---
title: Hypertensive heart disease
description: How years of high blood pressure change the heart, why the left ventricular wall thickens and the left atrium enlarges, what this leads to, how heart damage is found, which treatment approaches clinical guidelines describe, and when to call an ambulance.
type: disease
aliases:
  - hypertensive heart
  - HHD
  - left ventricular hypertrophy
  - LVH
sources:
  - tier: guideline
    org: minzdrav-rf
    title: Артериальная гипертензия у взрослых
    year: 2024
    doi: 10.15829/1560-4071-2024-6117
    url: https://cr.minzdrav.gov.ru/view-cr/62_3
  - tier: guideline
    org: minzdrav-rf
    title: Хроническая сердечная недостаточность
    year: 2024
    doi: 10.15829/1560-4071-2024-6162
    url: https://cr.minzdrav.gov.ru/view-cr/156_2
  - tier: guideline
    org: esc
    title: 2026 ESC Guidelines for the management of heart failure
    year: 2026
    doi: 10.1093/eurheartj/ehag100
    url: https://doi.org/10.1093/eurheartj/ehag100
  - tier: guideline
    org: esc
    title: 2024 ESC Guidelines for the management of elevated blood pressure and hypertension
    year: 2024
    doi: 10.1093/eurheartj/ehae178
    url: https://doi.org/10.1093/eurheartj/ehae178
  - tier: reference
    org: msd-manuals
    title: Hypertension (MSD Manual Professional Version)
    year: 2026
    url: https://www.msdmanuals.com/professional/cardiovascular-disorders/hypertension/hypertension
  - tier: reference
    org: msd-manuals
    title: High Blood Pressure (MSD Manual Consumer Version)
    year: 2025
    url: https://www.msdmanuals.com/home/heart-and-blood-vessel-disorders/high-blood-pressure/high-blood-pressure
  - tier: reference
    org: msd-manuals
    title: Acute Heart Failure (MSD Manual Professional Version)
    year: 2026
    url: https://www.msdmanuals.com/professional/cardiovascular-disorders/heart-failure/acute-heart-failure
sources_checked: 2026-10-14
review: null
---

Hypertensive heart disease is the set of changes that develop in the heart when blood pressure stays high for a long time: the heart has to work harder, the wall of the left ventricle thickens and becomes stiffer, the ventricle fills with blood less easily, and over time heart failure may develop.<Cite n={[5, 6]} /> In the International Classification of Diseases (ICD-10) it has its own category.<Cite n={1} /> How high blood pressure itself is found and treated is covered in the article on [hypertension](../hypertension/); this article is about what happens to the heart.

<Diagram name="hypertensive-heart-disease">
  <p slot="normal">
    The diagram shows the left atrium and the left ventricle. The atrium fills the ventricle with
    blood, and the ventricle pumps it to all of the body except the lungs.<Cite n={6} />
  </p>
  <p slot="disease">
    With long-standing high blood pressure the heart has to work harder, and the wall of the left
    ventricle thickens: this is left ventricular hypertrophy.<Cite n={[5, 6]} /> The thickened
    wall is stiffer than normal, so the ventricle fills with blood less easily and the left atrium
    has to contract harder.<Cite n={6} /> An enlarged left atrium is also counted among the signs
    of heart damage caused by hypertension.<Cite n={1} />
  </p>
</Diagram>

## Why it happens

<Patient>

The higher the pressure in the blood vessels, the more resistance the left ventricle has to overcome with every beat. Under this load its wall gradually thickens.<Cite n={[5, 6]} /> Thickened walls are stiffer than normal: the heart's chambers stretch less and are harder to fill with blood, which increases the heart's workload even further.<Cite n={6} /> These changes can lead to abnormal heart rhythms and [heart failure](../heart-failure/).<Cite n={6} />

Early in hypertension the organs show no changes: it is severe or long-standing hypertension that damages the heart, brain and kidneys.<Cite n={5} /> High blood pressure speeds up atherosclerosis, and severe or long-standing hypertension increases the risk of [coronary heart disease](../coronary-heart-disease/) and [heart attack](../myocardial-infarction/).<Cite n={5} /> Why blood pressure rises in the first place is covered in the article on [hypertension](../hypertension/).

</Patient>

<Student>

In ICD-10, hypertensive heart disease is category I11: I11.0 with (congestive) heart failure, I11.9 without it; combined heart and kidney involvement is coded I13.<Cite n={1} /> Increased afterload leads to gradual <Structure id="left-ventricle">left ventricular</Structure> hypertrophy and diastolic dysfunction; the ventricle may eventually dilate, causing dilated cardiomyopathy and heart failure, often worsened by arteriosclerotic coronary artery disease.<Cite n={5} /> Elevated BP leads to generalised arteriolosclerosis and accelerated atherogenesis.<Cite n={5} />

In the Russian Ministry of Health classification, ECG and echocardiographic signs of LVH are asymptomatic hypertension-mediated organ damage (HMOD), that is, stage II hypertensive disease (in the absence of associated clinical conditions). Heart failure, including HF with preserved EF, atrial fibrillation and coronary heart disease (myocardial infarction, angina, myocardial revascularisation) are associated clinical conditions and define stage III. The stage does not depend on the BP level.<Cite n={1} /> ESC: HMOD suggests long-standing or severe hypertension and is associated with increased cardiovascular risk.<Cite n={4} /> In Russia the main causes of chronic heart failure are hypertension and coronary heart disease, and half of patients have both.<Cite n={2} />

</Student>

## Symptoms

<Patient>

For a long time hypertensive heart disease goes unnoticed: high blood pressure usually causes no symptoms until complications develop in the organs.<Cite n={[1, 5]} /> That is why changes in the heart are often found during a check-up rather than because of symptoms.<Cite n={1} />

When [heart failure](../heart-failure/) develops, there is shortness of breath, including when lying down and at night, physical activity becomes harder, the person tires quickly, and the ankles swell. These symptoms also occur in other diseases, so a doctor works out their cause.<Cite n={2} />

High blood pressure is closely linked to [atrial fibrillation](../atrial-fibrillation/).<Cite n={1} /> When it appears in a person with hypertension, the outlook worsens and the risk of stroke and heart failure rises markedly.<Cite n={1} /> Hypertension is the leading risk factor for heart attack and coronary heart disease.<Cite n={1} />

</Patient>

<Student>

Typical HF symptoms are breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, reduced exercise tolerance, fatigue and ankle swelling; they are non-specific.<Cite n={2} /> About half of patients with HF have preserved LVEF.<Cite n={2} /> The Russian Ministry of Health heart failure guideline distinguishes chronic HF with reduced EF (40% or less), mildly reduced EF (41–49%) and preserved EF (50% or more).<Cite n={2} /> The 2026 ESC guideline changed this classification: HFmrEF has been removed, HFrEF now includes LVEF up to 50%, and HFpEF includes LVEF from 50% and above; stages of HF (A–D), ranging from risk factors to advanced HF, have also been adopted.<Cite n={3} /> EF categories in this article follow the Russian Ministry of Health guideline.

There is growing evidence of a close link between hypertension and an increased incidence of AF; hypertension is the most common comorbidity in patients with AF, and AF in a patient with hypertension worsens the prognosis and significantly increases the risk of cardioembolic stroke and HF.<Cite n={1} /> Coronary artery disease is the most common cause of death among treated hypertensive patients.<Cite n={5} />

</Student>

<HeartModel highlight={['left-ventricle', 'left-atrium']} />

## How it is diagnosed

<Patient>

Everyone with hypertension has an ECG: it helps to spot thickening of the left ventricular wall and rhythm disturbances.<Cite n={1} /> An ECG detects thickening less well than an ultrasound scan of the heart (echocardiography), so if the ECG shows changes or there are signs that the left ventricle is not working well, the doctor refers the person for echocardiography.<Cite n={1} /> It shows the structure and function of the heart.<Cite n={1} />

When listening to the heart, one of the earliest changes can be an extra sound, the fourth heart sound. It appears because the left atrium has to contract harder to fill the thickened, stiff ventricle.<Cite n={6} /> If there are signs of heart failure, tests are done as described in the article on [heart failure](../heart-failure/).

</Patient>

<EcgMonitor preset="hypertension">

A synthetic teaching model of the ECG in high blood pressure, not a recording from a real person. An ECG detects thickening of the left ventricular wall less well than echocardiography.<Cite n={1} /> The model does not draw any signs of thickening, so its ECG looks ordinary. Do not compare your own ECG with it.

</EcgMonitor>

<Student>

A 12-lead ECG is recommended for all patients with hypertension to detect LVH and assess cardiovascular risk; the ECG is less sensitive than echocardiography but is indispensable for documenting rhythm and heart rate and for detecting arrhythmias.<Cite n={1} /> ECG criteria for LVH in the Russian Ministry of Health guideline: Sokolow–Lyon index (SV1 + RV5–6) > 35 mm, R wave amplitude in aVL ≥ 11 mm, Cornell voltage (SV3 + RaVL) > 28 mm in men and > 20 mm in women, Cornell product > 2440 mm·ms.<Cite n={1} /> MSD: a broad, notched P wave indicates atrial hypertrophy and, although non-specific, may be one of the earliest signs; elevated QRS voltage, with or without evidence of ischaemia, may appear later and indicates LVH.<Cite n={5} />

Echocardiography to detect LVH is recommended for patients with hypertension who have ECG changes or symptoms or signs of LV dysfunction.<Cite n={1} /> Russian Ministry of Health thresholds for HMOD: LVH, LV mass/BSA > 115 g/m² in men and > 95 g/m² in women, or LV mass indexed to height to the power 2.7 > 50 g/m<sup>2.7</sup> in men and > 47 g/m<sup>2.7</sup> in women; concentric remodelling, RWT ≥ 0.43 with normal LV mass; diastolic dysfunction, septal e′ < 7 cm/s, lateral e′ < 10 cm/s; filling pressure, average E/e′ > 14; left atrial volume index > 34 mL/m²; systolic dysfunction, LV longitudinal strain < 20%.<Cite n={1} />

The 2026 ESC heart failure guideline gives a different, simplified set of echocardiographic criteria supporting a diagnosis of HF with preserved EF: LV hypertrophy, LV mass index ≥ 95 g/m² in women and ≥ 115 g/m² in men or relative wall thickness > 0.42; LA dilatation, volume indexed to BSA > 34 mL/m² in sinus rhythm and > 40 mL/m² in AF; E/e′ > 9 at rest; estimated systolic pulmonary artery pressure > 35 mm Hg or tricuspid regurgitation velocity at rest > 2.8 m/s.<Cite n={3} /> The Russian Ministry of Health and ESC sets differ in purpose and thresholds, and thresholds must not be carried over from one to the other. ESC lists LV hypertrophy and systemic hypertension among the causes of raised natriuretic peptide levels.<Cite n={3} />

</Student>

## How it is treated

<Patient>

The key is to keep blood pressure under control at all times: effective treatment of hypertension prevents most complications and prolongs life.<Cite n={5} /> How this is done with lifestyle and medicines is covered in the article on [hypertension](../hypertension/).

For people with a thickened left ventricular wall, the Russian Ministry of Health guideline recommends a combination of medicines that affect how the ventricle remodels: a blocker of the renin–angiotensin–aldosterone system together with a calcium channel blocker or a water tablet (diuretic).<Cite n={1} /> ACE inhibitors and angiotensin II receptor blockers, with adequate lowering of blood pressure, can prevent the wall from thickening or make the thickening regress.<Cite n={1} />

If heart failure has already developed, it is treated according to heart failure guidelines. Some blood pressure medicines are not recommended in heart failure with reduced ejection fraction.<Cite n={1} /> Atrial fibrillation is treated according to atrial fibrillation guidelines; unless there are contraindications, medicines that reduce blood clotting (anticoagulants) are prescribed to prevent stroke.<Cite n={1} /> The doctor decides which medicines are needed. Do not start, stop or change any medicine on your own.

</Patient>

<Student>

Russian Ministry of Health guideline: a RAAS inhibitor combined with a calcium channel blocker or a diuretic is recommended for all patients with LVH because of its proven effect on LV remodelling (ESC/ESH class I, level A).<Cite n={1} /> ACE inhibitors and ARBs effectively prevent or reverse HMOD, including LVH, with corresponding BP reduction.<Cite n={1} />

Heart failure is managed according to the Russian Ministry of Health chronic heart failure guideline; see the article on [heart failure](../heart-failure/). Non-dihydropyridine calcium channel blockers, imidazoline receptor agonists and alpha-blockers are not recommended in patients with hypertension and HFrEF.<Cite n={1} /> The 2026 ESC guideline recommends strict blood pressure control in patients with hypertension or stage B HF to reduce the risk of HF (class I, level A).<Cite n={3} />

Patients with hypertension and AF are managed according to current AF guidelines; in the absence of contraindications, patients with AF should receive oral anticoagulants to prevent stroke and other embolism, and adequate BP control in these patients reduces the rate of bleeding.<Cite n={1} /> Specific drugs, doses and blood pressure targets are not given here.

</Student>

## When to call an ambulance

Hypertensive heart disease develops over years, but its complications can need urgent help. Acute or worsening heart failure, pulmonary oedema and severe symptoms need immediate hospital treatment.<Cite n={7} /> If breathlessness suddenly gets much worse, especially at rest or lying down, or attacks of severe breathlessness start, call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK).<Cite n={2} />

Chest pain or discomfort should always be taken as a serious symptom: it can be a sign of angina, a heart attack or worsening heart failure.<Cite n={2} /> If the pain does not ease with rest, call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK) straight away and do not wait to see whether it goes away.<Cite n={2} /> The signs of a heart attack are described in the article on [myocardial infarction](../myocardial-infarction/). Fainting or loss of consciousness is a potentially serious situation, and medical help should be sought immediately.<Cite n={2} />

Very high blood pressure together with acute organ damage, for example acute heart failure or acute myocardial ischaemia, is a hypertensive crisis, in which blood pressure must be lowered urgently.<Cite n={1} /> More in the article on [hypertensive crisis](../hypertensive-crisis/); for the signs of stroke in atrial fibrillation, see the article on [atrial fibrillation](../atrial-fibrillation/).

<Quiz />