Hypertensive heart disease refers to changes in the myocardium that result from hypertension. The relationship between hypertensive heart disease and sudden cardiac death is well established, but there are few pathological studies. We examined the clinical and pathological features of hypertensive heart disease in sudden cardiac death victims from a national cardiovascular pathology registry. We investigated 5239 cases of sudden cardiac death between 1994 and 2018. Hearts were examined by two expert cardiac pathologists. Diagnostic criteria included history of hypertension, increased heart weight and left ventricular wall thickness in the absence of other causes. Collagen was quantified using picrosirius red staining and imaging software. Of 75 sudden cardiac death cases due to hypertensive heart disease (age at death: 54 ± 16 years; 56% males), 56 (75%) reported no prior cardiac symptoms. Thirty-four (45%) recorded a BMI ≥ 30. Only two (2.7%) had hypertensive heart disease diagnosed antemortem. Four (5%) were diagnosed clinically with hypertrophic cardiomyopathy, but lacked myocyte disarray at autopsy. All hearts showed concentric left ventricular hypertrophy and myocyte hypertrophy. Fibrosis was identified microscopically in 59 cases (81%). The posterior left ventricular wall showed the greatest increase in the percentage of collagen in hypertensive diseased hearts compared to controls (25.2% vs 17.9%, p = 0.034). Most sudden deaths due to hypertensive heart disease occur without prior cardiac symptoms; thus, clinical risk stratification is challenging. Hypertensive heart disease can be misdiagnosed in life as hypertrophic cardiomyopathy which has major implications for relatives. Pathologists require a history of hypertension and histology for a definitive diagnosis of hypertensive heart disease.
This is a preview of subscription content, access via your institution
Subscribe to Journal
Get full journal access for 1 year
only $9.92 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Tax calculation will be finalised during checkout.
Get time limited or full article access on ReadCube.
All prices are NET prices.
Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K. et al. Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries. Circulation. 2016;134:441–50.
Whelton PK, Carey RM, Aronow WS, Casey DE,Jr., Collins KJ, Dennison Himmelfarb C. et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:2199–269.
Grossman W, Paulus WJ. Myocardial stress and hypertrophy: a complex interface between biophysics and cardiac remodeling. J Clin Investig. 2013;123:3701–3.
Berk BC, Fujiwara K, Lehoux S. ECM remodeling in hypertensive heart disease. J Clin Investig. 2007;117:568–75.
Diez J. Mechanisms of cardiac fibrosis in hypertension. J Clin Hypertens. 2007;9:546–50.
Messerli FH. Hypertension and sudden cardiac death. Am J Hypertens. 1999;12:181S–8S.
Stevens SM, Reinier K, Chugh SS. Increased left ventricular mass as a predictor of sudden cardiac death: is it time to put it to the test? Circ Arrhythm Electrophysiol. 2013;6:212–7.
UK Office for National Statistics – Mortality statistics - underlying cause, sex and age (2013 to 2019).
Knight B. The myocardium in sudden death from hypertensive heart disease or aortic stenosis. Med Sci law. 1973;13:280–4.
Anderson KR. Hypertension and sudden cardiac death. NZ Med J. 1982;95:33–4.
Srinivasan NT, Schilling RJ. Sudden cardiac death and arrhythmias. Arrhythm Electrophysiol Rev. 2018;7:111–7.
Mellor G, Raju H, de Noronha SV, Papadakis M, Sharma S, Behr ER, et al. Clinical characteristics and circumstances of death in the sudden arrhythmic death syndrome. Circ Arrhythm Electrophysiol. 2014;7:1078–83.
Miles C, Westaby J, Ster IC, Asimaki A, Boardman P, Joshi A, et al. Morphometric characterization of collagen and fat in normal ventricular myocardium. Cardiovasc Pathol. 2020;48:107224.
Verdecchia P, Angeli F, Cavallini C, Aita A, Turturiello D, De Fano M, et al. Sudden cardiac death in hypertensive patients. Hypertension. 2019;73:1071–8.
Sheppard MN. The heart in Fabry’s disease. Cardiovasc Pathol. 2011;20:8–14.
Finocchiaro, G, Dhutia, H, Gray, B, Ensam, B, Papatheodorou, S, Miles, C, et al. Diagnostic yield of hypertrophic cardiomyopathy in first-degree relatives of decedents with idiopathic left ventricular hypertrophy. Europace. 2020;22:632–42.
Judd E, Calhoun DA. Management of hypertension in CKD: beyond the guidelines. Adv Chronic Kidney Dis. 2015;22:116–22.
Nyflot LT, Ellingsen L, Yli BM, Oian P, Vangen S. Maternal deaths from hypertensive disorders: lessons learnt. Acta Obstet Gynecol Scand. 2018;97:976–87.
Winkel BG, Risgaard B, Bjune T, Jabbari R, Lynge TH, Glinge C, et al. Gender differences in sudden cardiac death in the young-a nationwide study. BMC Cardiovasc Disord. 2017;17:19.
Everett B, Zajacova A. Gender differences in hypertension and hypertension awareness among young adults. Biodemogr Soc Biol. 2015;61:1–17.
Sandberg K, Ji H. Sex differences in primary hypertension. Biol Sex Differ. 2012;3:7.
Reckelhoff JF. Gender differences in the regulation of blood pressure. Hypertension 2001;37:1199–208.
Cuspidi C, Rescaldani M, Sala C, Grassi G. Left-ventricular hypertrophy and obesity: a systematic review and meta-analysis of echocardiographic studies. J Hypertens. 2014;32:16–25.
Bogle BM, Ning H, Goldberger JJ, Mehrotra S, Lloyd-Jones DM. A simple community-based risk-prediction score for sudden cardiac death. Am J Med. 2018;131:532–539 e535.
Russo I, Frangogiannis NG. Diabetes-associated cardiac fibrosis: Cellular effectors, molecular mechanisms and therapeutic opportunities. J Mol Cell Cardiol. 2016;90:84–93.
Rodrigues JC, Amadu AM, Dastidar AG, Szantho G, Ratcliffe LE, Burchell AE, et al. Insights into hypertensive heart disease phenotypes: spectrum of myocyte, interstitial and vascular changes by cardiovascular MRI. Heart. 2016;102:A4
Ravassa S, Lopez B, Querejeta R, Echegaray K, San Jose G, Moreno MU, et al. Phenotyping of myocardial fibrosis in hypertensive patients with heart failure. Influence on clinical outcome. J Hypertens. 2017;35:853–61.
Weidemann F, Herrmann S, Stork S, Niemann M, Frantz S, Lange V, et al. Impact of myocardial fibrosis in patients with symptomatic severe aortic stenosis. Circulation 2009;120:577.
Waterhouse DF, Ismail TF, Prasad SK, Wilson MG, O’Hanlon R. Imaging focal and interstitial fibrosis with cardiovascular magnetic resonance in athletes with left ventricular hypertrophy: implications for sporting participation. Br J Sports Med. 2012;46:i69–77.
Shenasa M, Shenasa H. Hypertension, left ventricular hypertrophy, and sudden cardiac death. Int J Cardiol. 2017;237:60–63.
Lip GY, Felmeden DC, Li-Saw-Hee FL, Beevers DG. Hypertensive heart disease. A complex syndrome or a hypertensive ‘cardiomyopathy’? Eur heart J. 2000;21:1653–65.
Aro AL, Chugh SS. Clinical diagnosis of electrical versus anatomic left ventricular hypertrophy: prognostic and therapeutic implications. Circ Arrhythm Electrophysiol. 2016;9:e003629.
Taverny G, Mimouni Y, LeDigarcher A, Chevalier P, Thijs L, Wright JM, et al. Antihypertensive pharmacotherapy for prevention of sudden cardiac death in hypertensive individuals. Cochrane Database Syst Rev. 2016;3:CD011745.
We would like to thank Cardiac Risk in the Young (CRY) for funding the cardiovascular laboratories located at St George’s, University of London.
The cardiovascular pathology laboratories at St George’s University of London are funded by Cardiac Risk in the Young. JW is funded by CRY and was funded by the National Institute for Health Research. CM is funded by the British Heart Foundation.
Conflict of interest
The authors declare no competing interest.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Westaby, J.D., Miles, C., Chis Ster, I. et al. Characterisation of hypertensive heart disease: pathological insights from a sudden cardiac death cohort to inform clinical practice. J Hum Hypertens 36, 246–253 (2022). https://doi.org/10.1038/s41371-021-00507-6
This article is cited by
Diffuse uptake of [68Ga]Ga-FAPI in the left heart in a patient with hypertensive heart disease by PET/CT
Journal of Nuclear Cardiology (2021)