Increased plasma vasopressin and serum uric acid in the low renin type of essential hypertension

In 22 50-year-old men with long-standing, untreated essential hypertension of the low renin type, venous plasma vasopressin concentrations were about three times those of 15 matched normotensive control subjects (p less than 0.005). These patients also had increased arterial concentrations of noradrenaline and adrenaline (p less than 0.05) but there was no direct association between these two catecholamines and vasopressin. On the other hand, adrenergic beta-receptor blockade with oxprenolol reduced both blood pressure and plasma vasopressin (p less than 0.01) while venous plasma dopamine concentrations significantly increased. In addition, the hypertensives had highly significantly increased serum uric acid (p less than 0.001) that correlated positively with venous vasopressin concentrations (p less than 0.05). According to these data, patients with the volume-sustained low renin type of essential hypertension have increased plasma vasopressin concentrations that probably are inversely related to dopaminergic nervous activity. The data also indicate that increased plasma vasopressin correlates with serum uric acid, most probably through increased tubular reabsorption of this acid.

Blood platelet release correlates with serum lipids in 50 year old men with essential hypertension

50 year old men with moderate, essential hypertension (n = 39) were compared to normotensive males of similar age (n = 31). The hypertensive men were heavier (10 kg in average, p less than 0.01), and had a higher pulse rate (5 beats per minute (p less than 0.05). Plasma beta-thromboglobulin, a marker of platelet release reaction, was 49% higher in the hypertensive group (p less than 0.01). Total cholesterol, LDL + VLDL cholesterol and serum triglycerides were not significantly different between the groups. In the hypertensive group, plasma beta-thromboglobulin concentration correlated significantly with total cholesterol (r = 0.47, p less than 0.01) as well as with LDL + VLDL cholesterol (r = 0.50, p less than 0.01). In the normotensive group no such correlation was found. The results suggest activation of platelets in hypertension, and suggest that in hypertension, even a normal cholesterol concentration may influence platelet function.

Platelet volume, platelet release reaction and platelet response to infused adrenaline are increased in essential hypertension

Hypertensive men aged 42 (n = 35) were compared to normotensive men of similar age (n = 44). Platelet numbers were similar in the two groups, but hypertensive men had larger venous platelets than the normotensive (7.46 versus 7.12 femtoliter, p = 0.01). Plasma concentration of beta-thromboglobulin (BTG), a marker of platelet release reaction, was increased in arterial blood in hypertension (40 versus 21 micrograms/l, p = 0.02). The normotensive subjects had markedly higher BTG concentration in venous compared to arterial blood (p less than 0.01), but this arterio-venous difference was not present in the hypertensive group. Twelve normotensive subjects received infused saline, which did not induce changes in platelet variables. Adrenaline was infused to 13 hypertensive and 12 normotensive subjects, with dose gradually increasing to 0.04 microgram/kg/min. Platelet count increased in both groups, but significantly more in the hypertensive group. Platelet volume and BTG both increased markedly in the hypertensive group, but not in the normotensive men. Thus, young men with hypertension have increased platelet activity and increased sensitivity to exogenous adrenaline.

Serum phosphate, blood pressure, and the metabolic syndrome--20-year follow-up of middle-aged men

The authors investigated the relationship between serum phosphate (S-phosphate) and the metabolic syndrome in a group of middle-aged hypertensive and normotensive men during 20-year follow-up. Fifty-six men participated. Of the original 34 normotensive men, hypertension developed in 17. In the group as a whole and in those in whom hypertension developed, there was a significant negative relationship between S-phosphate at baseline and mean blood pressure (MBP) at follow-up. A significant relationship was observed between S-phosphate at baseline and components of the metabolic syndrome in the group as a whole, in individuals with hypertension, and in individuals with the lowest S-phosphate levels at follow-up. S-phosphate at baseline predicted MBP 20 years later in a group of hypertensive and normotensive men. When grouped according to the number of components of the metabolic syndrome, individuals with the lowest serum phosphate levels had the highest number of risk factors. These findings may suggest a role of low S-phosphate in the development of hypertension and the metabolic syndrome.

Combining RAAS and calcium channel blockade: ACCOMPLISH in perspective

The Avoiding Cardiovascular events through COMbination therapy in Patients LIving with Systolic Hypertension (ACCOMPLISH) trial was the first trial to compare the cardiovascular outcomes of initial fixed-dose combination angiotensin-converting enzyme inhibitor (ACEI)/calcium channel blocker (CCB) and ACEI/diuretic therapy in patients with hypertension and high risk of cardiovascular events. The initial combination therapy was effective in this population, with ACEI/CCB therapy providing the greatest benefit (reduction in risk of cardiovascular events). Whether or not the findings of ACCOMPLISH can be applied to other renin-angiotensin-aldosterone system (RAAS) inhibitor/CCB combinations, such as angiotensin receptor blocker (ARB)/CCB combinations, has yet to be investigated. The present report reviews the results of ACCOMPLISH, data from trials comparing ARB and ACEI therapies, and findings from studies of ARB/CCB combination therapy that support the use and further study of combination therapy with RAAS inhibitors and CCBs.

Atrial Fibrillation and Renin–Angiotensin System Blockade in Hypertension

Atrial fibrillation is prevalent and increases morbidity and mortality. Hypertension is an important risk factor for atrial fibrillation development, and treatment with a blocker of the renin–angiotensin system (RAS) may reduce new-onset atrial fibrillation. Blockade of RAS may prevent left atrial dilatation, atrial fibrosis, dysfunction and conduction velocity slowing, and some studies even indicate direct anti-arrhythmic properties. As the general population is ageing, the prevalence of atrial fibrillation is expected to rise, and methods to prevent or postpone atrial fibrillation development, for example with optimal antihypertensive treatment, may be of clinical, prognostic and economic importance.

Incidence of atrial fibrillation in relation to changing heart rate over time in hypertensive patients: the LIFE study

BACKGROUND

Onset of atrial fibrillation (AF) has been linked to changes in autonomic tone, with increasing heart rate (HR) immediately before AF onset in some patients suggesting a possible role of acute increases in sympathetic activity in AF onset. Although losartan therapy and decreasing ECG left ventricular hypertrophy are associated with decreased AF incidence, the relationship of HR changes over time to development of AF has not been examined.

METHODS AND RESULTS

HR was evaluated in 8828 hypertensive patients without AF by history or on baseline ECG in the Losartan Intervention for End Point Reduction in Hypertension (LIFE) study. Patients were treated with losartan- or atenolol-based regimens and followed with serial ECGs annually which were used to determine HR and ECG left ventricular hypertrophy by Cornell product and Sokolow-Lyon voltage criteria. During mean follow-up of 4.7+/-1.1 years, new-onset AF occurred in 701 patients (7.9%). Patients with new AF had smaller decreases in HR to last in-treatment ECG or last ECG before AF (-2.7+/-13.5 versus -5.2+/-12.5 bpm), whether on losartan- (-0.4+/-13.5 versus -2.2+/-11.7 bpm) or atenolol-based treatment (-5.3+/-12.8 versus -8.3+/-12.6 bpm, all P<0.001). In univariate Cox analyses, higher HR on in-treatment ECGs was associated with an increased risk of new-onset AF, with a 15% greater risk of AF for every 10 bpm higher HR (95% CI 8% to 22%). In alternative analyses, persistence or development of a HR> or =84 (upper quintile of baseline HR) was associated with a 46% greater risk of developing AF (95% CI 19% to 80%). After adjusting for treatment with losartan versus atenolol, baseline risk factors for AF, baseline and in-treatment systolic and diastolic pressure and the known predictive value of baseline and in-treatment ECG left ventricular hypertrophy for new AF, higher in-treatment HR remained strongly associated with new AF with a 19% higher risk for every 10 bpm higher HR (95% CI 10% to 28%) or a 61% increased rate of AF in patients with persistence or development of a HR> or =84 (95% CI 27% to 104%, all P<0.001).

CONCLUSIONS

Higher in-treatment HR on serial ECGs is associated with an increased likelihood of new-onset AF, independent of treatment modality, blood pressure lowering, and regression of ECG left ventricular hypertrophy in patients with essential hypertension.

Increased sympathetic reactivity may predict insulin resistance: an 18-year follow-up study

Insulin resistance and sympathetic activity are related by a positive feedback system. However, which precedes the other still remains unclear. The present study aimed to investigate the predictive role of sympathoadrenal activity in the development of insulin resistance in an 18-year follow-up study. We also examined whether reactivity to 2 different stress tests, a cold pressor test and a mental stress test, would differ in their predictive power. The 2 tests are supposed to represent different reactivity mechanisms: alpha- and beta-adrenergic responses, respectively. At entry, arterial plasma epinephrine and norepinephrine concentrations were measured in 99 healthy men (age, 19.3 +/- 0.4 years, mean +/- SD) during rest, a mental stress test, and a cold pressor test. Fasting plasma glucose concentration was measured at entry and at follow-up. Insulin resistance at follow-up was calculated using the homeostasis model assessment of insulin resistance (HOMA-IR). Eighty subjects (81%) were eligible for follow-up after 18.0 +/- 0.9 years (mean +/- SD). The norepinephrine responses to cold pressor test at entry predicted plasma glucose concentration (r = 0.301, P = .010) and HOMA-IR (r = 0.383, P = .004) at follow-up in univariate analyses. In multiple regression analyses, corrected for fasting glucose at entry, family history of diabetes, blood pressure-lowering medication, body mass index at entry, and level of exercise, norepinephrine response to cold pressor test was found to be a positive predictor of future HOMA-IR (P = .010). This is the first long-term follow-up study in white subjects showing that sympathetic reactivity predicts future insulin resistance 18 years later. These findings may provide further insights into the pathophysiologic mechanisms of insulin resistance.

Do screening blood pressure and plasma catecholamines predict development of hypertension? Twenty-year follow-up of middle-aged men

OBJECTIVES

The sympathetic nervous system is implicated in the development and maintenance of hypertension. However, the predictive impact of arterial plasma catecholamines has never been reported. We investigated arterial catecholamines and blood pressures (BPs) prospectively over 20 years in a group of well-characterized middle-aged men.

METHODS

Fifty-six of original 79 men were available for the follow-up. Multiple regression analysis was done with mean BP at follow-up as a dependent variable, and arterial plasma catecholamines and BP at baseline as independent variables.

RESULTS

Half of the originally normotensive men developed hypertension during follow-up. There were significant differences in the screening BP values measured at baseline between the new hypertensives and the sustained normotensives. Multiple regression analysis revealed arterial adrenaline at baseline as an independent predictor of mean BP at follow-up in the new hypertensives (beta = 0.646, R2 = 0.42, p = 0.007). Furthermore, arterial noradrenaline at baseline was a negative independent predictor of mean BP at follow-up in the sustained normotensives (beta = -0.578, R2 = 0.334, p = 0.020). Noradrenaline increased with age in the group as a whole (1318+/-373 vs 1534+/-505 pmol/l, p = 0.010) while adrenaline did not change.

CONCLUSION

Our data suggest that arterial adrenaline is involved in the development of hypertension over 20 years in middle-aged men. Men with sustained normotension may have an inherent protection against sympathetic overactivity. Furthermore, screening BP at baseline in normotensive men differentiated between those who developed hypertension and those who remained normotensive at follow-up.

Predictors of blood pressure response to intensified and fixed combination treatment of hypertension: the ACCOMPLISH study

BACKGROUND

Avoiding Cardiovascular events through COMbination therapy in Patients LIving with Systolic Hypertension (ACCOMPLISH) is an outcome study investigating aggressive antihypertensive combination treatment. It has achieved a larger fraction of overall patients with blood pressure (BP) <140/90 mmHg (73.3%) and diabetic patients <130/80 mmHg (43.3%) at 12 months of follow-up than any other large outcomes trial. We have analyzed baseline predictors of BPs and BP control at 12 months.

METHODS

Blinded baseline and 12-month BP was available in 10,173 patients of whom 6132 had diabetes. Univariate and multivariate logistic regression models were used for BP control at 12 months; simple and multiple regression models were used for absolute BP value at 12 months. A stepwise procedure was used to select significant predictors in multivariate analyses.

RESULTS

Mean (SD) BP fell from 145.5/80.2 mmHg (18.2/10.7 mmHg) at randomization to 132.7/74.7 mmHg (16/9.6 mmHg) at 12 months. The main baseline predictors of achieving BP control were region (USA), Caucasian race and taking lipid-lowering drugs. The predictors of uncontrolled BP were higher baseline systolic BP values, more previous antihypertensive medications, proteinuria and previous thiazide use.

CONCLUSION

Patients in the USA, Caucasians and patients taking lipid-lowering therapy were most likely to reach BP targets with combination therapy. Strong predictors of uncontrolled hypertension were more severe hypertension, an established need for more antihypertensive drugs and target organ damage.

Sympathoadrenal stress reactivity is a predictor of future blood pressure: an 18-year follow-up study

In the present study we hypothesized that arterial catecholamine concentrations during rest and 2 laboratory stress tests were independent predictors of blood pressure at an 18-year follow-up. At entry, blood pressure, heart rate, and arterial plasma epinephrine and norepinephrine concentrations were measured in 99 healthy men (age: 19.3+/-0.4 years, mean+/-SD) at rest, during a mental arithmetic test, and during a cold pressor test. After 18.0+/-0.9 years of follow-up, resting blood pressure was measured. The norepinephrine and epinephrine concentrations during the mental arithmetic explained 12.7% of the variation of future systolic blood pressure after adjusting for initial resting blood pressure, family history, body mass index, and systolic blood pressure during the stress test in a multiple regression analysis (adjusted R(2)=0.651; P<0.001). To conclude, the present study shows that sympathetic nervous activity during mental arithmetic predicts future blood pressure, indicating a possible causal factor in the development of essential hypertension independent of the initial blood pressure.

Does sympathoadrenal activity predict changes in body fat? An 18-y follow-up study

BACKGROUND

Whether alterations in the sympathoadrenal system contribute to obesity or, rather, are consequences of it, is an unresolved issue.

OBJECTIVE

We hypothesized that the sympathoadrenal system plays a predictive role in the development of body fat.

DESIGN

At entry, arterial plasma epinephrine and norepinephrine concentrations were measured in 99 healthy men (x +/- SD age: 19.3 +/- 0.4 y) at rest and during a mental stress test and a cold pressor test. Body mass index (BMI; in kg/m(2)), waist circumference, and triceps skinfold thickness were measured at entry and after 18 y of follow-up.

RESULTS

Eighty subjects (81%) were available for follow-up analyses after a mean (+/-SD) of 18.0 +/- 0.9 y. The epinephrine responses to the mental stress test (E(MST)) showed a negative relation to changes in BMI (P = 0.01) and waist circumference (P = 0.007). The mean increase in BMI was 6.3 among subjects in the lowest E(MST) quartile and 3.7 in the remaining subjects. In multiple regression analyses corrected for level of exercise, BMI, waist circumference, and triceps skinfold thickness at entry, E(MST) was found to be a consistent negative predictor of future BMI (P = 0.005), waist circumference (P = 0.001), and triceps skinfold thickness (P = 0.05).

CONCLUSIONS

We present the first long-term follow-up study in whites showing that the epinephrine response to mental stress is a negative predictor of future BMI, waist circumference, and triceps skinfold thickness after 18 y of follow-up. These findings may provide further insights into the pathophysiology of obesity.

Gender differences in regression of electrocardiographic left ventricular hypertrophy during antihypertensive therapy

Although men and women differ in the magnitude of ECG left ventricular hypertrophy, whether gender differences exist in the degree of regression of ECG left ventricular hypertrophy during antihypertensive therapy is unclear. ECG left ventricular hypertrophy defined using gender-adjusted Cornell product and Sokolow-Lyon voltage criteria was assessed serially in 9193 hypertensive patients treated with losartan- or atenolol-based regimens. Changes in ECG left ventricular hypertrophy were measured from baseline to last in-study visit, and above-average regression of hypertrophy was identified by a >or=236-mm . ms reduction in Cornell product or >or=3.5-mm reduction in Sokolow-Lyon voltage. During mean follow-up of 4.8+/-0.9 years, women had less reduction in Cornell product (-149+/-823 versus -251+/-890 mm . ms) and Sokolow-Lyon voltage (-3.0+/-6.8 versus -4.8+/-7.7 mm) than men (both P<0.001). After adjusting for baseline ECG left ventricular hypertrophy levels, baseline and change in systolic and diastolic pressures, treatment group, age, and other baseline gender differences, women had significantly less reduction in both Cornell product (adjusted means: -137 versus -276 mm . ms; P<0.001) and Sokolow-Lyon voltage (-3.6 versus -4.1 mm; P=0.005) than men and were 32% less likely to have had greater than the median level of regression of Cornell product left ventricular hypertrophy (95% CI: 24% to 39%; P<0.001) and 15% less likely to have had regression of left ventricular hypertrophy by Sokolow-Lyon criteria (95% CI: 5% to 23%; P=0.003). Thus, women have less regression of ECG left ventricular hypertrophy than men in response to antihypertensive therapy, independent of baseline gender differences in the severity of ECG left ventricular hypertrophy and after taking into account treatment effects and blood pressure changes.

Effects of losartan in women with hypertension and left ventricular hypertrophy: results from the Losartan Intervention for Endpoint Reduction in Hypertension Study

Hypertension is a risk factor for cardiovascular disease and outcomes in women. These posthoc analyses from the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study evaluated losartan- versus atenolol-based therapy on the primary composite end point of cardiovascular death, stroke, and myocardial infarction and other end points in 4963 women. Fewer events occurred in women versus men. Women in the losartan group had significant reductions in the primary end point (215 [18.2 per 1000 patient-years] versus 261 [22.5 per 1000 patient-years]; hazard ratio [HR]: 0.82 [95% CI: 0.68 to 0.98]; P=0.031), stroke (109 versus 154; HR: 0.71 [95% CI: 0.55 to 0.90]; P=0.005), total mortality (HR: 0.77 [95% CI: 0.63 to 0.95]; P=0.014), and new-onset diabetes (HR: 0.75 [95% CI: 0.59 to 0.94]; P=0.015) versus the atenolol group, with no between-treatment difference for myocardial infarction (HR: 1.02 [95% CI: 0.74 to 1.39]; P=0.925), cardiovascular mortality (HR: 0.86 [95% CI: 0.64 to 1.14]; P=0.282), or hospitalization for heart failure (HR: 0.94 [95% CI: 0.68 to 1.28]; P=0.677). More women in the losartan group required hospitalization for angina (HR: 1.70 [95% CI: 1.16 to 2.51]; P=0.007). Risk reductions for the primary composite end point, stroke, total mortality, and new-onset diabetes were significantly greater with losartan- versus atenolol-based treatment in women with hypertension and left ventricular hypertrophy in the LIFE study. The risk reductions for losartan, along with the tests for the interaction of treatment and gender, indicated that the treatment effect was consistent in men and women for all of the end points tested, with the exception of hospitalization for angina.

Improved insulin sensitivity by the angiotensin II-receptor blocker losartan is not explained by adipokines, inflammatory markers, or whole blood viscosity

We have previously found improved insulin sensitivity after antihypertensive treatment with an angiotensin II-receptor blocker as compared with a calcium channel blocker in hypertensives. In this study, we compare the effect of these 2 principal different vasodilating agents on levels of adipokines, inflammatory variables, and whole blood viscosity in the same hypertensive patients with cardiovascular risk factors. We test whether potential differences in these variables might explain the difference seen in insulin sensitivity. Twenty-one hypertensive patients (11 women, 10 men) with mean age of 58.6 years and blood pressure of 160 +/- 3/96 +/- 2 mm Hg entered a 4-week run-in period with open-label amlodipine 5 mg. Thereafter, they were randomized double-blindly to additional treatment with amlodipine 5 mg or losartan 100 mg; and after 8 weeks of treatment, all patients underwent laboratory testing. After a 4-week washout phase with open-label treatment, the participants were crossed over to the opposite treatment regimen for 8 weeks before final examination. No significant differences were seen in the blood levels of adiponectin (7814 +/- 870 vs 8090 +/- 967 ng/mL), leptin (961 +/- 122 vs 965 +/- 147 pmol/L), resistin (11.7 +/- 1.0 vs 11.3 +/- 0.7 ng/mL), plasminogen activator inhibitor 1 activity (23.9 +/- 2.2 vs 25.1 +/- 2.2 U/mL), tumor necrosis factor alpha (1.35 +/- 0.11 vs 1.72 +/- 0.28 pg/mL), and high-sensitivity C-reactive protein (3.09 +/- 0.84 vs 2.09 +/- 0.42 mg/L) between treatment with amlodipine 10 mg or losartan 100 mg + amlodipine 5 mg, respectively. Although no significant differences in whole blood viscosity and blood pressure were observed between the 2 treatment regimens, a consistent trend toward lower viscosity was found at all shear rates as vasodilatory treatment was intensified (baseline to amlodipine 5 mg to amlodipine 10 mg to losartan 100 mg + amlodipine 5 mg). Our data do not support that effects on adipokines, inflammatory markers, and whole blood viscosity could explain improved insulin sensitivity seen on AT1-receptor blockade.

In-Treatment Resolution or Absence of Electrocardiographic Left Ventricular Hypertrophy Is Associated With Decreased Incidence of New-Onset Diabetes Mellitus in Hypertensive Patients

Treatment of hypertensive patients with electrocardiographic left ventricular hypertrophy with losartan-based therapy is associated with lower incidence of diabetes mellitus and greater regression of hypertrophy than atenolol-based therapy. However, whether in-treatment resolution or continued absence of electrocardiographic hypertrophy is independently associated with decreased incidence of diabetes is unclear. Electrocardiographic hypertrophy was evaluated over time in 7998 hypertensive patients without diabetes at baseline in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study who were treated with losartan- or atenolol-based regimens and followed with serial electrocardiograms and blood pressure determinations. Electrocardiographic hypertrophy was defined using gender-adjusted Cornell voltage-duration product criteria >2440 mm·ms. During mean follow-up of 4.6±1.2 years, diabetes developed in 562 patients (7.0%). In a Cox model adjusting for treatment assignment, in-treatment resolution or continued absence of Cornell product hypertrophy was associated with a 38% lower risk of new diabetes (HR 0.62, 95% CI 0.50 to 0.78). After adjusting for the association of new diabetes with prior antihypertensive treatment, baseline glucose, and Framingham risk score, baseline and in-treatment systolic and diastolic pressure, HDL, uric acid, and body mass index, and the decreased incidence associated with losartan-based therapy, in-treatment continued absence, or resolution of Cornell product hypertrophy remained associated with a 26% lower risk of new diabetes (HR 0.74, 95% CI 0.58 to 0.93). Thus, compared with presence of hypertrophy by Cornell product criteria during antihypertensive treatment, resolution or continued absence of Cornell product hypertrophy is associated with a lower incidence of diabetes, even after adjusting for the impact of treatment with losartan and other risk factors for diabetes.

The effect of baseline physical activity on cardiovascular outcomes and new-onset diabetes in patients treated for hypertension and left ventricular hypertrophy: the LIFE study

OBJECTIVES

Physical activity (PA) is a preventive strategy for cardiovascular disease and for managing cardiovascular risk factors. There is little information on the effectiveness of PA for the prevention of cardiovascular outcomes once cardiovascular disease is present. Thus, we studied the relationship between PA at baseline and cardiovascular events in a high-risk population.

DESIGN

A prespecified analyses of observational data in a prospective, randomized hypertension study.

SETTING

Losartan Intervention For Endpoint reduction in hypertension (LIFE) study.

SUBJECTS

Hypertension and left ventricular hypertrophy (LVH) (n = 9,193).

INTERVENTIONS

Losartan versus atenolol.

MAIN OUTCOME MEASURES

Reported level of PA: never exercise, exercise <or=30 min twice per week, or exercise >30 min twice per week at baseline and after a mean of 4.8 years of treatment with losartan- versus atenolol-based therapy. Risk reductions were calculated by level of PA for the primary composite end-point and its components cardiovascular death, stroke and myocardial infarction, and also all-cause mortality and new-onset diabetes.

RESULTS

A modest level of PA (>30 min twice per week) was associated with significant reductions in risk for the primary composite end-point [adjusted hazard ratio (aHR) 0.70, P < 0.001) and its components, all-cause mortality (aHR 0.65, P < 0.001), and new-onset diabetes (aHR 0.66, P < 0.001).

CONCLUSION

A modest level of self-reported PA (>30 min twice per week) in patients with hypertension and LVH in the LIFE study was associated with significant reductions in risk for the primary composite end-point and its components of cardiovascular death, stroke, and myocardial infarction, all-cause mortality, and new-onset diabetes.

Regression of electrocardiographic left ventricular hypertrophy is associated with less hospitalization for heart failure in hypertensive patients

BACKGROUND

Reduction of electrocardiographic left ventricular hypertrophy (LVH) has been associated with decreased cardiovascular death, stroke, myocardial infarction, and atrial fibrillation. However, whether reduction of electrocardiographic LVH is associated with decreased heart failure is unclear.

OBJECTIVE

To examine the relation of reduction of electrocardiographic LVH to incident heart failure.

DESIGN

Multicenter cohort study derived from a randomized, controlled trial.

SETTING

Losartan Intervention For Endpoint reduction in hypertension study.

PATIENTS

8479 hypertensive patients without history of heart failure who were randomly assigned to losartan or atenolol treatment.

MEASUREMENTS

Change in Cornell product electrocardiographic LVH between baseline and in-study electrocardiograms, examined as both a continuous variable and a dichotomous variable (above or below the median decrease of 236 mm x msec) to predict heart failure hospitalization occurring after the 6-month follow-up visit.

RESULTS

During mean follow-up of 4.7 years (SD, 1.1 years), 214 patients were hospitalized for heart failure (2.5%): 77 patients with an in-treatment decrease of 236 mm x msec or more (4.4 per 1000 patient-years) and 137 patients with a reduction less than 236 mm x msec during treatment (6.8 per 1000 patient-years). In a univariate Cox analysis in which change in Cornell product was treated as a time-varying continuous variable, decrease in Cornell product during treatment was associated with a decreased risk for new-onset heart failure, with a 24% lower risk for heart failure for every 817-mm x msec (1 SD of the mean) lower Cornell product (hazard ratio, 0.76 [95% CI, 0.72 to 0.80]). In a parallel analysis in which change in Cornell product was entered as a time-varying dichotomous variable, a greater-than-median in-treatment decrease in Cornell product (236 mm x msec) was associated with a 43% lower risk for heart failure (hazard ratio, 0.57 [CI, 0.44 to 0.76]). After adjustment for treatment, baseline risk factors for heart failure, baseline and in-treatment blood pressure, and baseline severity of electrocardiographic LVH, in-treatment decrease of Cornell product LVH in time-varying multivariate Cox models remained strongly associated with new heart failure hospitalization, with a 19% lower risk for every 817-mm . msec lower Cornell product treated as a continuous variable (hazard ratio, 0.81 [CI, 0.77 to 0.85]) or a 36% decreased rate of new heart failure in patients with an in-treatment reduction in Cornell product of 236 mm x msec or more (hazard ratio, 0.64 [CI, 0.47 to 0.89]; P < 0.001 for all comparisons).

LIMITATIONS

Use of electrocardiographic LVH to select patients may have increased risk compared with unselected hypertensive patients, and use of hospitalization for heart failure as the end point will underestimate the incidence of new heart failure.

CONCLUSION

Reduction in Cornell product electrocardiographic LVH during antihypertensive therapy is associated with fewer hospitalizations for heart failure, independent of blood pressure lowering, treatment method, and other risk factors for heart failure. ClinicalTrials.gov registration number: NCT00338260.

Effect of hemoglobin levels on cardiovascular outcomes in patients with isolated systolic hypertension and left ventricular hypertrophy (from the LIFE study)

The optimal hemoglobin level in patients with hypertension or heart failure is not yet defined. The aim of the present investigation was to examine the relation of hemoglobin with cardiovascular outcomes in high-risk patients with isolated systolic hypertension (ISH) and left ventricular hypertrophy (LVH). In 1,326 patients with ISH in the Losartan Intervention For Endpoint Reduction in Hypertension (LIFE) study, hemoglobin and cardiovascular outcomes were examined using Cox proportional hazard models. Baseline hemoglobin was negatively related to rate of cardiovascular death (hazard ratio 0.81 per 1 g/dl, 95% confidence interval [CI] 0.67 to 0.98, p = 0.032) after adjusting for baseline Framingham risk score, LVH, treatment, and estimated glomerular filtration rate. Hemoglobin decreased slightly during the study and the decrease was more pronounced in the losartan group (13.9 +/- 1.3 to 13.6 +/- 1.4 g/dl) than in the atenolol group (13.9 +/- 1.2 to 13.8 +/- 1.4 g/dl). Hemoglobin as a time-varying covariate was negatively associated with rate of cardiovascular death (hazard ratio 0.75, 95% CI 0.63 to 0.90, p <0.001) and stroke (hazard ratio 0.84, 95% CI 0.72 to 0.99, p = 0.040) after adjusting for baseline Framingham risk score, LVH, treatment, and estimated glomerular filtration rate. In conclusion, in this high-risk population with ISH and LVH, lower hemoglobin at baseline was associated with higher probability of cardiovascular death, and decrease in hemoglobin over time was associated with higher probability of cardiovascular death or stroke; this effect was attenuated by treatment with losartan.