Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Comment
  • Published:

Association between heart failure with preserved ejection fraction and hypertensive retinopathy: more questions than answers!

Journal of Human Hypertension volume 32, pages 390–391 (2018)Cite this article

Subjects

It is estimated that almost 50% of all patients who present with clinical heart failure have heart failure with preserved ejection fraction (HFpEF) [1]. Current studies suggest that the incidence of HFpEF appears to be rising [2]. This is often explained by an ageing population with all the risk factors for HFpEF; however, this could also be due to the increased awareness and diagnosis of HFpEF [2]. Patients with HFpEF were first demonstrated to be a distinct group by Gandhi et al. [3] who presented a series of 38 patients who were hypertensive, had signs and symptoms of heart failure and had preserved left ventricular (LV) systolic function on echocardiography. Since then this patients group has been subject to considerable amount of attention and research. They were given many names such as heart failure with normal ejection fraction (HFnEF), diastolic heart failure and finally HFpEF which is now the accepted terminology by both the American and European guidelines. The 2016 European Society of cardiology (ESC) guidelines on the diagnosis and treatment of heart failure [4] define patients as having HFpEF if they have an ejection fraction greater than 50% on echocardiography along with clinical signs and symptoms of heart failure, raised biomarkers and presence of either relevant structural heart disease such as LV hypertrophy (LVH) or left atrial enlargement or the presence of echocardiographic features of diastolic dysfunction.

There have been many attempts to explain the pathophysiological mechanisms involved and various pathogenetic models and explanations have been proposed to explain the heart failure in patients with preserved LV function. It was previously thought that diastolic dysfunction due to a stiff ventricle in elderly hypertensive patients was solely responsible for heart failure in these patients [5]. However, recent research suggests that it is much more complex than that. Paulus et al. [6] suggest a new paradigm in the development of HFpEF which now shifts focus onto microvascular inflammation which in turn leads to increased myocardial stiffness and thereby diastolic dysfunction. Hypertensive retinopathy on the other hand is a well-known vascular complication of hypertension and was first described in 1859 by Liebreich [7]. The primary response of the retinal arterioles to systemic hypertension is vasoconstriction. Sustained hypertension leads to disruption of the blood retinal barrier, increased vascular permeability and secondary arteriolosclerosis [8]. It is also well recognised that the presence of hypertensive retinopathy is an indication of a higher risk of presence of cardiovascular disease and is a risk factor for increased cardiovascular complications [9, 10]. The incidence of both hypertensive retinopathy and LVH increase with the duration of hypertension. One would therefore expect a correlation between hypertensive retinopathy and LVH and thereby diastolic dysfunction.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

References

  1. Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med. 2006;355:251–9.

    Article  PubMed  CAS  Google Scholar 

  2. Andersson C, Vasan RS. Epidemiology of heart failure with preserved ejection fraction. Heart Fail Clin. 2014;10:377–88.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Gandhi SK, Powers JC, Nomeir AM, Fowle K, Kitzman DW, Rankin KM, et al. The pathogenesis of acute pulmonary edema associated with hypertension. N Engl J Med. 2001;344:17–22.

    Article  PubMed  CAS  Google Scholar 

  4. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37:2129–200.

    Article  PubMed  Google Scholar 

  5. Zile MR, Baicu CF, Gaasch WH. Diastolic heart failure--abnormalities in active relaxation and passive stiffness of the left ventricle. N Engl J Med. 2004;350:1953–9.

    Article  PubMed  CAS  Google Scholar 

  6. Paulus WJ, Tschope C. A novel paradigm for heart failure with preserved ejection fraction: comorbidities drive myocardial dysfunction and remodeling through coronary microvascular endothelial inflammation. J Am Coll Cardiol. 2013;62:263–71.

    Article  PubMed  Google Scholar 

  7. Liebreich R. Ophthalmoskopischer Befund bei Morbus Brightii. Albrecht Von Graefes Arch Ophthalmol. 1859;5:265–8.

    Article  Google Scholar 

  8. Chatterjee S, Chattopadhyay S, Hope-Ross M, Lip PL. Hypertension and the eye: changing perspectives. J Hum Hypertens. 2002;16:667–75.

    Article  PubMed  CAS  Google Scholar 

  9. Duncan BB, Wong TY, Tyroler HA, Davis CE, Fuchs FD. Hypertensive retinopathy and incident coronary heart disease in high risk men. Br J Ophthalmol. 2002;86:1002–6.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  10. Wong TY, Klein R, Sharrett AR, Duncan BB, Couper DJ, Tielsch JM, et al. Retinal arteriolar narrowing and risk of coronary heart disease in men and women. The Atherosclerosis Risk in Communities Study. JAMA. 2002;287:1153–9.

    PubMed  Google Scholar 

  11. Fantini F, Adhyapak SM, Varghese K, Varghese M, Thomas T. Two heart failure phenotypes in arterial hypertension: a clinical study. J Hum Hypertens. 2017.

  12. Kanar BG, Kanar HS, Karatay A, Tigen K, Sonmez A. Assessment of left atrium and diastolic dysfunction in patients with hypertensive retinopathy: a real-time three-dimensional echocardiography-based study. Clin Exp Hypertens. 2017;39:696–704.

    Article  PubMed  CAS  Google Scholar 

  13. Yu CM, Lin H, Yang H, Kong SL, Zhang Q, Lee SW. Progression of systolic abnormalities in patients with “isolated” diastolic heart failure and diastolic dysfunction. Circulation. 2002;105:1195–201.

    Article  PubMed  Google Scholar 

  14. Bench T, Burkhoff D, O’Connell JB, Costanzo MR, Abraham WT, St John SM, et al. Heart failure with normal ejection fraction: consideration of mechanisms other than diastolic dysfunction. Curr Heart Fail Rep. 2009;6:57–64.

    Article  PubMed  Google Scholar 

  15. Paulus WJ, van Ballegoij JJ. Treatment of heart failure with normal ejection fraction: an inconvenient truth! J Am Coll Cardiol. 2010;55:526–37.

    Article  PubMed  Google Scholar 

  16. Massie BM, Carson PE, McMurray JJ, Komajda M, McKelvie R, Zile MR, et al. Irbesartan in patients with heart failure and preserved ejection fraction. N Engl J Med. 2008;359:2456–67.

    Article  PubMed  CAS  Google Scholar 

  17. Pitt B, Pfeffer MA, Assmann SF, Boineau R, Anand IS, Claggett B, et al. Spironolactone for heart failure with preserved ejection fraction. N Engl J Med. 2014;370:1383–92.

    Article  PubMed  CAS  Google Scholar 

  18. Yusuf S, Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, et al. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. Lancet. 2003;362:777–81.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Medicine, Sultan Qaboos University Hospital, 123, Muscat, Oman

    Sunil K. Nadar

Authors
  1. Sunil K. Nadar
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sunil K. Nadar.

Ethics declarations

Conflict of interest

The author declares that he has no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nadar, S.K. Association between heart failure with preserved ejection fraction and hypertensive retinopathy: more questions than answers!. J Hum Hypertens 32, 390–391 (2018). https://doi.org/10.1038/s41371-017-0022-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41371-017-0022-1

Search

Advanced search

Quick links