Comparison of enalapril versus nifedipine to decrease left ventricular hypertrophy in systemic hypertension (the PRESERVE trial)

Relation of Wnt Signaling Pathway Inhibitors (Sclerostin and Dickkopf-1) to Left Ventricular Mass Index in Maintenance Hemodialysis Patients

BACKGROUND

Left ventricular hypertrophy (LVH) is common in hemodialysis (HD) patients. It predicts poor prognosis. Several inhibitors regulate Wnt canonical pathways like Dickkopf-related protein-1 (Dkk-1) and sclerostin.

OBJECTIVES

To investigate the relationship between serum sclerostin, Dkk-1, left ventricular mass (LVM), and LVM index (LVMI) in HD patients.

METHODS

This is a cross-sectional study including 65 HD patients in our HD unit. Patients were divided into two groups according to LVMI (group 1 with LVMI < 125 gm/m2 (N = 29) and group 2 with LVMI > 125 gm/m2 (N = 36)). Echocardiographic evaluation of the LVM, aortic, and mitral valves calcification (AVC and MVC) was done. Serum levels of sclerostin and Dkk-1 and patients' clinical and biochemical data were recorded.

RESULTS

Group 2 showed significantly higher age, blood pressure, AVC, and MVC and significantly lower hemoglobin, sclerostin, and Dkk-1 levels. LVM and LVMI had a significant linear negative correlation to both serum sclerostin and Dkk-1 (r = -0.329 and -0.257, P=0.01 and 0.046 for LVM; r = -0.427 and -0.324, P=0.001 and 0.012 for LVMI, resp.). Serum Dkk-1 was an independent negative indicator for LVM and LVMI in multiple regression analyses (P=0.003 and 0.041 with 95% CI = -0.963 to -0.204 and -0.478 to -0.010, resp.).

CONCLUSION

Serum sclerostin and Dkk-1 were significantly lower in HD patients with increased LVMI > 125 gm/m2, and both had a significant linear negative correlation with LVM and LVMI. Dkk-1 was a significant negative independent indicator for LVM and LVMI in HD patients.

Left Atrial Anatomy and Function After Conversion From Atrial Fibrillation in Hypertrophic Hearts

The aim of the study was to evaluate the influence of left ventricular (LV) hypertrophy on left atrial (LA) electrical and mechanical function after cardioversion atrial fibrillation (A-Fib) of brief duration. Study group A included 100 patients with a first diagnosis of hypertension who had a moderate LV hypertrophy. The patient population included 64 men and 36 women with a mean age of 55 ±7 years who were hospitalized because of A-Fib and were cardioverted with external DC shock. Control group B included 100 patients without cardiac hypertrophy cardioverted because of lone A-Fib. Atrial function and size were assessed by Doppler echocardiography and the following parameters were measured: transmitral peak A velocity, atrial filling fraction, atrial ejection force, peak E velocity, deceleration time, and isovolumic relaxation time, LA maximal and minimal volume, and LV cardiac mass index. Baseline echocardiography showed that LA diameters and volumes were enlarged in all patients during A-Fib. After the restoration of sinus rhythm LA diameters and volumes decreased and the reduction was more evident in group B compared to group A. LA function as a continuous variable was negatively related to LV mass index ( r = -0.77), LA diameter ( r = -0.66 and r = -0.69 for the superoinferior diameter), LA maximal volume ( r = -0.61) and LA minimal volume ( r = -0.55) (all p<0.01). Atrial ejection force as a continuous variable was positively related to age ( r =0.78), peak A wave velocity ( r =0.71), systolic blood pressure ( r =0.51), and IVRT ( r =0.41) (all p<0.01). Hypertrophy influenced the recovery of atrial function after cardioversion of A-Fib. Atrial function was reduced in patients with LV hypertrophy even after A-Fib of brief duration.

Angiotensin II Receptor Blocker Telmisartan: Effect on Blood Pressure Profile and Left Ventricular Hypertrophy in Patients with Arterial Hypertension

In this open-label, non-comparative study, the anti-hypertensive efficacy and effect on left ventricular hypertrophy (LVH) of 24 weeks' treatment with once-daily telmisartan 40-80 mg was evaluated in 24 patients with mild-to-moderate hypertension and LVH. Patients were titrated to the higher dose of study drug at week 4 if they did not achieve blood pressure normalization (i.e. systolic blood pressure [SBP]/diastolic blood pressure [DBP] remained ≥ 140/90 mmHg). The anti-hypertensive action of telmisartan was assessed using clinic cuff measurements and 24-h ambulatory blood pressure monitoring, and left ventricular mass index (LVMI) was determined by two-dimensional echocardiography at baseline and after 24 weeks of therapy. Telmisartan significantly reduced mean 24-h, daytime and night-time SBP and DBP compared with baseline after 12 and 24 weeks of therapy. Target blood pressure levels, defined as SBP/DBP < 140/90 mm Hg, were achieved in 16 (69.6%) patients at the end of the treatment period. After 24 weeks of telmisartan treatment, LVMI decreased from 151.6 ± 5.4 to 135.1 ± 5.9 g/m2. In conclusion, anti-hypertensive treatment with telmisartan for 24 weeks produced significant reductions in blood pressure and regression of LVH, as assessed by LVMI, in patients with hypertension and LVH.

The association of metabolic syndrome with left ventricular mass and geometry in community-based hypertensive patients among Han Chinese

Background:

The association of metabolic syndrome (MS) with left ventricular (LV) hypertrophy is controversial. The objective of our study was to investigate the influence of MS on LV mass and geometry in community-based hypertensive patients among Han Chinese.

Materials and Methods:

This study included 1733 metabolic syndrome patients according to the International Diabetes Federation (IDF) definition and 2373 non-MS hypertension patients. LV hypertrophy was diagnosed by the criteria of LV mass ≥49.2 g/m^2.7 for men and 46.7 g/m^2.7 for women. LV geometric patterns (normal, concentric remodeling, concentric or eccentric hypertrophy) were calculated according to LV hypertrophy and relative wall thickness. Logistic regression analysis was used to determine odds ratio (OR) and 95% confidence interval (CI) of MS for LV hypertrophy and LV geometry abnormality.

Results:

The LV mass and LV mass index were higher in the MS group than in the non-MS group. In multiple adjusted models. LV mass index, LV mass, interventricular septum, and post wall were raised with the increased number of MS disorders. MS was associated with increased LV hypertrophy risk (unadjusted OR 1.38; 95% CI 1.21-1.57); age, sex, and blood pressure (BP; adjusted OR 1.39; 95% CI 1.22-1.59). MS was also associated with increased risk of eccentric hypertrophy in male and female patients. MS was only associated with increased risk of concentric hypertrophy in female patients; and MS was not associated with concentric remodeling.

Conclusion:

LV mass and LV mass index were associated with the increased number of MS disorders in the Chinese community-based hypertensive population. MS was not only associated with increased LV hypertrophy risk, but also associated with concentric and eccentric LV geometry abnormality, especially in females.

Primary Carnitine deficiency in the Faroe Islands: health and cardiac status in 76 adult patients diagnosed by screening

BACKGROUND

Carnitine deficiency can cause cardiomyopathy and cardiac arrhythmia. The prevalence in the Faroe Islands is the highest reported in the world (1:300). A nationwide screening program identified 76 Faroese adult patients (15-80 years) with Primary Carnitine Deficiency (PCD). We describe prior and current health status and symptoms in these patients, especially focusing on cardiac characteristics.

METHODS

Upon identification, patients were immediately admitted for physical examination, ECG, blood tests and initiation of L-carnitine supplementation. Medical records were reviewed and patients were interviewed. Echocardiography and blood tests were performed in 35 patients before and after L-carnitine supplementation.

RESULTS

All patients were either asymptomatic or had minor symptoms when diagnosed. Echocardiography including LVEF, global longitudinal strain and dimensions were normal apart from left ventricular hypertrophy with normal systolic function in one young male. Symptoms, e.g. fatigue, were reported in 43 % with a reduction to 12 % (p < 0.01) following initiation of L-carnitine supplementation. Eighty two % reported participation in sports of which 52 % were on a competitive level. ECGs showed limited changes and blood tests were normal. Mean plasma free carnitine increased from 6.1 μmol/L to 15.1 μmol/L (p < 0.01) within 50 days of L-carnitine supplementation.

CONCLUSION

PCD in adults can cause serious symptoms, but adult Faroese patients identified through a screening program were predominantly asymptomatic with a normal cardiac structure and function.

Hemodynamic and echocardiographic profiles in African American compared with White offspring of hypertensive parents: the HyperGEN study

BACKGROUND

Alterations in cardiovascular structure and function have been shown to precede the finding of elevated blood pressure.

METHODS

This study is part of the Hypertension Genetic Epidemiologic Network (HyperGEN) in which genetic and environmental determinants of hypertension were investigated in 5 geographical field centers. All nonhypertensive offspring (n = 1,035) were included from the entire HyperGEN study population that consists of 2,225 hypertensive patients and 1,380 nonhypertensive patients who had adequate echocardiographic left ventricular (LV) mass measurements. Participants were compared by self-declared race (African American and white).

RESULTS

Nonhypertensive African American offspring were younger (aged 31 years vs. 38 years), more likely to be female, and had a higher body mass index (BMI) and higher systolic blood pressure (SBP) than their white counterparts. After adjusting for age, sex, SBP, pulse pressure (PP), BMI, diabetes status, and family effects, we observed statistically significant and potentially pathophysiological differences (all with P ≤ 0.001) with greater LV mass/height, relative wall thickness, and posterior wall thickness and with lesser midwall shortening, PP/stroke volume, and (PP/stroke volume)/fat-free body mass.

CONCLUSION

This study shows that ethnic differences in hemodynamic and echocardiographic profiles exist in a large, population-based cohort of nonhypertensive offspring of hypertensive parents.

Quantification of cardiomyocyte hypertrophy by cardiac magnetic resonance: implications for early cardiac remodeling

BACKGROUND

Cardiomyocyte hypertrophy is a critical precursor to the development of heart failure. Methods to phenotype cellular hypertrophy noninvasively are limited. The goal was to validate a cardiac magnetic resonance-based approach for the combined assessment of extracellular matrix expansion and cardiomyocyte hypertrophy.

METHODS AND RESULTS

Two murine models of hypertension (n=18, with n=15 controls) induced by l-N(G)-nitroarginine methyl ester (L-NAME) and pressure overload (n=11) from transaortic constriction (TAC) were imaged by cardiac magnetic resonance at baseline and 7 weeks after L-NAME treatment or up to 7 weeks after TAC. T1 relaxation times were measured before and after gadolinium contrast. The intracellular lifetime of water (τic), a cell size-dependent parameter, and extracellular volume fraction, a marker of interstitial fibrosis, were determined with a model for transcytolemmal water exchange. Cardiomyocyte diameter and length were measured on FITC-wheat germ agglutinin-stained sections. The τic correlated strongly with histological cardiomyocyte volume-to-surface ratio (r=0.78, P<0.001) and cell volume (r=0.75, P<0.001). Histological cardiomyocyte diameters and cell volumes were higher in mice treated with L-NAME compared with controls (P<0.001). In the TAC model, cardiac magnetic resonance and histology showed cell hypertrophy at 2 weeks after TAC without significant fibrosis at this early time point. Mice exposed to TAC demonstrated a significant, longitudinal, and parallel increase in histological cell volume, volume-to-surface ratio, and τic between 2 and 7 weeks after TAC.

CONCLUSION

The τic measured by contrast-enhanced cardiac magnetic resonance provides a noninvasive measure of cardiomyocyte hypertrophy. Extracellular volume fraction and τic can track myocardial tissue remodeling from pressure overload.

Effect of telmisartan on the regression of the left ventricular hypertrophy in the patients of essential hypertension

INTRODUCTION

An increase in the Left Ventricular Mass as a result of muscle hypertrophy, has emerged as a powerful pressure independent risk factor for the cardiovascular mortality and morbidity. It is associated with a risk of death that is 3 times greater than the risk which is associated with hypertension alone. For the development of Left Ventricular Hypertrophy (LVH), in addition to a chronic increase in the pressure and/or volume overload, an elevation in the plasma ACE activity, plasma aldosterone levels, and the angiotensin-II concentrations play a major role .In this study, the effect of Telmisartan, a selective angiotension-II receptor blocker, was compared with that of Atenolol, a selective β1adrenergic receptor blocker, on the regression of LVH in the patients of essential hypertension.

MATERIAL AND METHOD

Essential hypertensive patients with LVH were selected for this study, as per the inclusion and exclusion criteria. This study was carried out on two groups of hypertensive patients with LVH: Group-1: The patients who were taking telmisartan 80 mg OD. Group-2: The patients who were taking atenolol 50 mg OD. The blood pressure was measured and echocardiography was done in both the groups, prior to the treatment and 6 months after the treatment in the Department of Cardiology, MKCG Medical College Hospital, Brahmapur, India. The data were analysed by using the Student's 't' test.

RESULTS

In the cases of Left Ventricular Mass Index (LVMI), which is a better indicator of LVH, in the Atenolol group, the mean value changed from 143.93 ± 2.44 gm/m(2) to 130.16 ± 2.88 gm/m(2) (t=5.83,p<0.01versus baseline).In the Telmisartan group, the mean value changed from 184.67 ± 7.14 gm/m(2) to 133.41± 4.24 gm/m(2) (t=12.12, p<0.001versus baseline). On comparing Telmisartan with Atenolol, Telmisartan was found to produce a greater (27.49%) reduction than Atenolol (9.68%). In the Telmisartan group, 13 patients out of 26 patients achieved a target value of LVMI that was <134 gm/m(2) in males and <110 gm/m(2) in females (50%). In the Atenolol group, only 9 patients out of 22patients achieved a target value (40.90%).

CONCLUSION

Thus, Telmisartan a selective AT1antagonist, possesses pharmacological effects beyond a blood pressure reduction in which the blockade of the AT1receptor may lead to attenuation of the growth promoting action of Ang II. From this study, it is clear that Telmisartan is superior to Atenolol in achieving a regression of LVH, which is a better indicator of the cardiovascular morbidity and mortality.

Factors Influencing the 99th Percentile of Cardiac Troponin I Evaluated in Community-Dwelling Individuals at 70 and 75 Years of Age

BACKGROUND

We aimed to investigate the effects of sex, prevalent cardiovascular disease (CVD), and aging on the 99th percentile of cardiac troponin I (cTnI).

METHODS

cTnI was measured using a high-sensitivity assay (Abbott Diagnostics) in 814 community-dwelling individuals at both 70 and 75 years of age. We determined the cTnI 99th percentiles separately using nonparametric methods in the total sample, in men and women, and in individuals with and without CVD.

RESULTS

The cTnI 99th percentile at baseline was 55.2 ng/L for the total cohort. Higher 99th percentiles were noted in men (69.3 ng/L) and individuals with CVD (74.5 ng/L). The cTnI 99th percentile in individuals free from CVD at baseline (n = 498) increased by 51% from 38.4 to 58.0 ng/L during the 5-year observation period. Relative increases ranging from 44% to 83% were noted across all subgroups. Male sex [odds ratio, 5.3 (95% CI, 1.5–18.3)], log-transformed N-terminal pro-B-type natriuretic peptide [odds ratio, 1.9 (95% CI, 1.2–3.0)], and left-ventricular mass index [odds ratio, 1.3 (95% CI, 1.1–1.5)] predicted increases in cTnI concentrations from below the 99th percentile (i.e., 38.4 ng/L) at baseline to concentrations above the 99th percentile at the age of 75 years.

CONCLUSIONS

cTnI concentration and its 99th percentile threshold depend strongly on the characteristics of the population being assessed. Among elderly community dwellers, higher concentrations were seen in men and individuals with prevalent CVD. Aging contributes to increasing concentrations, given the pronounced changes seen with increasing age across all subgroups. These findings should be taken into consideration when applying cTnI decision thresholds in clinical settings.

Lack of reduction of left ventricular mass in treated hypertension: the strong heart study

Background

Hypertensive left ventricular mass (LVM) is expected to decrease during antihypertensive therapy, based on results of clinical trials.

Methods and Results

We assessed 4‐year change of echocardiographic LVM in 851 hypertensive free‐living participants of the Strong Heart Study (57% women, 81% treated). Variations of 5% or more of the initial systolic blood pressure (SBP) and LVM were categorized for analysis. At baseline, 23% of men and 36% of women exhibited LV hypertrophy (LVH, P<0.0001). At the follow‐up, 3% of men and 10% of women had regression of LVH (P<0.0001 between genders); 14% of men and 15% of women, free of baseline LVH, developed LVH. There was an increase in LVM over time, more in men than in women (P<0.001). Participants whose LVM did not decrease had similar baseline SBP and diastolic BP, but higher body mass index (BMI), waist/hip ratio, heart rate (all P<0.008), and urinary albumin/creatinine excretion (P<0.001) than those whose LVM decreased. After adjusting for field center, initial LVM index, target BP, and kinship degree, lack of decrease in LVM was predicted by higher baseline BMI and urinary albumin/creatinine excretion, independently of classes of antihypertensive medications, and significant effects of older age, male gender, and percentage increase in BP over time. Similar findings were obtained in the subpopulation (n=526) with normal BP at follow‐up.

Conclusions

In a free‐living population, higher BMI is associated with less reduction of hypertensive LVH; lack of reduction of LVM is independent of BP control and of types of antihypertensive treatment, but is associated with renal damage.

Left atrial volume as predictor of valve replacement and cardiovascular events in patients with asymptomatic mild to moderate aortic stenosis

BACKGROUND

Left atrial (LA) size is known to increase with chronically increased left ventricular (LV) filling pressure. We hypothesized that LA volume was predictive of aortic valve replacement (AVR) and cardiovascular events in a large cohort of patients with asymptomatic mild to moderate aortic valve stenosis.

METHODS

Transthoracic echocardiography was performed in 1,758 patients in the Simvastatin and Ezetemibe in Aortic Stenosis study. LA volume was measured in the apical four-chamber view in 1,503 patients (85%). The relation of LA volume to AVR or a combined endpoint of cardiovascular events (AVR, congestive heart failure due to aortic stenosis or death from cardiovascular causes) was evaluated.

RESULTS

AVR was performed in 415 (28%) patients, whereas 505 (34%) reached the combined endpoint. A significant but weak association of increased LA volume and risk of the combined endpoint was found (log-rank test: P = 0.02), but this relation did not reach any significance in a multivariate model adjusting for age, gender, aortic valve area index, LV ejection fraction, LV hypertrophy, hypertension, and mitral regurgitation. LA volume was not predictive of AVR (log-rank test: P = 0.3).

CONCLUSION

In asymptomatic patients with mild to moderate Aortic valve stenosis (AS), LA volume was not predictive of the combined endpoint of Aortic valve replacement, development of heart failure or cardiac death. AVA and presence of LV hypertrophy were the only predictors of events in multivariate analysis.

Left atrial size and function as predictors of new-onset of atrial fibrillation in patients with asymptomatic aortic stenosis: the simvastatin and ezetimibe in aortic stenosis study

BACKGROUND

Left atrial (LA) size and function change with chronically increased left ventricular (LV) filling pressures. It remains unclear whether these variations in LA parameters can predict new-onset atrial fibrillation (AF) in asymptomatic patients with aortic stenosis (AS).

METHODS

Data were obtained in asymptomatic patients with mild-to-moderate AS (2.5 ≤ transaortic Doppler velocity ≤ 4.0m/s), preserved LV ejection fraction (EF), no previous AF, and were enrolled in the Simvastatin and Ezetimibe in Aortic Stenosis study. Peak-aortic velocity, LA(max) volume & LAmin volume were measured by echocardiography. LA conduit (LA(con)) volume was defined as LV stroke volume-LA stroke volume. LA function was expressed as LA-EF (LA(max)-LAmin volume/LA(max)).

RESULTS

In the 1159 patients included, new-onset AF occurred in 71 patients (6.1%) within a mean follow-up of 4.2 ± 0.9 years. Mean age was 66 ± 9.7 years, aortic valve area index 0.6 ± 0.2 cm(2)/m(2), LV mass 99.2 ± 29.7 g/m(2), LA(max) volume 34.6 ± 12.0 mL/m(2), LAmin volume 17.9 ± 9.3 mL/m(2), LA-EF 50 ± 15% and LA(con) volume 45 ± 21 mL/m(2). Baseline LAmin volume predicted new-onset AF in Cox multivariable analysis (HR:2.3 [95%CI:1.3-4.4], P<0.01), and added prognostic information on AF development beyond conventional risk factors (likelihood ratio, P<0.01). In comparison of c-indexes LAmin volume was superior to all other LA measurements. Net reclassification index improved by 15.9% when adding LAmin volume to a model with classic risk factors for AF (P=0.01).

CONCLUSION

LAmin volume independently predicted new-onset AF in patients with asymptomatic AS and was superior to LA-EF, LA(con) and LA(max) volumes and conventional risk factors.

Level of education and risk of heart failure: a prospective cohort study with echocardiography evaluation

AIMS

With increasing socioeconomic disparity in cardiovascular risk factors, there is a need to assess the role of socioeconomic factors in chronic heart failure (CHF) and to what extent this is caused by modifiable risk factors.

METHODS AND RESULTS

In a prospective cohort of 18 616 men and women without known myocardial infarction or CHF examined in 1976-78, 1981-83, 1991-94, and 2001-03 in the Copenhagen City Heart Study, we studied the effect of education on CHF incidence. During a median follow-up of 21 years (range 0-31), 2190 participants were admitted to hospital for CHF. Age-adjusted hazard ratio (HR) for intermediary (8-10 years) and high level of education (>10 years) with low (< 8 years) as reference was 0.69 (0.62-0.78) and 0.52 (0.43-0.63), respectively, with similar associations in men and women. After adjusting for updated cardiovascular risk factors, corresponding HRs were 0.75 (0.67-0.85) and 0.61 (0.50-0.73). In a random subset of the population examined with echocardiography in 2001-03 (n = 3589), education was associated with left ventricular (LV) hypertrophy, LV dilatation, reduced LV ejection fraction, and severe diastolic dysfunction (P for trend, all <0.05), whereas no association was found for mild diastolic dysfunction (P for trend, 0.61). With the exception of LV hypertrophy, significant associations persisted after adjustment for potential mediating factors.

CONCLUSION

In this cohort study, the level of education was associated with cardiac dysfunction and predicted future hospital admission for CHF. Only a minor part of the excess risk was mediated through traditional cardiovascular risk factors. Strategies to reduce this inequality should be strengthened.

In-treatment reduced left atrial diameter during antihypertensive treatment is associated with reduced new-onset atrial fibrillation in hypertensive patients with left ventricular hypertrophy: The LIFE Study

OBJECTIVE

It is unclear whether improvement of left atrial (LA) and ventricular (LV) structure results in reduction in new-onset atrial fibrillation (AF). The aim of the present study was to examine whether changes in-treatment LA diameter were related to changes in risk of new-onset AF.

METHODS

We followed 939 hypertensive patients with electrocardiographic LV hypertrophy randomized to atenolol or losartan-based regimens in the LIFE Study for a mean of 4.8 years with echocardiograms at enrolment and annually during treatment.

RESULTS

New-onset AF occurred in 46 patients (10.2/1000 patient-years of follow-up). At baseline, patients with new-onset AF were older, had higher systolic blood pressure and heart rate as well as higher prevalence of LA dilatation, but had similar prevalences of LV hypertrophy and mitral or aortic valve disease. In univariate Cox analysis baseline LA diameter (HR=4.67 per cm increase [95% CI 2.86-7.65], p<0.001) and LV mass index (HR=1.11 per 10 g/m(2) increase [95% CI 1.02-1.22], p<0.05) both predicted new-onset AF. In multivariate analysis, increased baseline LA diameter increased the risk of new-onset AF (HR=5.16 per cm [95% CI 2.85-9.35], p<0.001) whereas reduction of in-treatment LA diameter reduced the risk (HR=0.21 per cm lower LA diameter during treatment [95% CI 0.14-0.32], p<0.001) with adjustment for in-treatment LV mass in-treatment systolic blood pressure, age and Framingham risk score.

CONCLUSION

LA diameter at baseline and during antihypertensive treatment were equally strong predictors of new-onset AF independent of the level of arterial pressure, LV mass and other covariates. Prevention of AF during antihypertensive treatment may be improved by antihypertensive therapy that reduces LA size in addition to controlling blood pressure.

Cardiovascular morbidity in COPD: A study of the general population

Although there are a number of studies on the coexistence of heart disease and COPD among patients acutely admitted to hospital, this relationship has not been accurately described in the general population. Especially data on the prevalence of both reduced lung function and impaired left ventricular ejection fraction (LVEF) are sparse. We used data from the 4th examination of The Copenhagen City Heart Study, which comprises 5,890 individuals with data on pulmonary and cardiac symptoms, risk factors for cardiovascular diseases, pulmonary function tests, ECG and relevant medical history. Among the participants a randomly selected subgroup of 3,469 individuals underwent both spirometry and echocardiography. The participants were classified according to COPD stage using the international GOLD staging according to FEV(1) in % of predicted. The prevalence of COPD was 5.7% for mild COPD (GOLD stage 1), 9.4% for moderate COPD (GOLD stage 2) and 2.5% for severe and very severe COPD (GOLD stages 3+4). Individuals with COPD were older and had a higher prevalence of cardiovascular risk factors and a higher prevalence of cardiovascular diseases. Among the echocardiographical findings, only the presence of left ventricular hyperthrophy was significantly more frequent among individuals with COPD (17.7%) than among participants without COPD (12.1%.), yet this relationship was no longer significant after statistical adjustment for age and gender. In the general population, subjects with COPD have a higher prevalence of cardiovascular diseases and an unfavourable cardiovascular risk profile compared with individuals without COPD, but this was mainly related to higher age among the participants with COPD.

Left atrial volume combined with atrial pump function identifies hypertensive patients with a history of paroxysmal atrial fibrillation

Identifying patients at high risk for the occurrence of atrial fibrillation is one means by which subsequent thromboembolic complications may be prevented. Left atrial enlargement is associated with progression of atrial remodeling, which is a substrate for atrial fibrillation, but impaired atrial pump function is also another aspect of the remodeling. Our objective was to differentiate patients with a history of paroxysmal atrial fibrillation using echocardiography. We studied 280 hypertensive patients (age: 66+/-7 years; left ventricular ejection fraction: 65+/-8%), including 140 consecutive patients with paroxysmal atrial fibrillation and 140 age- and sex-matched control subjects. Left atrial volume was measured using the modified Simpson method at both left ventricular end systole and preatrial contraction and was indexed to body surface area. Peak late-diastolic mitral annular velocity was measured during atrial contraction using pulsed tissue Doppler imaging as an atrial pump function. Left atrial volume index measured at left ventricular end systole had a 74% diagnostic accuracy and a 71% positive predictive value for identifying patients with paroxysmal atrial fibrillation; these values for the ratio of left atrial volume index at left ventricular end systole to the peak late-diastolic mitral annular velocity were 82% and 81%, respectively, and those for the ratio of left atrial volume index at preatrial contraction to the peak late-diastolic mitral annular velocity were 86% and 90%, respectively. In conclusion, left atrial size combined with atrial pump function enabled a more accurate diagnosis of a history of paroxysmal atrial fibrillation than conventional parameters.

Influence of regression of left ventricular hypertrophy on left atrial size and function in patients with moderate hypertension

OBJECTIVES

The aim of the study was to evaluate the effect of regression of left ventricular (LV) hypertrophy on left atrial (LA) size and function in patients treated with telmisartan, an angiotensin II receptor blocker.

METHODS

Patients population included 80 patients with mild-moderate LV hypertrophy treated with telmisartan. Patients were followed over a period of 12 months from the start of telmisartan treatment. LA size was measured during systole from the parasternal long-axis view from M-mode. Atrial function was assessed by Doppler-echocardiography and the following parameters were measured: transmitral peak A velocity, atrial filling fraction, atrial ejection force (AEF), peak E velocity, deceleration time and isovolumic relaxation time, LA maximal and minimal volume, and LV cardiac mass index (LVMI).

RESULTS

All patients had an increased LVMI and decrease during follow-up. LA dimensions were greater at baseline and reduced after 1 year of treatment. LA volume indexes maximal volume, minimal volume and P volume were reduced compared with baseline value (maximal volume from 35+/-5 to 32+/-5, p<0.05; minimal volumes from 14+/-2 to 10+/-4, p<0.05). AEF, a parameter of atrial systolic function, increased from 12+/-3 to 15+/-2.4 (p<0.01). The reduction of LA volumes correlate with reduction of LVMI (LA maximal volume and LVMI r = 0.45; p<0.01; LA minimal volume and LVMI r = 0.34; p<0.05). A positive correlation was also found between LV mass index and P volume (r = 0.41; p<0.01), LV mass index and LA active emptying volume (r = 0.39; p<0.01), and LV mass index and LA total emptying volume (r = 0.38; p<0.05).

CONCLUSIONS

The present study suggests that regression of LV hypertrophy due to telmisartan is associated with reduction of LA volumes that expresses variation of LV end-diastolic pressure. The reduction of LV end-diastolic pressure is associated with an increase in diastolic filling and with a significant reduction of active and passive emptying contribution of left atrium to LV stroke volume.

Metabolism of collagen is altered in hypertensives with increased intima media thickness

BACKGROUND

Increased intima media thickness (IMT) of common carotid arteries (CCAs) and left ventricular mass index (LVMI) are independent risk factors for vascular events and may be related to accumulation of extracellular proteins due to altered metabolism of collagen.

METHODS

IMT and LVMI were measured ultrasonographically in 50 males with newly diagnosed, untreated, essential hypertension (HTN, 37.7 +/- 13.1 years), and 14 controls (C, 32.6 +/- 9.7 years). Serum levels of procollagen type I carboxy-terminal propeptide (PICP), procollagen type III amino-terminal propeptide (PIIINP), carboxy-terminal telopeptide (ICTP), matrix metalloproteinase (MMP-1) and tissue inhibitor of metalloproteinase-1 (TIMP-1) were determined using immunoassays.

RESULTS

IMT was significantly higher in HTN than in C (0.6 +/- 0.1 vs 0.4 +/- 0.1 mm, p < 0.001) as well as LVMI (119.5 +/- 39.9 vs 106.8+/-18.7 g/m2, p = 0.04) and serum TIMP-1 (in HNT 691.7 +/- 124.6 ng/ml; in C 577.5+/-70.8 ng/ml, p < 0.001). Other parameters did not differ between these groups. The sum of PICP and ICTP was higher in HTN (165.0 +/- 46.9 microg/l), than in C (147.1 +/- 26.0 microg/l, p = 0.03). TIMP-1 correlated with IMT (r = 0.33, p = 0.02) in hypertensives.

CONCLUSIONS

We suggest that the collagenase-anticollagenase system is abnormal in essential hypertension and contributes to cardiovascular remodeling. Increased IMT may be related to the accumulation of extracellular proteins due to altered metabolism of collagen.

Cardiac dysfunction assessed by echocardiographic tissue Doppler imaging is an independent predictor of mortality in the general population

BACKGROUND

Tissue Doppler imaging (TDI) detects left ventricular dysfunction in patients with heart failure and normal ejection fraction, but the prognostic significance of left ventricular dysfunction by TDI in the general population is unknown.

METHODS AND RESULTS

Within the Copenhagen City Heart Study, a large community-based population study, cardiac function was evaluated in 1036 participants by both conventional echocardiography and TDI. Averages of peak systolic (s'), early diastolic (e'), and late diastolic (a') velocities from 6 mitral annular sites were used. TDI was furthermore quantified by a combined index (eas index) of diastolic and systolic performance: e'/(a' x s'). During follow-up (median, 5.3 years), 90 participants died. Left ventricular dysfunction by TDI, in terms of low s' (hazard ratio, 1.23 per 1-cm/s decrease; P<0.05) and a' (hazard ratio, 1.20 per 1-cm/s decrease; P=0.001), were significant predictors of death in Cox proportional-hazards models adjusted for clinical variables (age, sex, body mass index, heart rate, hypertension, diabetes mellitus, and ischemic heart disease) and conventional echocardiography. The adjusted hazard ratio for death in the third tertile compared with the first tertile of the combined index of systolic and diastolic performance by TDI was 2.5 (P<0.005).

CONCLUSIONS

In the general population, in which most are free of left ventricular systolic dysfunction and restrictive diastolic filling using conventional echocardiographic parameters, left ventricular dysfunction by TDI is a powerful and independent predictor of death, especially when systolic performance and diastolic performance are considered together, recognizing their interdependency and their complex relation to deteriorating cardiac function.

B-type natriuretic peptides and their relation to cardiovascular structure and function in a population-based sample of subjects aged 70 years

The aim of the present study was to evaluate whether B-type natriuretic peptides (BNPs) could serve as screening markers for the detection of preclinical vascular disease in the community. BNP and N-terminal-pro-BNP were analyzed in 1,000 subjects aged 70 years participating in the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS) study and were related to different measures of endothelial function and activation, arterial compliance, carotid atherosclerosis, and echocardiographic findings. The median levels were 42.0 ng/L for BNP and 110.7 ng/L for N-terminal-pro-BNP. On adjusted multivariate analysis, the 2 BNPs were related to increased left ventricular mass and impaired left ventricular systolic and diastolic function but not to any of the other assessed entities reflecting preclinical vascular disease. In conclusion, BNPs are strong markers of increased left ventricular mass and impaired cardiac performance but cannot be regarded as useful screening markers for the detection of preclinical states of vascular disease in elderly subjects.

Left ventricular filling pressure estimation at rest and during exercise in patients with severe aortic valve stenosis: comparison of echocardiographic and invasive measurements

BACKGROUND

The Doppler index of left ventricular (LV) filling (E/e') is recognized as a noninvasive measure for LV filling pressure at rest but has also been suggested as a reliable measure of exercise-induced changes. The aim of this study was to investigate changes in LV filling pressure, measured invasively as pulmonary capillary wedge pressure (PCWP), at rest and during exercise to describe the relation with E/e' in patients with severe aortic stenosis.

METHODS

Twenty-eight patients with an aortic valve areas<1 cm(2) performed a multistage supine bicycle exercise test until exhaustion. PCWP, E/e'(septal), and E/e'(lateral) were determined simultaneously by echocardiography at rest and at maximal tolerated workload.

RESULTS

PCWP increased significantly from 18+/-8 mm Hg at rest to 39+/-10 mm Hg at peak exercise (P < .0001). E, e'(septal), and e'(lateral) increased with exercise, whereas E/e'(septal) remained unchanged (19+/-6 vs 19+/-6; P=NS), and only minimal changes were observed in E/e'(lateral) (14+/-4 vs 15+/-4; P=.05). E/e'(septal) and E/e'(lateral) were significantly correlated with PCWP at rest (r=0.72, P < .0001, and r=0.67, P < .0001, respectively) as well as at peak exercise (r=0.66, P=.0003, and r=0.47, P=.02, respectively), with nearly similar slopes of the linear regression lines. The intercepts, however, increased by 18 mm Hg (P=.01) and by 19 mm Hg (P=.01) at peak exercise, respectively. Changes in E/e'(septal) and E/e'(lateral) were not related to changes in PCWP with exercise (P=NS). Instead, the ratio of E velocity during exercise to e'(septal) at rest (E(exercise)/e'(septal, rest)) was correlated with PCWP during exercise (r=0.61, P=.001), and furthermore, E(exercise)-E(rest)/e'(septal, rest) was related to changes in PCWP (r=0.45, P=.02). The results for the lateral side were r=0.50 (P=.01) and r=0.44 (P=.03), respectively.

CONCLUSIONS

E/e' is well correlated with PCWP at rest. However, E/e' cannot be used to detect exercise-induced changes in PCWP in patients with severe aortic stenosis. Using the ratio of E during exercise to e' at rest may result in a better estimate of the increase in PCWP during exercise.

Preclinical systolic and diastolic dysfunction assessed by tissue Doppler imaging is associated with elevated plasma pro-B-type natriuretic peptide concentrations

BACKGROUND

Heart failure is a major public health problem. To improve its grave prognosis, early identification of cardiac dysfunction is mandatory. Conventional echocardiography is not suitable for this. Tissue Doppler imaging (TDI), however, could be so.

METHODS AND RESULTS

Within a large community-based population-study (n = 1012), cardiac function was evaluated by conventional echocardiography (left ventricular hypertrophy, dilatation, systolic, and severe diastolic dysfunction), TDI, and plasma proBNP. Averages of peak systolic (s'), early diastolic (e'), and late diastolic (a') velocities from 6 mitral annular sites were used. TDI was furthermore quantified by a combined index (eas-index) of diastolic and systolic performance: e'/(a' x s'). Compared with controls, persons with elevated plasma proBNP concentrations (n = 100) displayed lower systolic and diastolic performance by TDI, in terms of lower s' (P = 0.017) and a' (P < .001), and higher e'/a' (P = .002) and eas-index (P < .001). This pattern remained significant after multivariable adjustment for age, sex, body mass index, heart rate, estimated glomerular filtration rate, hypertension, diabetes, ischemic heart disease, and conventional echocardiography. Furthermore, TDI provided incremental information over conventional echocardiography in predicting elevated plasma proBNP concentrations.

CONCLUSIONS

Preclinical systolic and diastolic dysfunction by TDI is associated with elevated plasma proBNP levels, even when conventional echocardiography is normal.

Overestimation of left ventricular mass and misclassification of ventricular geometry in heart failure patients by two-dimensional echocardiography in comparison with three-dimensional echocardiography

BACKGROUND

Accurate assessment of left ventricular hypertrophy (LVH) and ventricular geometry is important, especially in patients with heart failure (HF). The aim of this study was to compare the assessment of ventricular size and geometry by 2D and 3D echocardiography in normotensive controls and among HF patients with a normal and a reduced ejection fraction.

METHODS

One hundred eleven patients, including 42 normotensive patients without cardiac disease, 41 hypertensive patients with HF and a normal ejection fraction (HFNEF), and 28 patients with HF and a low ejection fraction (HFLEF), underwent 2DE and freehand 3DE. The differences between 2DE and 3DE derived LVM were evaluated by use of a Bland-Altman plot. Differences in classification of geometric types among the cohort between 2DE and 3DE were determined.

RESULTS

Two-dimensional echocardiography overestimated ventricular mass compared to 3D echocardiography (3DE) among normal (166 +/- 36 vs. 145 +/- 20 gm, P = 0.002), HFNEF (258 +/- 108 vs. 175 +/- 47gm, P < 0.001), and HFLEF (444 +/- 136 vs. 259 +/- 77 gm, P < 0.001) patients. The overestimation of mass by 2DE increased in patients with larger ventricular size. The use of 3DE to assess ventricular geometry resulted in reclassification of ventricular geometric patterns in 76% of patients with HFNEF and in 21% of patients with HFLEF.

CONCLUSION

2DE overestimates ventricular mass when compared to 3DE among patients with heart failure with both normal and low ejection fractions and leads to significant misclassification of ventricular geometry in many heart failure patients.

The effect of nondipping blood pressure patterns on cardiac structural changes and left ventricular diastolic functions in normotensives

BACKGROUND

Cardiac structural changes have been reported to be more prominent in nondipper normotensives than the dipper ones. But the influence of nondipping status on cardiac diastolic functions of normotensives has not been studied yet. In this study, we investigated the effect of nondipping status on both cardiac structural changes and left ventricular (LV) diastolic functions in normotensives.

METHODS

We performed ambulatory blood pressure (BP) monitoring (ABPM) and echocardiography in 62 normotensive subjects with the following criteria: (1) office BP < 140/90 mmHg; (2) average 24-hour ambulatory BP < 130/80 mmHg.

RESULTS

In the evaluation by tissue Doppler imaging (TDI), the early diastolic myocardial peak velocity (Em) and Em/late diastolic myocardial peak velocity (Am) ratio (Em/Am ratio) were lower in nondippers than those in dippers (P = 0.009 and P < 0.001, respectively). Isovolumic relaxation time (IRT) and myocardial performance index (MPI) were higher in nondippers than those in dippers (P = 0.036 and P = 0.026, respectively). Nondipping status, independent of other factors, was observed to cause both a decrease in the Em and Em/Am ratio and an increase in IRT. However, its effect on IRT was not statistically significant (coefficient =-0.27, P = 0.027; coefficient =-0.37, P = 0.002; coefficient = 0.20, P = 0.082, respectively).

CONCLUSIONS

Nondipping of nocturnal BP seems to be a determinant of cardiac remodeling and LV diastolic dysfunction (LVDD) and may result in a cardiovascular (CV) risk independent of the increase in LV mass (LVM) in normotensives.

Left atrial volume in patients with asymptomatic aortic valve stenosis (the Simvastatin and Ezetimibe in Aortic Stenosis study)

Left atrial (LA) size is known to increase with persistently increased left ventricular (LV) filling pressure. We therefore hypothesized that LA volume might reflect the severity of aortic valve stenosis (AS). Transthoracic echocardiography was performed in 1,758 patients with asymptomatic AS (transaortic Doppler velocity > or =2.5 and < or =4 m/s) in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. LA volume was measured in end-systole in the apical 4-chamber view in 1,503 patients (85%), and aortic valve area (AVA) was estimated by the continuity equation and indexed by body surface area. Mean values for age and AVA were 67 +/- 10 years and 1.27 +/- 0.5 cm2, respectively, and 574 were women (38%). Mean value for LA volume indexed (LAVI) was 36 +/- 13 ml/m2. Enlargement of LA volume (> or =32 ml/m2) was found in 57% of patients. AVA indexed was significantly correlated to LAVI (r = -0.1, p = 0.0002). Multivariate analysis showed that LAVI was significantly related to AVA indexed (beta = -4.1, p = 0.007) in a model that also included mitral regurgitation (beta = 2.8, p <0.0001), history of hypertension (beta = 2.2, p = 0.002), LV end-diastolic volume (beta = 0.05, p <0.0001), presence of LV hypertrophy (beta = 3.4, p <0.0001), and restrictive LV filling pattern (beta = 3.5, p = 0.01). Gender and LV ejection fraction were eliminated from the final model. In conclusion, LA volume is often enlarged in asymptomatic patients with AS. Furthermore, LA volume is related to AVA even when adjusting for other known risk factors for increased LA volume including of measurements of diastolic function.

Myocardial fibrosis and diastolic dysfunction in patients with hypertension: results from the Swedish Irbesartan Left Ventricular Hypertrophy Investigation versus Atenolol (SILVHIA)

OBJECTIVES

Hypertensive left ventricular hypertrophy (LVH) is associated with cardiomyocyte hypertrophy and an excess in myocardial collagen. Myocardial fibrosis may cause diastolic dysfunction and heart failure. Circulating levels of the carboxy-terminal propeptide of procollagen type I (PICP), an index of collagen type I synthesis, correlate with the extent of myocardial fibrosis. This study examines myocardial fibrosis in relation to blood pressure, left ventricular mass (LVM), and diastolic function.

METHODS

We examined PICP levels in 115 patients with hypertensive LVH, 38 with hypertension but no hypertrophy, and 38 normotensive subjects. Patients with LVH were subsequently randomly assigned to the angiotensin II type 1 receptor blocker irbesartan or the beta1 receptor blocker atenolol for 48 weeks. Diastolic function was evaluated by tissue velocity echocardiography (n=134). We measured basal septal wall velocities of early (Em) and late (Am) diastolic myocardial wall motion, Em velocity deceleration time (E-decm), and isovolumic relaxation time (IVRTm).

RESULTS

Compared with the normotensive group, PICP was elevated and left ventricular diastolic function was impaired in the hypertensive groups, with little difference between patients with and without LVH. PICP related to blood pressure, IVRTm, Em, and E/Em, but not to LVM. Irbesartan and atenolol reduced PICP similarly. Only in the irbesartan group did changes in PICP relate to changes in IVRTm, and LVM.

CONCLUSION

Myocardial fibrosis and diastolic dysfunction are present in hypertension before LVH develops. The findings with irbesartan suggest a role for angiotensin II in the control of myocardial fibrosis and diastolic function in patients with hypertension with LVH.

Masked hypertension in diabetes mellitus: a potential risk

The prevalence and clinical significance of masked hypertension (MHT) in diabetics have infrequently been described. The authors assessed the association of MHT (defined using a clinic blood pressure [BP] <140/90 mm Hg and daytime ambulatory BP > or = 135/85 mm Hg) with microvascular and macrovascular end organ damage in 81 clinically normotensive Japanese diabetic persons. The prevalence of silent cerebral infarcts (SCIs), increased left ventricular mass, and albuminuria were evaluated. Of 81 patients, 38 (46.9%) were classified as having MHT and showed significantly more SCIs (mean +/- SE: 2.5+/-0.5 vs 1.1+/-0.2; P=.017), and more albuminuria (39% vs 16%; P=.025), but no increase in left ventricular mass index, than the normotensive persons in office and on ambulatory BP monitoring group. The prevalence of MHT in this diabetic population was high (47%). Diabetic patients with MHT showed evidence of brain and kidney damage. Hence, out-of-office monitoring of BP may be indicated in diabetics whose BP is normal in the clinic.

Discriminating between cardiac and pulmonary dysfunction in the general population with dyspnea by plasma pro-B-type natriuretic peptide

OBJECTIVES

This study was designed to determine whether measurement of plasma pro-B-type natriuretic peptide (proBNP) could be used in discriminating between cardiac and pulmonary dyspnea in the general population.

BACKGROUND

Natriuretic peptides are useful markers in ruling out acute cardiac dyspnea in the emergency department, but their diagnostic significance in evaluating chronic dyspnea in the general population is unknown.

METHODS

Within the Copenhagen City Heart Study, a large, community-based population study, dyspnea was evaluated by spirometry, oxygen saturation, echocardiography, and plasma proBNP.

RESULTS

Of 2,929 participants, 959 reported dyspnea. The plasma proBNP concentration was higher in the group with dyspnea (mean 17.8 pmol/l; 95% confidence interval [CI] 16.3 to 19.4 pmol/l) than in the group without (10.6 pmol/l; 95% CI 10.0 to 11.4 pmol/l; p < 0.001). In the group with dyspnea, left ventricular hypertrophy and/or systolic dysfunction was associated with a 2.6-fold increase in plasma proBNP concentration (p < 0.001), whereas pulmonary dysfunction was not associated with increased plasma proBNP (p = 0.66). Using multivariable regression analysis, a model to estimate the expected concentration of plasma proBNP based on age and gender was established for dyspneic subjects: an actual plasma proBNP concentration below half of the expected value ruled out left ventricular systolic and diastolic dysfunction (sensitivity 100%, 95% CI 100% to 100%; specificity 15%, 95% CI 12% to 17%).

CONCLUSIONS

In the general population with dyspnea, plasma proBNP concentrations are increased in left ventricular dilatation, hypertrophy, systolic dysfunction, or diastolic dysfunction, but are unaffected by pulmonary dysfunction.

Evaluation of dyspnoea in a sample of elderly subjects recruited from general practice

The objectives of this study were to investigate the cause of dyspnoea in a sample of elderly individuals and to assess the diagnostic yield of a three-step examination algorithm for the evaluation of dyspnoea paired with a cost analysis. A total of 152 subjects were examined. A predefined diagnostic approach in three steps was carried out to find the cause of dyspnoea. Step 1 included lung spirometry and ECG; step 2 included lung diffusion capacity, echocardiography, haemoglobin and thyroid function; and step 3 included cardiac magnetic resonance imaging, chest radiography and exercise test. Of 129 subjects with dyspnoea, 68 (53%) had signs of lung disease, 27 (21%) had heart disease, a total of 43 (33%) were obese, 20 (16%) were obese without other causes of dyspnoea and five (4%) had general physical deconditioning. Twelve per cent had none of the above-mentioned potential causes of dyspnoea. Steps 1, 1 + 2 and 1 + 2 + 3 revealed a cause of dyspnoea in 39%, 63%, and 73% of subjects respectively. The cost per diagnosed case at steps 2 and 3 was twice and 3.5 times the cost per diagnosed case at step 1. In this sample of elderly subjects, a potential cause of dyspnoea was identified in most cases, the most frequent being lung disease followed by heart disease and obesity. These data shed light on the diagnostic yield that can be expected from a relatively simple diagnostic approach, including the most frequent recommended initial screening tests. As expected, the incremental nature of this algorithm translated into incremental costs per diagnosis achieved.

Cardiac structure and function and arterial circulation in hypertensive patients with and without metabolic syndrome

High blood pressure (BP) is one of the crucial determinants of the metabolic syndrome (MS). The extent to which MS, diagnosed according to the criteria of the International Federation of Diabetes, impacts on cardiovascular organ damage, independently of BP, is debated. Three hundred and forty hypertensive patients and 100 normotensive controls underwent the following procedures: (1) physical examination and resting BP measurements, (2) 24 h ambulatory BP monitoring, (3) laboratory routine examination, (4) echocardiography, (5) carotid ultrasonography and (6) ankle-brachial BP index. The syndrome was found in 104 of the 340 hypertensive patients (30.6). In comparison to those without MS, those with MS had significantly higher prevalence of left ventricular (LV) hypertrophy by mass/height(2.7) criteria (46 vs 42%, P<0.01) but not by LV mass/body surface criteria (30 vs 31%); the ratio between early-to-late peak velocities of the LV filling waves (E/A) was higher (E/A=0.99+/-0.14 vs 0.89+/-0.15, P<0.01) and left atrium was larger (3.8+/-0.3 vs 3.5+/-0.5 cm, P<0.01). Both hypertensive groups had significantly greater LVM and carotid intima-media thickness than normotensives, without between-group-difference. In this hypertension outpatient clinic almost one-third hypertensive patients have MS. They show a deterioration in structure and function of the heart in comparison to hypertensive patients without MS, but no difference was detected in the carotid and peripheral arterial circulation.

Metabolic Syndrome Less Strongly Associated With Target Organ Damage Than Syndrome Components in a Healthy, Working Population

The authors investigated the associations between target organ damage and individual components of the metabolic syndrome (MS) compared with the MS itself. Carotid intima-media thickness (IMT), carotid plaque, and left ventricular mass index (LVMI) were assessed by ultrasonography in 356 participants who were free of overt cardiovascular disease. Participants with the MS (n=33) had higher LVMI and carotid IMT than those without the MS (n=323), but the percentage of patients who had carotid plaque was similar. Individually, each component of the MS was significantly associated with the 3 measures of target organ damage. In bivariate and multivariate analyses, the association of clinic systolic blood pressure to both LVMI and carotid IMT and the negative association of high-density lipoprotein cholesterol with carotid plaque were stronger than and independent of the MS. The data suggest that physicians should evaluate blood pressure and high-density lipoprotein cholesterol as well as other cardiovascular risk factors without regard to whether a patient meets the criteria for the MS.

No evidence for left ventricular diastolic dysfunction in asymptomatic normotensive type 2 diabetic patients: a case-control study with new echocardiographic techniques

OBJECTIVE

We sought to determine whether abnormalities of left ventricular structure and function could be detected in asymptomatic type 2 diabetic patients free of cardiovascular complications.

RESEARCH DESIGN AND METHODS

We compared 48 subjects with type 2 diabetes (34 men, 50+/-6 years) without hypertension, coronary artery disease and microangiopathic complications with 30 age-matched healthy controls. Left ventricular diastolic function was assessed by conventional Doppler echocardiography and new echocardiographic techniques (tissue Doppler imaging, color M-mode propagation velocity). A pseudonormal (PN) pattern of left ventricular filling was screened by several methods including Valsalva maneuver.

RESULTS

Systolic function was normal in all patients. There was no significant difference in conventional and new echocardiographic Doppler indices of diastolic function between patients and control subjects. A PN diastolic function frequently suggested by the Valsalva maneuver (20 patients) was excluded using the new parameters.

CONCLUSIONS

Diastolic dysfunction is not as frequent as previously described in selected patients with type 2 diabetes free of microangiopathic complications. New Doppler echocardiographic methods provide, in contrast with the Valsalva maneuver, a reliable estimate of diastolic function and should be incorporated in the non-invasive screening for diabetic cardiomyopathy.

Left Atrial Size and Risk of Major Cardiovascular Events During Antihypertensive Treatment

The influence of left atrial size on cardiovascular events during antihypertensive treatment has not been reported previously from a long-term, prospective, randomized hypertension treatment trial. We recorded left atrial diameter by annual echocardiography and cardiovascular events in 881 hypertensive patients (41% women) with electrocardiographic left ventricular hypertrophy aged 55 to 80 (mean: 66) years during a mean of 4.8 years of randomized losartan- or atenolol-based treatment in the Losartan Intervention for Endpoint Reduction in Hypertension Study. During follow-up, a total of 88 primary end points (combined cardiovascular death, myocardial infarction, or stroke) occurred. In Cox regression, baseline left atrial diameter/height predicted incidence of cardiovascular events (hazard ratio: 1.98 per cm/m [95% CI: 1.02 to 3.83 per cm/m]; P =0.042) adjusted for significant effects of Framingham risk score and history of atrial fibrillation. Greater left atrial diameter reduction during follow-up was associated with greater reduction in left ventricular hypertrophy, absence of new-onset atrial fibrillation or mitral regurgitation during follow-up, and losartan-based treatment (B=−0.13±0.03 cm/m; P <0.001) in multiple linear regression, adjusting for baseline left atrial diameter/height. However, in time-varying Cox regression analysis, left atrial diameter reduction was not independent of left ventricular hypertrophy regression in predicting cardiovascular events during follow-up. In conclusion, left atrial diameter/height predicts risk of cardiovascular events independent of other clinical risk factors in hypertensive patients with left ventricular hypertrophy and may be useful in pretreatment clinical assessment of cardiovascular risk in these patients.

Genome-wide linkage mapping for valve calcification susceptibility loci in hypertensive sibships: the Hypertension Genetic Epidemiology Network Study

It remains unclear whether genetic factors contribute to the susceptibility to valve calcification. Accordingly, echocardiograms and genotyping were performed in 1871 hypertensive siblings who participated in the Hypertension Genetic Epidemiology Network Study. Genome-wide affected sibpair nonparametric linkage analysis was conducted using the allele-sharing method implemented in the Merlin computer program. A total of 1014 sibships from 858 families were evaluated for aortic valve sclerosis or mitral annular calcification. Of these, 78 sibships from 68 families contained > or =2 affected siblings with > or =1 type of valve calcification (142 affected siblings). All 3 of the traits showed a modest degree of familial aggregation, with sibling recurrence risk (SD) and sibling recurrence risk ratio (95% CI) being 0.25 (0.035) and 2.31 (1.72 to 3.11) for aortic valve sclerosis, 0.25 (0.035) and 1.78 (1.36 to 2.33) for mitral annular calcification, and 0.31 (0.030) and 1.52 (1.24 to 1.85) for aortic valve sclerosis and mitral annular calcification, respectively. Affected sibpair linkage analysis revealed the highest logarithm of odds score (3.14) in chromosome 16 at 105.6 cM for aortic valve sclerosis. Other chromosomal regions with logarithm of odds score > or =1.9 were found in chromosomes 19 (2.88), 16 (2.63), 1 (2.12), and 2 (2.03) for aortic valve sclerosis and chromosome 13 (2.12) for any valve calcification. There was no logarithm of odds score > or =1.9 for mitral annular calcification. Our study shows strong linkage of aortic valve sclerosis to chromosome 16q22.1-q22.3 and suggestive linkage to chromosome 19p13.11-p11 and identifies several other promising genomic regions that may contain specific susceptibility loci for valve calcification.

Exercise performance during losartan- or atenolol-based treatment in hypertensive patients with electrocardiographic left ventricular hypertrophy (a LIFE substudy)

The objective of the study was to assess the influence of left ventricular (LV) hypertrophy regression on exercise capacity in hypertensive patients. Doppler echocardiography was performed at rest and during exercise in 51 patients with electrocardiographic LV hypertrophy before and after 1 year of randomized blinded losartan- or atenolol-based antihypertensive treatment. After 1 year, blood pressure was comparably reduced by 32/14 and 27/13 mmHg, respectively, in the losartan and atenolol groups, but the atenolol group had higher mean LV mass index (118 vs 103 g/m2) and lower LV ejection fraction (61% vs 67%) and midwall shortening (15.8% vs 16.8%) (all p<0.05). Resting diastolic Doppler indices remained unchanged and did not differ between the groups. Peak oxygen uptake during exercise was virtually unchanged after 1 year and did not differ between the groups in spite of a lower peak exercise heart rate in atenolol-treated patients. In multivariate analysis, higher peak oxygen uptake at 1 year was associated with lower body mass index, and higher systolic blood pressure and shorter isovolumic relaxation time at peak exercise (multiple R2 = 0.51, p<0.01), while age, gender, heart rate increase during exercise, reduction in LV mass and study treatment did not enter. In conclusion, reduction in blood pressure and LV mass induced by losartan or atenolol treatment was not accompanied by improved exercise capacity after 1 year. The results may be explained by persistent impairment of myocardial relaxation influencing exercise capacity.

Evaluation of the Electrocardiographic Criteria for Left Ventricular Hypertrophy With Use of Three-Dimensional Echocardiography

BACKGROUND

Left ventricular hypertrophy (LVH) is a common condition that carries an increased risk of cardiovascular events. Use of ECG in detection of LVH is limited because of the reported low sensitivity. Conventional echocardiographic techniques used as the standard for estimating left ventricular (LV) mass have limitations related to the position of the image plane and shape of the ventricle. Three-dimensional echocardiography is free of these limitations and therefore is more accurate. We hypothesized that accuracy of ECG criteria for LVH would improve when LV mass was assessed by three-dimensional echocardiography.

RESULTS

For most of the criteria, sensitivity, specificity and accuracy improved when LV mass was assessed by three-dimensional echocardiography. Two-dimensional echocardiography significantly overestimated LV mass as compared with the three-dimensional method.

CONCLUSIONS

Sensitivity, specificity, and accuracy of the ECG criteria improved when LV mass was estimated by three-dimensional echocardiography. This improvement may be attributed at least in part to superior accuracy of three-dimensional measurements.

Echocardiographic partition values and prevalence of left ventricular hypertrophy in hypertensive Nigerians

BACKGROUND

Left ventricular hypertrophy (LVH) is a well known independent risk factor for cardiovascular events. It has been shown that combination of left ventricular mass (LVM) and relative wall thickness (RWT) can be used to identify different forms of left ventricular (LV) geometry. Prospective studies have shown that LV geometric patterns have prognostic implications, with the worst prognosis associated with concentric hypertrophy. The methods for the normalization or indexation of LVM have also recently been shown to confer some prognostic value especially in obese population. We sought to determine the prevalence of echocardiographic lLVH using eight different and published cut-off or threshold values in hypertensive subjects seen in a developing country's tertiary centre.

METHODS

Echocardiography was performed in four hundred and eighty consecutive hypertensive subjects attending the cardiology clinic of the University college Hospital Ibadan, Nigeria over a two-year period.

RESULTS

Complete data was obtained in 457 (95.2%) of the 480 subjects (48.6% women). The prevalence of LVH ranged between 30.9-56.0%. The highest prevalence was when LVM was indexed to the power of 2.7 with a partition value of 49.2 g/ht2.7 in men and 46.7 g/ht2.7 in women. The lowest prevalence was observed when LVM was indexed to body surface area (BSA) and a partition value of 125 g/m2 was used for both sexes. Abnormal LV geometry was present in 61.1%-74.0% of our subjects and commoner in women.

CONCLUSION

The prevalence of LVH hypertensive patients is strongly dependent on the cut-off value used to define it. Large-scale prospective study will be needed to determine the prognostic implications of the different LV geometry in native Africans.