International joint consensus document on hypertension and cardiac arrhythmias
Hypertension and cardiac arrhythmias: executive summary of a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE)
Hypertensive heart disease leads to cardiac arrhythmias due to structural and functional pathophysiological changes of the myocardium, as well as due to electrolyte abnormalities caused by antihypertensive therapies. This new consensus document covers all aspects of arrhythmias in hypertensive patients and provides up-to-date recommendations for clinical practice. The statement is evidence-based and mostly based on published data. Evidence and expert opinions from several countries are considered. A ranking of recommendations is indicated, a system that is not directly similar to the categorization by official society guideline recommendations, which also include a grade for the level of evidence. Find below a summary of the most important recommendations.
Recommendations for the management of supraventricular arrhythmias
- Oral amiodarone may be considered for the ongoing management of patients with symptomatic supraventricular tachycardia (SVT) who are not candidates for, or prefer not to undergo, catheter ablation, and in whom beta blockers, diltiazem, flecainide, propafenone, sotalol, or verapamil are ineffective or contraindicated.
- The priority in the treatment of patients with AF is stroke prevention, and AF patients with hypertension have a CHA2DS2-VASc score of at least 1. Therefore, effective stroke prevention should be considered with oral anticoagulation (OAC) as well as good BP control.
- With additional stroke risk factors and a CHA2DS2-VASc score ≥2, OAC is recommended, as well-controlled vitamin K antagonist (VKA) [TTR >70%] or a non-VKA oral anticoagulants (NOAC), with a preference for the latter.
- The HAS-BLED score should be used to identify ‘high risk’ patients for bleeding (score ≥3) for more careful review and follow-up, and to address the reversible bleeding risk factors, like uncontrolled hypertension. However, a high HAS-BLED score alone is not a reason to withhold OAC.
- AF ablation is recommended in hypertensive patients with symptomatic AF recurrences despite receiving antiarrhythmic drug therapy, who prefer further rhythm control therapy, and may be considered as first therapy in selected individuals as an alternative to antiarrhythmic drug therapy depending on patient choice, benefit, and risk.
- In patients with re-entrant SVT and isthmus dependent flutter, catheter ablation is recommended and is associated with a high success and low complication rate.
Recommendations for the management of ventricular arrhythmias
- Patients with frequent ventricular premature beats (VPBs), couplets, or non-sustained ventricular arrhythmias (NSVA) should undergo a careful clinical history and examination, blood chemistry, a 12-lead ECG, and a 24-h Holter recording.
- Transthoracic echocardiography should be considered when assessing hypertensive patients with arrhythmias to assess for signs of hypertensive or structural heart disease.
- Exercise testing or other functional testing for ischemia may be considered for patients with suspected CAD and frequent VPBs or associated symptoms, both for assessing suppression or worsening of VPBs and for evaluating the presence of myocardial ischemia. Further non-invasive testing or coronary angiography may be considered if necessary.
- Electrolyte levels, glucose, and thyroid studies should be checked to assess for reversible, secondary causes of increased ventricular ectopy.
- Identification of non-prescription or non-pharmacologic sources of increased adrenergic stimulation, including intake of alcohol, caffeine, other stimulants including recreational drugs, should be documented through history taking in order to provide appropriate counselling and assistance.
- Frequent VPBs and/or non-sustained ventricular tachycardia should prompt investigation for structural heart disease, including with transthoracic echocardiography or cardiac MRI.
- In patients with severe structural heart diseases, such as severe LVH, history of MI and HF, a hemodynamically significant valvular disease, flecainide, or propafenone should be avoided. Sotalol should be avoided in LVH patients. Diltiazem and verapamil are contraindicated in HFrEF.
In their editorial article, Kjeldsen and Wachtell add some comments on AF, as it constitutes >90% of all arrhythmias that occur in people with hypertension and they note that AF is in most cases a typical complication of hypertension, and even more so than stroke or HF.
- In advanced hypertensive disease, the stiff arteries with high hemodynamically increased afterload and stretch of atrial walls with atrial chamber dilation and pressure up into the pulmonary veins may be a key mechanism for promoting unstable electrical properties that lead to AF.
- The relationship between the history of hypertension and the risk of AF persists despite confounding by either extensive vascular disease or diabetes, or possibly these diseases even escalate the relationship.
- When an unfavorable hemodynamic state increases the risk of AF, AF as such should be regarded as target organ damage.
- Taking annual ECGs may still miss a number of patients with new-onset paroxysmal AF, and newer methods for more continuous monitoring in mega-trials are needed.
- Data suggest that reducing left atrial size during antihypertensive therapy translates into reduced risk of new-onset AF.