Phenotyping the Hypertensive Heart

Marijana Tadic; Cesare Cuspidi; Thomas H. Marwick


Eur Heart J. 2022;43(38):3794-3810. 

In This Article

Abstract and Introduction


Graphical Abstract

Role of echocardiography and other imaging techniques in patients with hypertension. Echocardiography can assess risk in asymptomatic patients with suboptimal blood pressure (BP) control and other risk factors for left ventricular (LV) dysfunction. In symptomatic patients, echocardiography is helpful for the recognition of target organ damage. Selected individuals, where LV changes are disproportionate to BP may benefit from further imaging testing to exclude other causes for increased LV mass and other pathologic processes. CAD, coronary artery disease; CMR, cardiac magnetic resonance; CTCA, computed tomography coronary angiography; HF, heart failure; HHD, hypertensive heart disease; LVH, left ventricular hypertrophy.

Arterial hypertension remains the most frequent cardiovascular (CV) risk factor, and is responsible for a huge global burden of disease. Echocardiography is the first-line imaging method for the evaluation of cardiac damage in hypertensive patients and novel techniques, such as 2D and D speckle tracking and myocardial work, provide insight in subclinical left ventricular (LV) impairment that would not be possible to detect with conventional echocardiography. The structural, functional, and mechanical cardiac remodelling that are detected with imaging are intermediate stages in the genesis of CV events, and initiation or intensification of antihypertensive therapy in response to these findings may prevent or delay progressive remodelling and CV events. However, LV remodelling—especially LV hypertrophy—is not specific to hypertensive heart disease (HHD) and there are circumstances when other causes of hypertrophy such as athlete heart, aortic stenosis, or different cardiomyopathies need exclusion. Tissue characterization obtained by LV strain, cardiac magnetic resonance, or computed tomography might significantly help in the distinction of different LV phenotypes, as well as being sensitive to subclinical disease. Selective use of multimodality imaging may therefore improve the detection of HHD and guide treatment to avoid disease progression. The current review summarizes the advanced imaging tests that provide morphological and functional data about the hypertensive cardiac injury.


Hypertensive heart disease (HHD) represents a constellation of cardiac modifications induced by arterial hypertension, with multiple phenotypes of left ventricular (LV) structure and function. These changes evolve over time, and their relationship with blood pressure (BP) is confounded by frequently co-existing diseases, including obesity and diabetes (Table 1). Manifestations of HHD may be functional or structural. Although LV hypertrophy (LVH), a consequence of the LV adaptation to chronic pressure load, is a common manifestation of HHD,[1] it is not a sine qua non. Left ventricular hypertrophy may be associated (and even preceded) by LV functional changes including reduced elasticity and compliance and increased LV stiffness, leading to abnormal diastolic function and LV mechanics.[2] Diffuse interstitial myocardial fibrosis is the main histological feature associated with HHD,[3] and it is now possible to visualize and quantify this with advanced imaging techniques, especially cardiac magnetic resonance (CMR).[3] The early recognition of myocardial fibrosis may allow therapeutic responses to prevent the development of heart failure (HF) with preserved or reduced ejection fraction (HFpEF and HFrEF).[3] The transition between HHD and clinical HF is influenced by not only BP control, but also a variety of exogenous influences, including obesity and sleeping disorders (primarily obstructive sleep apnoea).[4,5]

The global prevalence of hypertension was around 1.4 billion in 2010, and is likely to increase to 1.6 billion by 2025.[6] Suboptimal BP control is common—over 2/3 of treated patients—and this is an important driver of the prevalence of HHD. Left ventricular hypertrophy is reported in >40% of hypertensive patients,[7] and LV diastolic dysfunction (LVDD) is present in between 40 and 85%.[8] Hypertensive heart disease is significantly associated with coronary artery disease, stroke, and all-cause mortality.[9]