arterial blood pressure. Left ventricular hypertrophy, i.e. an increase in wall thickness at the expense of left ventricular volume, is an adaptive mechanism observed in patients with long standing arterial hypertension. Severe left ventricular hypertrophy is associated with a reduction in left ventricular compliance, impaired coronary reserve, ventricular ectopy, and impaired contractile function. Left ventricular hypertrophy can be reduced by antihypertensive therapy; however, not all antihypertensive agents have the same effect on left ventricular hypertrophy despite their similar effects on arterial blood pressure. Angiotensin converting enzyme (ACE) inhibitors appear to be the most powerful agents for reducing left ventricular hypertrophy, followed by the nondihydropyridine calcium antagonists. In addition to reducing left ventricular mass and arterial blood pressure, certain calcium antagonists also improve left ventricular filling, suppress ventricular ectopy, and maintain or enhance contractile function. However, despite these beneficial effects, it is not known whether the risk of cardiovascular morbidity and mortality can be prevented or reduced by specific antihypertensive agents.