Submitted Successfully!
To reward your contribution, here is a gift for you: A free trial for our video production service.
Thank you for your contribution! You can also upload a video entry or images related to this topic.
Version Summary Created by Modification Content Size Created at Operation
1 -- 1418 2022-04-24 18:12:22 |
2 format correction Meta information modification 1418 2022-04-25 03:24:22 |

Video Upload Options

Do you have a full video?


Are you sure to Delete?
If you have any further questions, please contact Encyclopedia Editorial Office.
Blasi, F.; De Ponti, R.; Marazzato, J.; Golino, M.; Verdecchia, P.; Angeli, F. Hypertension and Arrhythmias. Encyclopedia. Available online: (accessed on 24 April 2024).
Blasi F, De Ponti R, Marazzato J, Golino M, Verdecchia P, Angeli F. Hypertension and Arrhythmias. Encyclopedia. Available at: Accessed April 24, 2024.
Blasi, Federico, Roberto De Ponti, Jacopo Marazzato, Michele Golino, Paolo Verdecchia, Fabio Angeli. "Hypertension and Arrhythmias" Encyclopedia, (accessed April 24, 2024).
Blasi, F., De Ponti, R., Marazzato, J., Golino, M., Verdecchia, P., & Angeli, F. (2022, April 24). Hypertension and Arrhythmias. In Encyclopedia.
Blasi, Federico, et al. "Hypertension and Arrhythmias." Encyclopedia. Web. 24 April, 2022.
Hypertension and Arrhythmias

Because of demographic aging, the prevalence of arterial hypertension (HTN) and cardiac arrhythmias, namely atrial fibrillation (AF), is progressively increasing. Not only are these clinical entities strongly connected, but, acting with a synergistic effect, their association may cause a worse clinical outcome in patients already at risk of ischemic and/or haemorrhagic stroke and, consequently, disability and death.

hypertension atrial fibrillation primary hyperaldosteronism

1. Introduction

The overall prevalence of hypertension (HTN) in adults is roughly 30–45% [1] and becomes even more common with advancing age [2]. HTN is also a well-known risk factor for atrial fibrillation (AF) [3][4][5], which may even occur when borderline values of blood pressure (BP) are recorded [6][7][8][9][10]. Moreover, AF exerts an important prognostic role in hypertensive patients, thus potentially leading to ischaemic and haemorrhagic stroke, hospitalisations for heart failure, and, in the worst circumstances, death [10][11][12]. Therefore, it stands to reason that primary prevention measures devoted to reducing incident AF are required to avoid potentially troublesome cardiac and cerebrovascular events which may occur in this clinical scenario. Moreover, increasing age and the associated burden of other comorbidities such as diabetes mellitus, heart failure, coronary artery disease, chronic kidney disease, obesity, and obstructive sleep apnea would synergistically act with HTN as major contributors to AF development and progression [10].

2. Common Pathophysiological Aspects Explaining the Link between Hypertension and Cardiac Arrhythmias

As observed in animal models, HTN per se is associated with ion channel imbalance and the progressive development of myocardial fibrosis in hypertensive hearts [13][14][15]. The ensuing molecular and structural alterations would therefore represent a fertile substrate for arrhythmogenesis. On the one hand, HTN-related shear stress would lead to both a long outward potassium (K+) current (Kv1.5) [13] and the altered release of intracellular calcium (Ca2+) from the sarcoplasmic reticulum [14], thus leading to a shorter action potential duration and delayed afterdepolarizations (DAD) in myocardial cells, respectively. In fact, a shorter action potential duration would predispose to enhanced automatism and re-entrant mechanisms [16]. In addition to ion channel abnormalities, HTN is also associated with maladaptive gap junction remodelling due to the abnormal expression of gap junction proteins such as connexin 43 and 40 [15][17] which would determine the abnormal conduction properties and fibrotic evolution of myocardial tissue, thus prompting nonuniform anisotropy, slow conduction, and, therefore, arrhythmogenesis in hypertensive hearts. In addition to this, cardiovascular risk factors, HTN included, are accompanied by low-grade inflammation and oxidative stress, which further promote ion channels and connexin downregulation/dysfunction, abnormal Ca2+ handling, and, finally, the activation of profibrotic signaling, which would all promote arrhythmogenesis [18].
Furthermore, as displayed on Figure 1, the HTN-related activation of the renin–angiotensin–aldosterone (RAA) cascade and sympathetic nervous system (SNS), in addition to myocardial ischemia in hypertrophic hearts, would also play a major role in the pathogenesis of cardiac arrhythmias in HTN [19][20].
Figure 1. Electro-pathological and clinical changes occurring in hypertensive hearts. ARP, atrial refractory period; SNS, sympathetic nervous system; CV, conduction velocity; CX43, connexin 43; DADs, delayed afterdepolarizations; EADs, early afterdepolarizations; ECM, extracellular matrix; LA, left atrial; LA Vol, left atrial volume; LV, left ventricular; RAAS, renin–angiotensin–aldosterone system. See text for further details.

3. Early Detection of Atrial Fibrillation in Hypertensive Patients: A Proposed Algorithm

Despite all efforts to prevent AF in hypertensive patients, structural heart disease and atrial cardiomyopathy in this setting would nonetheless cause progressive atrial derangement and electrical vulnerability, thus promoting a vicious cycle known as “atrial failure”, which is intimately connected with AF development [21].
It is well known that AF is a potentially life-threatening cause of cerebral thromboembolism, and clinically silent forms might wreak even greater havoc if not recognised in a timely manner. For these reasons, hypertensive patients with an uncertain history of AF and evidence of prior cerebrovascular events should be accurately studied to differentiate strokes of cardioembolic origin from those secondary to atherosclerotic disease or cerebral haemorrhage [22]. In these cases, ECG monitoring can be helpful to identify patients with clinically silent AF [23][24], and, in the case of cryptogenic stroke, an implantable cardiac monitor (ICM) should be considered [10]. Over the last decade, cardiac implantable electronic devices (CIEDs) [25], ICM included [26], have proved extremely helpful in the early detection of subclinical AF episodes, but it is still debated which arrhythmic burden should prompt immediate oral anticoagulation in these patients. For the sake of clarity, clinically silent AF is defined for asymptomatic arrhythmia episodes detected on 12-lead ECG or an ECG strip; conversely, subclinical AF is represented by arrhythmia detected by CIEDs [10]. However, differentiating clinical from subclinical AF is not a matter of mere speculation. In fact, subclinical AF seems to portend a lower thromboembolic risk compared with clinical AF [27], and no clear cause–effect relationship between subclinical AF and ischemic stroke has been clearly proven in this setting [25]. However, the longer the duration of subclinical AF episodes, the greater their association with thromboembolic events [28]. For this reason, a recent European Heart Rhythm Association (EHRA) consensus document suggested oral anticoagulation administration for subclinical AF episodes longer than 5.5 h/day only when a significant risk of cerebral thromboembolism is established (i.e, CHA2DS2Vasc scores ≥ 2 and 3 in men and women, respectively) [27]. Whether this strategy pays off in terms of better clinical outcome is unclear. In fact, by randomising elderly patients with stroke risk factors and no AF history to the ICM strategy or usual care, the LOOP study did not prove the superiority of ICM over controls in terms of better clinical outcome after early AF detection [26]. Several issues raised by the same investigators might explain the overall negative results of this trial, such as the inadequate estimate of the primary outcome event rate, the relatively short duration of follow-up, and the initiation of oral anticoagulation for subclinical episodes lasting as low as 6 min. In keeping with prior observations [28], these results would suggest that not all subclinical AF episodes may benefit from early anticoagulation, and two ongoing randomized controlled trials might provide clearer answers in patients with CIEDs [29][30].
Moreover, in this already hazy scenario, it is all but crystal-clear which hypertensive patients with neither stroke history nor CIEDs/ICM should be screened for silent AF, and, not least, through which modality. On the one hand, the burden of cardiovascular comorbidities and blood biomarkers might play an important role in identifying people at a sufficient risk to warrant AF screening [31]. The thorough assessment of the P wave morphology on surface ECG may also be useful in identifying potential risk markers for AF, such as prolonged P wave duration, left atrial enlargement, and advanced interatrial (i.e., Bachmann bundle) block. [32]. Similar observation can be made for LVH, diastolic dysfunction, and left atrial enlargement as assessed on transthoracic echocardiogram [32]. However, what would be the best approach for AF screening in high-risk patients? On one side of the spectrum of the available modalities for AF screening, on account of the low cost and the great sensitivity yield, radial pulse taking should be regarded as the first option to be offered in patients aged ≥65 years and deemed at high risk of developing AF. Surface ECG analysis in the case of arrhythmic pulse is therefore warranted, and, if clinical AF is confirmed, oral anticoagulation should be promptly administered according to the patient’s thromboembolic risk profile [10]. Furthermore, a variety of screening technologies have been developed over the years and with progressively better AF detection accuracy [33], but no comparative trials have been carried out so far with any of these devices. Accordingly, European guidelines on AF diagnosis and management [10] strongly recommend a single-lead ECG tracing of ≥30 s or 12-lead ECG to confirm a diagnosis of clinical AF when detected by screening tools. Although similar observation can be applied to the use of ICM in the same setting, the positive clinical interaction observed in the LOOP trial between high blood pressure values and better clinical outcome in early anticoagulated patients in the ICM arm may prompt the use of an implantable loop recorder (ILR) as a screening tool in selected patients with HTN.
In conclusion, AF detection in its early stage is paramount, and an appropriate therapy might eschew severe complications potentially leading to disability and death in the affected patients. However, it should be ascertained which patients portend a greater risk of AF and thereby who should be screened for this arrhythmia and by which modality. While waiting for sounder results from ongoing clinical trials, Figure 2 provides a proposed algorithm for silent/subclinical AF detection and management in hypertensive patients.
Figure 2. Proposed algorithm for early detection and management of silent and subclinical atrial fibrillation episodes. AF = atrial fibrillation; CIED = cardiac implantable electronic devices; ICM = internal cardiac monitor; ILR = internal loop recorder; HTN = hypertension.


  1. Williams, B.; Mancia, G.; Spiering, W.; Agabiti Rosei, E.; Azizi, M.; Burnier, M.; Clement, D.L.; Coca, A.; de Simone, G.; Dominiczak, A.; et al. ESC/ESH Guidelines for the Management of Arterial Hypertension, The Task Force for the Management of Arterial Hypertension of the European Society of Cardiology and the European Society of Hypertension, The Task Force for the Management of Arterial Hypertension of the European Society of Cardiology and the European Society of Hypertension. J. Hypertens. 2018, 36, 1953–2041.
  2. Chow, C.K.; Teo, K.K.; Rangarajan, S.; Islam, S.; Gupta, R.; Avezum, A.; Bahonar, A.; Chifamba, J.; Dagenais, G.; Diaz, R.; et al. PURE Study Investigators. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA 2013, 310, 959–968.
  3. Lip, G.Y.H.; Coca, A.; Kahan, T.; Boriani, G.; Manolis, A.S.; Olsen, M.H.; Oto, A.; Potpara, T.S.; Steffel, J.; Marín, F.; et al. Hypertension and cardiac arrhythmias, A consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLEACE). Europace 2017, 19, 891–911.
  4. Laukkanen, J.A.; Khan, H.; Kurl, S.; Willeit, P.; Karppi, J.; Ronkainen, K.; Di Angelantonio, E. Left ventricular mass and the risk of sudden cardiac death, A population based study. J. Am. Heart Assoc. 2014, 3, e001285.
  5. Manolis, A.; Doumas, M.; Poulimenos, L.; Kallistratos, M.; Mancia, G. The unappreciated importance of blood pressure in recent and older atrial fibrillation trials. J. Hypertens. 2013, 31, 2109–2117.
  6. Conen, D.; Tedrow, U.B.; Koplan, B.A.; Glynn, R.J.; Buring, J.E.; Albert, C.M. Influence of systolic and diastolic blood pressure on the risk of incident atrial fibrillation in women. Circulation 2009, 119, 2146–2152.
  7. Grundvold, I.; Skretteberg, P.T.; Liestøl, K.; Erikssen, G.; Kjeldsen, S.E.; Arnesen, H.; Erikssen, J.; Bodegard, J. Upper normal blood pressures predict incident atrial fibrillation in healthy middle-aged men, A 35-year follow-up study. Hypertension 2012, 59, 198–204.
  8. Nalliah, C.J.; Sanders, P.; Kalman, J.M. The impact of diet and lifestyle on atrial fibrillation. Curr. Cardiol. Rep. 2018, 20, 137.
  9. Dzeshka, M.S.; Shantsila, A.; Shantsila, E.; Lip, G.Y.H. Atrial fibrillation and hypertension. Hypertension 2017, 70, 854–861.
  10. Hindricks, G.; Potpara, T.; Dagres, N.; Arbelo, E.; Bax, J.J.; Blomström-Lundqvist, C.; Boriani, G.; Castella, M.; Dan, G.A.; Dilaveris, P.E.; et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur. Heart J. 2021, 42, 373–498.
  11. Lip, G.Y.; Andreotti, F.; Fauchier, L.; Huber, K.; Hylek, E.; Knight, E.; Lane, D.; Levi, M.; Marín, F.; Palareti, G.; et al. European Heart Rhythm Association. Bleeding risk assessment and management in atrial fibrillation patients. Executive summary of a position document from the European Heart Rhythm Association , endorsed by the European Society of Cardiology working group on thrombosis. Thromb. Haemost. 2011, 106, 997–1011.
  12. Palareti, G.; Cosmi, B. Bleeding with anticoagulation therapy—who is at risk, and how best to identify such patients. Thromb. Haemost. 2009, 102, 268–278.
  13. Boycott, H.E.; Barbier, C.S.; Eichel, C.A.; Costa, K.D.; Martins, R.P.; Louault, F.; Dilanian, G.; Coulombe, A.; Hatem, S.N.; Balse, E. Shear stress triggers insertion of voltage-gated potassium channels from intracellular compartments in atrial myocytes. Proc. Natl. Acad. Sci. USA 2013, 110, E3955–E3964.
  14. Woo, S.H.; Risius, T.; Morad, M. Modulation of local Ca2+ release sites by rapid fluid puffing in rat atrial myocytes. Cell Calcium 2007, 41, 397–403.
  15. Fialova, M.; Dlugosova, K.; Okruhlicová, L.; Kristek, F.; Manoach, M.; Tribulová, N. Adaptation of the heart to hypertension is associated with maladaptive gap junction connexin-43 remodeling. Physiol. Res. 2008, 57, 7–11.
  16. Lau, D.H.; Mackenzie, L.; Kelly, D.J.; Psaltis, P.J.; Brooks, A.G.; Worthington, M.; Rajendram, A.; Kelly, D.R.; Zhang, Y.; Kuklik, P.; et al. Hypertension and atrial fibrillation, Evidence of progressive atrial remodeling with electrostructural correlate in a conscious chronically instrumented ovine model. Heart Rhythm. 2010, 7, 1282–1290.
  17. Tribulova, N.; Bacova, B.S.; Benova, T.; Viczenczova, C. Can we protect from malignant arrhythmias by modulation of cardiac cell-to-cell coupling? J Electrocardiol. 2015, 48, 434–440.
  18. Andelova, K.; Bacova, B.S.; Sykora, M.; Hlivak, P.; Barancik, M.; Tribulova, N. Mechanisms Underlying Antiarrhythmic Properties of Cardioprotective Agents Impacting Inflammation and Oxidative Stress. Int. J. Mol. Sci. 2022, 23, 1416.
  19. Verdecchia, P.; Angeli, F.; Reboldi, G. Hypertension and Atrial Fibrillation. Doubts and Certainties from Basic and Clinical Studies. Circ Res. 2018, 122, 352–368.
  20. Afzal, M.R.; Savona, S.; Mohamed, O.; Mohamed-Osman, A.; Kalbfleisch, S.J. Hypertension and Arrhythmias. Heart Failure Clin. 2019, 15, 543–550.
  21. Boriani, G.; Imberti, J.F.; Vitolo, M. The challenge to improve knowledge on the interplay between subclinical atrial fibrillation, atrial cardiomyopathy, and atrial remodeling. J. Cardiovasc. Electrophysiol. 2021, 32, 1364–1366.
  22. Rabkin, S.W.; Moe, G. The case against using hypertension as the only criterion for oral anticoagulation in atrial fibrillation. Can. J. Cardiol. 2015, 31, 576–579.
  23. Freedman, B.; Camm, J.; Calkins, H.; Healey, J.S.; Rosenqvist, M.; Wang, J.; Albert, C.M.; Anderson, C.S.; Antoniou, S.; Benjamin, E.J.; et al. AF-Screen Collaborators. Screening for atrial fibrillation, A report of the AF-SCREEN International Collaboration. Circulation 2017, 135, 1851–1867.
  24. Healey, J.S.; Alings, M.; Ha, A.; Leong-Sit, P.; Birnie, D.H.; de Graaf, J.J.; Freericks, M.; Verma, A.; Wang, J.; Leong, D.; et al. ASSERT-II Investigators. Subclinical atrial fibrillation in older patients. Circulation 2017, 136, 1276–1283.
  25. Healey, J.S.; Connolly, S.J.; Gold, M.R.; Israel, C.W.; Van Gelder, I.C.; Capucci, A.; Lau, C.P.; Fain, E.; Yang, S.; Bailleul, C.; et al. ASSERT Investigators. Subclinical atrial fibrillation and the risk of stroke. N. Engl. J. Med. 2012, 366, 120–129, Erratum in N. Engl. J. Med. 2016, 374, 998.
  26. Svendsen, J.H.; Diederichsen, S.Z.; Højberg, S.; Krieger, D.W.; Graff, C.; Kronborg, C.; Olesen, M.S.; Nielsen, J.B.; Holst, A.G.; Brandes, A.; et al. Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study), A randomised controlled trial. Lancet 2021, 398, 1507–1516, Erratum in Lancet 2021, 398, 1486.
  27. Gorenek, B.; Bax, J.; Boriani, G.; Chen, S.A.; Dagres, N.; Glotzer, T.V.; Healey, J.S.; Israel, C.W.; Kudaiberdieva, G.; Levin, L.Å.; et al. ESC Scientific Document Group. Device-detected subclinical atrial tachyarrhythmias, Definition, implications and management-an European Heart Rhythm Association (EHRA) consensus document, endorsed by Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2017, 19, 1556–1578, Erratum in Europace 2017, 19, 1507; Erratum in Europace 2018, 20, 658.
  28. Van Gelder, I.C.; Healey, J.S.; Crijns, H.J.G.M.; Wang, J.; Hohnloser, S.H.; Gold, M.R.; Capucci, A.; Lau, C.P.; Morillo, C.A.; Hobbelt, A.H.; et al. Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT. Eur. Heart J. 2017, 38, 1339–1344.
  29. Lopes, R.D.; Alings, M.; Connolly, S.J.; Beresh, H.; Granger, C.B.; Mazuecos, J.B.; Boriani, G.; Nielsen, J.C.; Conen, D.; Hohnloser, S.H.; et al. Rationale and design of the Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation (ARTESiA) trial. Am. Heart J. 2017, 189, 137–145.
  30. Paulus, K.; Blank, B.F.; Calvert, M.; Camm, A.J.; Chlouverakis, G.; Diener, H.C.; Goette, A.; Huening, A.; Lip, G.Y.H.; Simantirakis, E.; et al. Probing oral anticoagulation in patients with atrial high rate episodes. Rationale and design of the Non vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes (NOAH—AFNET 6) trial. Am. Heart J. 2017, 190, 12–18.
  31. Diederichsen, S.; Haugan, K.J.; Brandes, A.; Graff, C.; Krieger, D.; Kronborg, C.; Holst, A.G.; Nielsen, J.B.; Køber, L.; Højberg, S.; et al. Incidence and predictors of atrial fibrillation episodes as detected by implantable loop recorder in patients at risk From the LOOP study. Am. Heart J. 2019, 219, 117–127.
  32. Pérez-Riera, A.R.; Barbosa-Barros, R.; Pereira-Rejálaga, L.E.; Nikus, K.; Shenasa, M. Electrocardiographic and Echocardiographic Abnormalities in Patients with Risk Factors for Atrial Fibrillation. Card. Electrophysiol. Clin. 2021, 13, 211–219.
  33. Jones, N.R.; Taylor, C.J.; Hobbs, F.D.R.; Bowman, L.; Casadei, B. Screening for atrial fibrillation, A call for evidence. Eur. Heart J. 2020, 41, 1075–1085.
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to : , , , , ,
View Times: 456
Revisions: 2 times (View History)
Update Date: 25 Apr 2022