Dear Editor:
Hypertension is highly prevalent1-3 and it is the cause of numerous complications, the most common and important of which are of cardiac origin.3-5 In spite of this, no practical classification of hypertensive heart disease (HHD) is available. We present a new trichotomous classification of HHD, similar to the tumor, node, and metastasis (TNM) classification used for cancer.
Hypertension causes both structural and functional changes in the heart that affect both the atrial and the ventricular myocardium, as well as the epicardial and intramural coronary arteries.6-13 These changes give rise to the three main types of heart disease associated with hypertension: heart failure, myocardial ischemia, and atrial fibrillation, which may arise independently or in combination, and involve different degrees of severity and different phases of evolution.
However, the definition and classifications of HHD so far published do not always agree nor do they include all the possibilities. The first classification, proposed by the New York Heart Association, equated HHD to heart failure in a patient with hypertension.14 Later, the definition of HHD was limited to the presence of hypertensive, left ventricular hypertrophy15 or, at most, diastolic dysfunction16 or other purely hemodynamic abnormalities.17 The various classifications of HHD proposed (Table 1) all suffer from the same lack of detail,18-22 in spite of the importance given by the clinical practice guidelines to the detection of hypertension-associated complications when planning treatment.23
We propose the term "hypertensive heart disease" to encompass the complex and variable set of effects that cause the chronic increase in blood pressure in the heart of a patient with hypertension. This nomenclature would therefore include the presence of anatomic16 or biochemical signs17,24 of left ventricular hypertrophy or ventricular dysfunction, be either diastolic or systolic, of myocardial ischemia and rhythm abnormalities.
As a consequence, we propose a trichotomous classification of HHD that contemplates the three main manifestations indicated previously. This type of classification is very common. The most historic is the TNM classification, which has been in use in oncology for over 50 years. Each one of the 3 headings is subsequently assigned a score of 0 to 3 (from the mildest or early forms to the most severe or advanced forms), also of current use in cardiology.
Table 2 summarizes the proposed classification. The denomination "VIA" refers to the three main components: ventricle, ischemia, and arrhythmia. With regard to ventricular involvement, the 3 categories selected correspond to the three phases of the old "hypertensive heart disease:" left ventricular hypertrophy (diagnosed by electrocardiogram, echocardiogram or biochemical markers); diastolic dysfunction, with or without heart failure; and systolic dysfunction, either asymptomatic or symptomatic. The ischemia in patients with hypertension is often due to microvascular dysfunction; in more advanced cases the epicardial coronary vessels may be affected and an acute coronary syndrome may appear. Finally, atrial fibrillation is the most common arrhythmia in hypertension; although a certain degree of overlapping may exist, it usually starts by being paroxystic and finishes by being permanent, and, in certain cases, can be complicated by an embolic event.
