Melissa Walton-Shirley, MD


August 29, 2016

I use a heart model to talk to patients about hypertension. I explain that our arteries and myocardium are like garden hoses and are only meant to tolerate so much PSI. I teach that a BP of >140/90 mm Hg produces fibrosis, heart failure, intracranial bleeding, and stroke. I use my hands to demonstrate the difference between the cleansing squeeze of the left atrial contraction and the writhing erratic fibrillation that begets pooling and mobile clot. I try to make the connection for patients between hypertension and atrial fibrillation by pointing out that hypertension is much more than a number. I joke that cardiologists are to be envied by palm readers and that we're better predictors of their future than the delicate impressions left by tiny tea leaves on a shiny white saucer. Maybe if I modify my talk a bit with a few interesting things reviewed in Sunday's session entitled "Atrial Fibrillation and Hypertension: Implications for Clinical Practice," more patients will change. Here are a few tidbits from that very excellent morning session.

From Dr Maria Angela Losi, University of Naples Federico II, Italy

  • AF can increase the severity of renal dysfunction by loss of left atrial kick and cardiac output.

  • Carotid intima media thickness (CIMT) is a strong independent predictor for future AF in patients with hypertension.

  • Left atrial size dilates in 12% of hypertension-treated patients, but left atrial size can change. Obese women are at the greatest risk for left atrial enlargement. LA size can be used as a goal for treatment.

From Dr Giuseppe Schillaci, University of Perugia, Italy

  • The higher the number of premature atrial complexes (PACs) on 24-hour Holter, the higher the risk of developing AF, but we don't know the cutoff or threshold number yet.

  • Brain natriuretic peptide (BNP), but not CRP, is predictive of AF risk.

  • The definition of hypertension in the CHADS VASC scoring system is the following: Resting BP of >140/90 on at least two occasions or being on current antihypertensive treatment.

From Dr John Camm, St George's University, London, UK

  • Hypertension is associated with coagulation and platelet issues as well as endothelial dysfunction, not just the presence of AF.

  • In rat studies, warfarin increased intracranial bleeding by 30%. Bleeding was reduced to 10% by utilization of apixaban (Eliquis, Bristol-Myers Squibb). If the rats were not hypertensive there was no intracranial bleeding.

  • Modifiable risk factors for bleeding in anticoagulated hypertensive AF patients included systolic BP >160, eight alcoholic drinks per week, NSAID use, and labile INR.

From Dr Tonje Aksnes, Oslo University Hospital, Norway

  • 50% of the population in industrialized countries will develop hypertension.

  • 972 million people in the world suffer from hypertension, and in the near future, this number will rise to 1.5 billion.

  • The presence of hypertension increases the risk of developing AF by twofold.

  • Hypertension is the most important modifiable risk factor for AF and therefore stroke risk.

  • The European Society of Hypertension recommends an ECG for all hypertensive patients to assess for markers of left ventricular hypertrophy and left atrial enlargement and to assess heart rhythm.

  • Even high-normal blood pressures as low as 128 to 138 mm Hg systolic may predict AF risk.

  • Blocking the renin angiotensin system reduces the incidence of AF by as much as 33% and can prevent progression from paroxysmal to persistent AF.

  • There has been no noted difference in benefit between ACE inhibitors and ARB efficacy with regard to the impact of prophylaxis of atrial fibrillation.

The echocardiogram, the ECG, and sometimes a Holter are already on my initial list of orders for patients who walk in the door for hypertension management. I also include a recommendation for proteinuria and retinal screening. I give nearly all of them a copy of both the Mediterranean diet and the DASH diets. More important, I emphasize that risk is changeable. After all, the real reason most patients visit us is to learn their future and whether or not they can change it for the better. Today's talk is just more proof that hypertensive patients surely can.


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