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Evidence Based Case Reports

Systematic Review in Cohort Study


COMPARISON OF THE INCIDENCE OF HEART FAILURE
BETWEEN PATIENTS WITH UNCONTROLLED
HYPERTENSION AND PATIENTS WITH CONTROLLED
HYPERTENSION

Made by:
Yohanes Mario, 0706259993

Supervised by:
Dr. Yoga Iwanoff Kasmir, SpPD
Consultant of Rheumatology

Department of Internal Medicine


Faculty of Medicine University of Indonesia
Jakarta
September 2011

Evidence Based Case Reports


Systematic Review in Cohort Study
COMPARISON OF THE INCIDENCE OF HEART FAILURE
BETWEEN PATIENTS WITH UNCONTROLLED
HYPERTENSION AND PATIENTS WITH CONTROLLED
HYPERTENSION

Made by:
Yohanes Mario, 0706259993

Supervised by:
Dr. Yoga Iwanoff Kasmir, SpPD
Consultant of Rheumatology

Department of Internal Medicine


Faculty of Medicine University of Indonesia
Jakarta
September 2011

ORIGINALITY STATEMENT
This paper is truly from my work
And all the source that i take and refer to are true

Name

: Yohanes Mario

NPM

: 0706259993

Date

: 3 September 2011

Signature

ANTIPLAGIARISM STATEMENT
I, who sign under, truly state that this report was authored without any
plagiarism according to the valid rule in Universitas Indonesia.
In the later day, if we are proved for plagiating, i will take full responsibility
and accept any penalty from Universitas Indonesia.

Jakarta, 3 September 2011

Yohanes Mario

Evidence Based Case Report


COMPARISON OF THE INCIDENCE OF HEART FAILURE BETWEEN
PATIENTS WITH UNCONTROLLED HYPERTENSION AND PATIENTS
WITH CONTROLLED HYPERTENSION
Mario. Y*
*

Faculty of Medicine Student, University of indonesia, class 2007


Summary Box
Heart failure is a disease that affect the heart and make heart failure. The disease is determined
by prolonged hypertensive condition. Uncontrolled hypertension is the trigger to make
hypertensive heart disease spread among the patient with hypertension.
Total Word Count: 1123 words
Abstract:
Background: Diagnosis of hypertension is made from systolic above 140 mmHg and diastolic
above 90 mmHg. Compliance of patient to take medicine that control hypertension is prevention
from complication. One of the hypertension complication is heart failure.
Aim: knowing the difference of hypertensive heart disease incidence between patients with
uncontrolled hypertension and patients with controlled hypertension.
Method: Pubmed and embase were conducted to search all the study about the role of
uncontrolled hypertension in hypertensive heart disease. There are only one article from pubmed
that approriate to the clinical question. We use uncontrolled hypertension or prolonged
hypertension, male, heart failure or congestive heart failure, published at 2011 as inclusion
criteria. Journals that dont give the information that appropriate to the clinical question, animal
study, published before 2011, RCT study, therapeutic study are excluded.
Result: from a journal by Anand Iyer, BS et all about Uncontrolled Hypertension and Increased
Risk for Incident Heart Failure in Older Adults with Hypertension: Findings from a PropensityMatched Prospective Population Study, we found that incident HF developed in 23% and 26% of
participants with controlled and uncontrolled hypertension

respectively during 13 years of

follow-up (matched hazard ratio {HR} when uncontrolled hypertension was compared with
uncontrolled hypertension,
Conclusion: uncontrolled hypertension have a bigger role than controlled hypertension to make
heart failure

Clinical Scenario
Male, 39 years old came to the Cipto Mangunkusumo hospital with chief complaint dyspnea
since 10 hours before came to hospital. Dyspnea come on effort, dyspnea do not come in night,
dyspnea minimized by rest. Several hours before patient went to a general hospital in Jakarta. He
diagnosed as chronic renal failure. He got some medicine and he felt better. He was sent to
CiptoMangunkusumo Hospital to take approriate treatment. On anamnesis we didnt find
hemoptoe, cough with secretion, febrile, chest pain, nausea and vomit. The patient suffered from
hypertension since 2001 and didnt get medicine, diabetes mellitus since 2009. We didnt find
limbs paresthesia on anamnesis but we found visual disturbance. He said that he suffer from
visual disturbance 1 year ago. We found hypertension and asthma in his family root, but we
didnt find diabetes mellitus. In clinical examination we find that everything in normal limit
except jugular vein pressure 5-1 H20 and edema pretibial.
Introduction
Heart failure (HF) is a clinical syndrome in which an abnormality of cardiac structure or function
is responsible for the inability of the heart to eject or fill with blood at a rate commensurate with
the requirements of the metabolizing tissues. HF results in a constellation of clinical
manifestations, including, in various combinations, circulatory congestion, dyspnea, fatigue, and
weakness. The severity of the clinical manifestations are commonly described according to
criteria developed by the New York Heart Association. HF is a major public health problem in
industrialized nations. It appears to be the only common cardiovascular condition that is
increasing in prevalence and incidence in North America and Europe. In the United States, HF is
responsible for almost 1 million hospital admissions and 50,000 deaths annually. Since HF is
more common in the elderly, its prevalence is likely to continue to increase as the population
ages1.
Rapid elevation of arterial pressure, as may occur in abrupt discontinuation of antihypertensive
medication in patients with hypertension, may result in cardiac decompensation.Cardiac
compensation for the excessive workload imposed by increased systemic pressure is at first
sustained by concentric left ventricular hypertrophy, characterized by an increase in wall
thickness. Ultimately, the function of this chamber deteriorates, the cavity dilates, and the
symptoms and signs of heart failure appear2

Clinical question
Are patient with uncontrolled hypertension more likely to develop heart failure than patient with
controlled hypertension?
Methods
Search strategy

Table 1 search strategy used in pubmed and embase conducted on 3rd September,
2011

A pubmed and embase search were conducted on 3rd September, 2011. We use following
Medical Subject Heading: uncontrolled hypertension , prolonged hypertension, congestive
heart failure, heart failure. The search result are shown in table 1.
Selection criteria
The first filtering based on free article and pay article. The second filtering based on in- and
exclusion criteria. Studies about elderly male population, and published in the last 2 years were
included. Study about, RCT study, therapy, female, and published before 2010 were excluded.
After that, screening title were conducted. After reading the abstract there was one article that
suitable with the query.

Critical appraisal
The only article was appraised by consensus by all authors using validity, importance and
applicability question. The result was shown in table 3.

Table 3 critical appraisal

Discussion
Uncontrolled hypertension was associated with increased risk of other cardiovascular morbidity
and mortality. These findings highlight the importance of hypertension control, in particular the
control of SBP, in reducing the incidence of HF and other adverse outcomes in older adults with
hypertension. This is important as hypertension has the highest attributable risk for incident HF,
and can often be easily controlled3.
The limitation of this study are patients with uncontrolled hypertension defined using the average
of three baseline BP recording, which may be less reliable than 24-hour recording. However, the
higher pre-match prevalence of LVH in our study suggests that those with uncontrolled
hypertension may have had their BP uncontrolled for a long period of time. It is possible that
participants with controlled hypertension at baseline may have developed uncontrolled
hypertension during follow-up and those with uncontrolled hypertension at baseline had their BP

controlled during follow-up. However, such regression dilution is likely to underestimate the true
association and not pose a threat to the validity of our findings5

Conclusion and Recommendation


From this systematic review we can conclude that keeping the blood tension controlled are a
prevention from heart failure.
Currently there is no randomized clinical trial based evidence suggesting that aggressive
lowering of SBP to <140 mm Hg may provide additional benefit in terms of reducing
cardiovascular morbidity and mortality4. We recommend for another study to make RCT study
that observe the role of aggresive lowering SBP to <140 mm Hg in reducing cardiovascular
morbidity and mortality.
Because geriatric patient have another comorbid like diabetes mellitus, kidney insufficiency, and
another else which can be a confounder, we recommend to make prognostic study to measure the
ratio of those confounder. Those comorbid can be confounder for uncontrolled hypertension to
make heart failure.

REFERENCE
1. Kasper et al. Harrisons Principle of Internal Medicine. 16th ed. Philadelphia:
McGrawHill; 2005. Part 8, page 1367
2. Kasper et al. Harrisons Principle of Internal Medicine. 16th ed. Philadelphia:
McGrawHill; 2005. Part 8, page 1467
3. Gottdiener JS, Arnold AM, Aurigemma GP, Polak JF, Tracy RP, Kitzman DW, Gardin
JM,Rutledge JE, Boineau RC. Predictors of congestive heart failure in the elderly: the
Cardiovascular Health Study. J Am Coll Cardiol 2000;35:16281637. [PubMed:
10807470]
4. Port S, Demer L, Jennrich R, Walter D, Garfinkel A. Systolic blood pressure and
mortality. Lancet 2000;355:175180. [PubMed: 10675116]
5. Clarke R, Shipley M, Lewington S, Youngman L, Collins R, Marmot M, Peto R.
Underestimation of risk associations due to regression dilution in long-term follow-up of
prospective studies. Am J Epidemiol 1999;150:341353. [PubMed: 10453810] Iyer et al.
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