Abnormalities of diastolic function, ranging from asymptomatic heart disease[28][29][30] to overt heart failure,[31][32] are common in hypertensive patients. Patients with diastolic heart failure have a preserved ejection fraction, which is a measure of systolic function.[33][34] Diastolic dysfunction is an early consequence of hypertension-related heart disease and is exacerbated by left ventricular hypertrophy[34][20] and ischemia.
Hypertension is also associated with impaired cognition in an aging population,[42][43][43][44][45] Hypertension-related cognitive impairment and dementia may be a consequence of a single infarct due to occlusion of a "strategic" larger vessel[46] or multiple lacunar infarcts due to occlusive small vessel disease resulting in subcortical white matter ischemia.[47][47][45][47][43] Several clinical trials suggest that antihypertensive therapy has a beneficial effect on cognitive function, although this remains an active area of investigation.[48][49][50]
Hypertensive retinopathy is a condition characterized by a spectrum of retinal vascular signs in people with elevated blood pressure.[56] It was first described by Liebreich in 1859.[57] The retinalcirculation undergoes a series of pathophysiological changes in response to elevated blood pressure.[58] In the initial, vasoconstrictive stage, there is vasospasm and an increase in retinal arteriolar tone owing to local autoregulatory mechanisms. This stage is seen clinically as a generalized narrowing of the retinal arterioles. Persistently elevated blood pressure leads to intimal thickening, hyperplasia of the media wall, and hyaline degeneration in the subsequent, sclerotic, stage. This stage corresponds to more severe generalized and focal areas of arteriolar narrowing, changes in the arteriolar and venular junctions, and alterations in the arteriolar light reflex (i.e., widening and accentuation of the central light reflex, or "copper wiring").[59]
This is followed by an exudative stage, in which there is disruption of the blood–retina barrier, necrosis of the smooth muscles and endothelial cells, exudation of blood and lipids, and retinal ischemia. These changes are manifested in the retina as microaneurysms, hemorrhages, hard exudates, and cotton-wool spots. Swelling of the optic disk may occur at this time and usually indicates severely elevated blood pressure (i.e., malignant hypertension). Because better methods for the control of blood pressure are now available in the general population, malignant hypertension is rarely seen. In contrast, other retinal vascular complications of hypertension, such as macroaneurysms and branch-vein occlusions, are not uncommon in patients with chronically elevated blood pressure. These stages of hypertensive retinopathy however, may not be sequential.[60][58] For example, signs of retinopathy that reflect the exudative stage, such as retinalhemorrhage or microaneurysm, may be seen in eyes that do not have features of the sclerotic stage,[58] The exudative signs are nonspecific, since they are seen in diabetes and other conditions.
In addition to contributing to the pathogenesis of hypertension, blood vessels may be a target organ for atherosclerotic disease secondary to long-standing elevated blood pressure. Hypertensive patients with arterial disease of the lower extremities are at increased risk for future cardiovascular disease. Although patients with stenotic lesions of the lower extremities may be asymptomatic, intermittent claudication is the classic symptom of PAD. This is characterized by aching pain in the calves or buttocks while walking that is relieved by rest. The ankle-brachial index is a useful approach for evaluating PAD and is defined as the ratio of noninvasively assessed ankle to brachial (arm) systolic blood pressure. An ankle-brachial index < 0.90 is considered diagnostic of PAD and is associated with >50% stenosis in at least one major lower limb vessel. Several studies suggest that an ankle-brachial index < 0.80 is associated with elevated blood pressure, particularly systolic blood pressure.
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