Diastolic heart failure is characterized by increased left ventricular mass, wall thickness, and increased left ventricular end diastolic pressure. Increased myocardial collagen(Drug information on collagen) deposition leads to thickening and impaired compliance and relaxation during diastole. Despite a normal ejection fraction on echocardiography, pulmonary edema and decreased exercise tolerance develop in patients with diastolic heart failure as a result of impaired ventricular filling. Uncontrolled hypertension and excessive dietary salt intake exacerbate clinical symptoms.

Cerebrovascular disease. Hypertension is a major modifiable risk factor for stroke, the third leading cause of death in the United States.¹³ The relationship between systolic hypertension and stroke is linear, and stroke risk rises further when other findings of end-organ damage, particularly LVH, are present.¹⁴

Kidney disease. Chronic kidney disease (CKD) is both a result and a cause of systolic hypertension. Hypertension is common in CKD and becomes more prevalent with the decrease in glomerular filtration rate.¹⁵ As the number of nephrons declines, the kidney loses its ability to regulate salt excretion and, ultimately, BP. Inappropriate activation of the renin-angiotensin system, impaired nitric oxide synthesis, and an overactive sympathetic nervous system have also been implicated in mediating hypertension in renal disease.^16-18  As renal disease worsens, systolic BP increases, which leads in turn to more severe kidney disease.

TREATMENT
Lifestyle interventions. Any therapeutic regimen for managing hypertension should include nonpharmacological interventions. The JNC 7 guidelines recommend limitations on dietary sodium (to 2400 mg/d) and alcohol(Drug information on alcohol) intake, along with weight reduction and aerobic exercise.² Researchers who devised the Dietary Approaches to Stop Hypertension (DASH) diet found that adherence to this diet, which is low in sodium and rich in whole grains, fruits, and vegetables, led to significant reductions in BP compared with a typical American diet.¹⁹ Further reduction of dietary sodium resulted in even larger reductions in SBP for persons with and without hypertension.²⁰

The Prevention of Myocardial Infarction Early Remodeling (PREMIER) trial examined the effects on BP of additional dietary modification, increased physical activity, and limited alcohol intake when combined with the DASH diet. Results demonstrated that the group with the combined interventions had greater reductions in SBP than the groups with less extensive intervention.^21,22  If patients are not sufficiently motivated to strictly follow the DASH approach, we suggest that they avoid adding salt to their food and try as often as possible to eat meals at (or from) home, where salt content can be controlled.

Consumption of more alcohol than what is considered standard (more than 2 drinks at one sitting for women, and more than 3 drinks for men) is associated with elevated BP both acutely and chronically.^23,24  Based on these findings but taking into consideration the evidence of the possible cardioprotective effects of red wine, most experts recommend no more than moderate alcohol intake in patients with hypertension.

Weight loss alone can lead to significant decreases in BP. A study of overweight patients with hypertension demonstrated significant reductions in 24-hour ambulatory BP that correlated with degree of weight loss.²⁵ Patients able to maintain significant weight loss for at least several years also saw modest reductions in BP.²⁶ Unfortunately, many persons find it hard to maintain weight loss, which limits the effectiveness of this therapy.

Increasing physical activity can prevent or reduce hypertension. When compared with persons who remain sedentary, those who engage in aerobic exercise experience significant reductions in BP.²⁷ Effects can be seen with only moderate-intensity exercise, especially with longer duration.²⁸

Pharmacotherapy. Most persons with systolic hypertension require medication along with lifestyle modification to achieve BP goals (Table 1). The goal BP depends on the patient. For patients with isolated systolic hypertension and no other cardiovascular risk factors, the goal is a BP of less than 140/90 mm Hg. Patients with cardiovascular disease risk factors, such as diabetes mellitus, CKD, known coronary artery disease, or previous stroke, benefit from greater BP reduction, with a goal of less than 130/80 mm Hg.

Diuretics. Many experts recommend thiazide diuretics as first-line therapy for uncomplicated hypertension, particularly when the goal is SBP reduction. Results of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) found equivalent or superior protection from cardiovascular end points in the thiazide arm.²⁹

Thiazide diuretics are sometimes associated with adverse metabolic effects, such as glucose intolerance, hyperuricemia, and hypokalemia, and they are less effective in controlling BP in patients with impaired kidney function (men with creatinine levels of about 2 mg/dL, women with levels of about 1.8 mg/dL) than in those with normal kidney function. In patients with impaired renal function, a loop diuretic such as bumetanide(Drug information on bumetanide) is often used. We frequently add amiloride or an aldosterone antagonist, such as spironolactone(Drug information on spironolactone) or eplerenone, as a second diuretic with good results; periodic measurement of potassium levels is required. There is renewed interest in aldosterone antagonists because of their apparent ability to improve vascular remodeling.³⁰