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Characterisation of hypertensive heart disease: pathological insights from a sudden cardiac death cohort to inform clinical practice


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.

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Fig. 1: A flowchart illustrating the selection of cases for inclusion into the study and for inclusion into collagen quantification.
Fig. 2: The macroscopic and microscopic appearance of hypertensive heart disease.
Fig. 3: Population pyramid and scatterplot of weight and heart weight.
Fig. 4: Collagen percentage in the right ventricle (RV) and left ventricle (LV) for 10 hypertensive heart disease cases vs age and sex matched non-cardiac death controls as assessed by picrosirius red staining and semi-autonomous quantification using Visiopharm software.


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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.

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Correspondence to J. D. Westaby.

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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).

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