Comparison in systemic hypertension of left ventricular mass and geometry with systolic and diastolic function in patients <65 to > or = 65 years of age

Chronic inhibition of phosphodiesterase 5 with tadalafil affords cardioprotection in a mouse model of metabolic syndrome: role of nitric oxide

Patients with metabolic syndrome (MetS) often exhibit generalized endothelial and cardiac dysfunction with decreased nitric oxide (NO) production and/or bioavailability. Since phosphodiesterase 5 (PDE5) inhibitors restore NO signaling, we hypothesized that chronic treatment with long-acting PDE5 inhibitor tadalafil may enhance plasma NO levels and reduce cardiac dysfunction following ischemia/reperfusion (I/R) injury in C57BL/6NCrl-Leprdb-lb/Crl mice with MetS phenotypes. Adult male MetS mice were randomized to receive vehicle solvent or tadalafil (1 mg/kg,i.p.) daily for 28 days and C57BL/6NCrl mice served as healthy wild-type controls. After 28 days, cardiac function was assessed by echocardiography and hearts from a subset of mice were isolated and subjected to 30 min of global ischemia followed by 60 min of reperfusion (I/R) in ex vivo Langendorff mode. Body weight, blood lipids, and glucose levels were elevated in MetS mice as compared with wild-type controls. The dyslipidemia in MetS was ameliorated following tadalafil treatment. Although left ventricular (LV) systolic function was minimally altered in the MetS mice, there was a significant diastolic dysfunction as indicated by reduction in the ratio of peak velocity of early to late filling of the mitral inflow, which was significantly improved by tadalafil treatment. Post-ischemic cardiac function, heart rate, and coronary flow decreased significantly in MetS mice compared to wild-type controls, but preserved by tadalafil treatment. Myocardial infarct size was significantly smaller following I/R, which was associated with higher plasma levels of nitrate and nitrite in the tadalafil-treated MetS mice. In conclusion, tadalafil induces significant cardioprotective effects as shown by improvement of LV diastolic function, lipid profile, and reduced infarct size following I/R. Tadalafil treatment enhanced NO production, which may have contributed to the cardioprotective effects.

Difference in the prevalence of subclinical left ventricular impairment among left ventricular geometric pattern in a community-based population

BACKGROUND

Left ventricular (LV) hypertrophy is reported to cause LV diastolic dysfunction. This study aimed to examine the prevalence of LV diastolic dysfunction in each group categorized by the geometric pattern of LV hypertrophy in a community-based population.

METHODS

We studied 1260 community-dwelling subjects who experienced no symptoms of obvious heart disease (461 men, 799 women) and who participated in annual health check-ups in a rural Japanese community. The subjects were divided into 4 groups according to LV mass index and relative wall thickness: normal geometry, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy. We investigated the prevalence of LV diastolic dysfunction in the overall and stratified population by LV geometric pattern. LV diastolic function was determined by 3 echocardiographic parameters of LV diastolic function: early diastolic myocardial velocity, the ratio of early diastolic mitral inflow velocity and myocardial velocity, and indexed left atrial dimension. LV diastolic dysfunction was defined as the presence of abnormal values in more than 2 of 3 echocardiographic parameters.

RESULTS

The prevalence of LV diastolic dysfunction was higher in the categories with more severe LV hypertrophy. However, LV mass index, rather than relative wall thickness, was a significant determinant of LV diastolic dysfunction, after adjustment for comorbidities. In addition, 71 (10%) out of 740 subjects with normal LV geometric pattern had LV diastolic dysfunction even without obvious LV geometric change.

CONCLUSIONS

The prevalence of LV diastolic dysfunction was higher in the subjects with more severe LV hypertrophy in a community-based population. Subclinical LV diastolic dysfunction without obvious LV geometric change should be noted and its clinical impact should be elucidated.

Echocardiographic Correlation between Right Ventricular Function and Left Atrial Volume

Background

Few reports exist on the relationship of the left ventricular diastolic dysfunction (LVDD) with its most important features including enlargement of the left atrium and left ventricular hypertrophy (LVH), and with the right ventricular (RV) function.

Objective

To determine the correlation between the left atrial size and the RV function and dimensions in patients with and without LVDD and LVH.

Methods

Fifty patients were included, 25 (40% men) of them with LVDD, aged 67.1 ± 10.6 years (study group) and 25 without LVDD (52% men) aged 49.9 ± 16.3 years (control group). Patients underwent transthoracic echocardiography with evaluation of the left atrial size and volume (LAV), LVDD, LVH, and RV function and dimensions. P-values < 0.05 were considered statistically significant.

Results

LAV > 34 mL/m² and left atrial size > 40 mm were associated with lower absolute values of tricuspid annular plane systolic excursion (TAPSE) and RV lateral S' (p ≤ 0.001, Pearson's correlation coefficient -0.4 and -0.38, respectively) in the study group. Patients in the study group showed higher incidence of LVH (p = 0.02) and greater left atrial diameter (p = 0.03) compared with the control group. In addition, greater left atrial diameter (p = 0.02) and LAV (p = 0.01) values were found in patients with LVDD grade II compared with LVDD grade I.

Conclusions

The present study determined, for the first time, the correlation of left atrial enlargement with progressive RV dysfunction in patients with LVDD.

Early diastolic strain rate measurements by cardiac MRI in breast cancer patients treated with trastuzumab: a longitudinal study

We evaluated temporal changes in early diastolic strain rates by cardiovascular magnetic resonance (CMR) as an early detector of trastuzumab-induced ventricular dysfunction. We conducted a prospective, multi-centre, longitudinal observational study of 41 trastuzumab-treated breast cancer women who underwent serial CMR (baseline, 6, 12, and 18 months). Two blinded readers independently measured left ventricular ejection fraction (LVEF), peak systolic strain parameters (global longitudinal strain [GLS] and global circumferential strain [GCS]), and early diastolic strain rate parameters (global longitudinal diastolic strain rate [GLSR-E], global circumferential diastolic strain rate [GCSR-E], and global radial diastolic strain rate [GRSR-E]), by feature tracking (FT-CMR) using CMR42. There was a significant decline in peak systolic strain GLS and GCS at 6 months (p = 0.024 and p < 0.001, respectively) and 12 months (p = 0.002 and p < 0.001, respectively), followed by recovery at 18 months, which paralleled decline in LVEF at 6 months (p = 0.034) and 12 months (p = 0.012). Conversely, early diastolic strain rates GLSR-E and GCSR-E did not significantly change over 18 months (p > 0.10), while GRSR-E was marginally significant at 12 months (p = 0.021). There was no significant correlation between changes at 6 months in LVEF and GLSR-E or GRSR-E (p > 0.10), and a marginally significant weak correlation between LVEF and GCSR-E (p = 0.046). Among trastuzumab-treated patients without overt cardiotoxicity, there was no consistent temporal change in FT-CMR-derived diastolic strain rate parameters up to 18 months, in contrast to decline in systolic strain and LVEF. Systolic strains by FT-CMR are likely more useful than diastolic strain rates for monitoring subclinical trastuzumab-related myocardial dysfunction.ClinicalTrials.gov identifier NCT01022086.

Left ventricular mass-geometry and silent cerebrovascular disease: The Cardiovascular Abnormalities and Brain Lesions (CABL) study

BACKGROUND

Although abnormal left ventricular geometric patterns have prognostic value for morbidity and mortality, their possible association with silent cerebrovascular disease has not been extensively evaluated.

METHODS

We examined 665 participants in the CABL study who underwent transthoracic echocardiography and brain magnetic resonance imaging. Participants were divided into 4 geometric patterns: normal geometry (n=397), concentric remodeling (n=89), eccentric hypertrophy (n=126), and concentric hypertrophy (n=53). Subclinical cerebrovascular disease was defined as silent brain infarcts (SBIs) and white matter hyperintensity volume (WMHV; expressed as log-transformed percentage of the total cranial volume).

RESULTS

Silent brain infarcts were observed in 94 participants (14%). Mean log-WMHV was -0.97±0.93. Concentric hypertrophy carried the greatest risk for both SBI (adjusted odds ratio [OR] 3.39, P<.001) and upper quartile of log-WMHV (adjusted OR 3.35, P<.001), followed by eccentric hypertrophy (adjusted ORs 2.52 [P=.001 for SBI] and 1.96 [P=.004] for log-WMHV). Concentric remodeling was not associated with subclinical brain disease. In subgroup analyses, concentric and eccentric hypertrophies were significantly associated with SBI and WMHV in both genders and nonobese participants, but differed for SBI by age (all ages for eccentric hypertrophy, only patients ≥70years for concentric hypertrophy) and by race-ethnicity (Hispanics for eccentric hypertrophy, blacks for concentric hypertrophy; no association in whites).

CONCLUSIONS

Left ventricular hypertrophy, with both eccentric and concentric patterns, was significantly associated with subclinical cerebrovascular disease in a multiethnic stroke-free general population. Left ventricular geometric patterns may carry different risks for silent cerebrovascular disease in different sex, age, race-ethnic, and body size subgroups.

Left Ventricular Diastolic Function Assessment of a Heterogeneous Cohort of Pulmonary Arterial Hypertension Patients

BACKGROUND

Pulmonary arterial hypertension (PAH) is known to trigger right ventricular (RV) remodeling that might compromise left ventricular (LV) filling due to inter-ventricular interdependence. In this study, we aimed to examine standard echocardiographic measurements of LV diastolic function in PAH patients.

METHODS

In this retrospective study, we identified clinical as well as complete echocardiographic data from 128 chronic PAH patients to fully assess LV diastolic dysfunction (LVDD) using standard recommended Doppler guidelines. Accordingly, patients were divided into three groups: LVDD 0, LVDD 1 and LVDD 2.

RESULTS

The mean age of the studied population was 57 ± 14 years with a mean pulmonary artery systolic pressure (PASP) of 55 ± 21 mm Hg. A total of 36% of the study patients had normal LV diastolic function. However, 64% had LVDD with LVDD stage 1 being the most common (48%). In terms of echocardiographic data, significant differences were found among the three LVDD groups in regards to PASP, LV end systolic and diastolic volumes, tricuspid annular plane systolic excursion, right ventricular fractional area change as well as many other tissue Doppler imaging parameters. Finally, just age and PASP were predictors of abnormal LV diastolic function (P < 0.05).

CONCLUSIONS

Impaired relaxation is a common abnormality in PAH patients. Additional studies are warranted to determine whether LVDD alters prognosis or is related to changes in the symptomatic profile of this group of patients.

Echocardiographic Assessment of Left Ventricular Structure in Hypertension and the Impact on Clinical Outcomes

Hypertension (HTN) is present in nearly 50 million individuals, or approximately 29% of the adult US population. The prevalence of HTN is higher in men, increases with age, and varies among ethnic groups. Alterations of left ventricular structure and function can be present in patients with HTN and accurately characterized by echocardiography. The presence of left ventricular hypertrophy with increased left ventricular mass has prognostic implications in patients with HTN.

Assessment and impact of diastolic function by echocardiography in elderly patients

Doppler echocardiography is the gold standard for assessment of diastolic dysfunction, which is increasingly recognised as a cause of heart failure, especially in the elderly. Using a combination of Doppler echocardiography techniques, it is possible to identify grades of diastolic dysfunction, estimate left ventricular filling pressures and establish the chronicity of diastolic dysfunction. These physiologically-derived measures have been widely validated against invasive measurements of left heart pressures and have been shown to be prognostically valuable in a wide range of clinical settings. This review explores the mechanisms, and approaches to the assessment of diastolic dysfunction in the elderly. The challenge for clinicians is to identify pathophysiological changes from those associated with normal ageing. When used in combination, and taking age into account, Doppler echocardiographic parameters are helpful in the assessment of dyspnoea in older patients and provide prognostic insights.

Gender differences in predictors of left ventricular myocardial relaxation in non-obese, healthy individuals

Background

Previous studies indicate that individuals with metabolic syndrome (MetS) might be at risk for left ventricular (LV) diastolic dysfunction. However, little is known about which metabolic factors contribute to the development of LV dysfunction in individuals who are not obese or overweight and who do not have diabetes mellitus and/or cardiovascular disease.

Methods

Participants without diabetes mellitus, systolic dysfunction, or other heart diseases underwent a thorough physical examination, including tissue Doppler echocardiography. A peak early mitral annular velocity (e′) of <5.0 was designated as indicating abnormal LV myocardial relaxation (LVMR). We performed single and multiple logistic regression analyses of e′ and cardiovascular risk factors, including MetS factors and indicators of major organ dysfunction. Normal-weight subjects (body mass index <25 kg/m²) were also analyzed.

Results

A total of 1055 individuals (mean age, 63 ± 13 years) participated, of which 307 (29.1%) had MetS and 199 (18.9%) had abnormal LVMR. Multiple logistic regression analysis revealed waist circumference (WC) (odds ratio [OR] 1.04, P < 0.05) and age (OR 1.10, P < 0.05) to be predictors of abnormal LVMR. In normal-weight subjects (n = 806), aging (OR 1.08, P < 0.01), abnormal WC (OR 3.80, P < 0.01), and renal dysfunction (OR 2.14, P < 0.01) were predictors of abnormal LVMR. Among MetS factors, abnormal WC in men (OR 3.70, P < 0.01) and high diastolic blood pressure (DBP) in women (OR 4.00, P = 0.01) were related to abnormal LVMR.

Heart rate variability and target organ damage in hypertensive patients

Background

We evaluated the association between linear standard Heart Rate Variability (HRV) measures and vascular, renal and cardiac target organ damage (TOD).

Methods

A retrospective analysis was performed including 200 patients registered in the Regione Campania network (aged 62.4 ± 12, male 64%). HRV analysis was performed by 24-h holter ECG. Renal damage was assessed by estimated glomerular filtration rate (eGFR), vascular damage by carotid intima-media thickness (IMT), and cardiac damage by left ventricular mass index.

Results

Significantly lower values of the ratio of low to high frequency power (LF/HF) were found in the patients with moderate or severe eGFR (p-value < 0.001). Similarly, depressed values of indexes of the overall autonomic modulation on heart were found in patients with plaque compared to those with a normal IMT (p-value <0.05). These associations remained significant after adjustment for other factors known to contribute to the development of target organ damage, such as age. Moreover, depressed LF/HF was found also in patients with left ventricular hypertrophy but this association was not significant after adjustment for other factors.

Conclusions

Depressed HRV appeared to be associated with vascular and renal TOD, suggesting the involvement of autonomic imbalance in the TOD. However, as the mechanisms by which abnormal autonomic balance may lead to TOD, and, particularly, to renal organ damage are not clearly known, further prospective studies with longitudinal design are needed to determine the association between HRV and the development of TOD.

Telmisartan improves morphologic and functional changes in both left ventricular myocardium and carotid arterial wall in patients with hypertension: assessment by tissue Doppler imaging and carotid ultrasonography

OBJECTIVE

The aim of the present study was to clarify the beneficial effects of telmisartan on the morphologic and functional changes in left ventricular (LV) myocardium and carotid arterial wall in patients with hypertension (HT) using tissue Doppler imaging and carotid ultrasonography.

METHODS

Telmisartan (20-40 mg daily) was administered to 35 previously untreated patients with HT. Conventional and pulsed tissue Doppler echocardiography were performed after medication had been continued for 1-2 months with normal values for blood pressure (BP) (phase I) and for 12 months (phase II). Subclinical atherosclerosis also was determined by measuring the intima-media thickness (IMT) and stiffness β of the left and right common carotid arteries using B- and M-mode ultrasonography.

RESULTS

In the phase II, the LV mass index and isovolumic relaxation time were lower, the peak systolic and early diastolic mitral annular motion velocities were greater compared to the phase I. The stiffness β and mean IMT were lower in the phase II than in the phase I. On multivariate regression analyses, age, BP, and LV diastolic variables emerged as stronger predictors of carotid arterial IMT and stiffness β.

CONCLUSIONS

The 1-year use of telmisartan improved LV hypertrophy, regional LV myocardial contraction and relaxation, and carotid atherosclerosis in patients with HT. Our results support cardio- and arterioprotective benefits from continuous long-term telmisartan monotherapy, and combined analysis of tissue Doppler imaging and carotid ultrasonography may be a useful tool for understanding ventriculoarterial coupling in patients with HT.

An analysis of cardiac remodeling in the elderly population. EPICARDIAN study

The aims of this study were to investigate left ventricular morphology in a sample of elderly Spanish individuals and to assess differences between hypertensives and normotensives. Data were obtained from a subsample (N=242) of participants in the EPICARDIAN study who live to the Lista district of Madrid: they included 191 (78.8%) hypertensives and 51 (21.2%) normotensives. Left ventricular remodeling patterns were classified as: type I (normal), type II (concentric remodeling), type III (concentric hypertrophy) or type IV (eccentric hypertrophy). The overall prevalences were: 74 (30.5%) type I, 62 (25.9%) type II, 53 (21.8%) type III and 53 (21.8%) type IV. A comparison of hypertensives and normotensives showed that the prevalences were: 42 (22.3%) type I, 50 (26.1%) type II, 50 (26.1%) type III and 49 (25.5%) type IV in hypertensives and 31 (60%) type I, 13 (26%) type II, 3 (6%) type III and 4 (8%) type IV in normotensives (P< .0005). Ventricular remodeling without hypertrophy was common in the elderly, an observation that could have prognostic implications.

Cardiac diastolic dysfunction is prevalent in HIV-infected patients

Combination antiretroviral therapy (ART) has markedly improved survival in HIV-infected patients, but not without significant adverse effects including ART-associated dyslipdemia and insulin resistance, which may in part contribute to an increased risk of cardiovascular events. Other contributing factors to cardiovascular risk may include uncontrolled HIV replication, the effects of HIV and ART on vascular endothelium and inflammatory cytokines. Diastolic dysfunction may be an early sign of cardiovascular disease. Our objective was to determine the prevalence of diastolic dysfunction in HIV-infected patients without cardiovascular symptoms. We enrolled 91 subjects in a cross-sectional study of HIV-infected patients without cardiovascular symptoms between September 2004 and August 2005, to assess whether demographics, HIV-related factors, cardiac risk factors, and ART were associated with diastolic dysfunction. All subjects underwent two-dimensional transthoracic echocardiography with tissue Doppler imaging. Subjects were predominately male with a median age of 38 (interquartile range [IQR]: 33, 42) years and median ART duration 6.15 (IQR: 2.1, 8.4) years. Subjects had low Framingham risk scores. Diastolic dysfunction was observed in 34 patients (37%; 95% confidence interval [CI] 27.4, 48.1). Cardiac risk factors or poor prognostic indicators of AIDS progression were uncommon with no difference between subjects with or without diastolic dysfunction. A nonstatistically significant trend in increased rate of diastolic dysfunction was observed in patients receiving protease inhibitors 1 year or more, 44% versus 28%, respectively (univariate odds ratio 2.02, 95% CI 0.83 to 4.90). This was not observed with prolonged use of either non-nucleoside or nucleoside reverse transcriptase inhibitors. A high prevalence of diastolic dysfunction (37%) in a cohort of HIV-infected patients on ART at low risk for AIDS and cardiovascular disease was demonstrated.

Systemic Lupus Erythematosus Predicts Increased Left Ventricular Mass

BACKGROUND

Systemic lupus erythematosus (SLE) is associated with premature atherosclerosis and vascular stiffening. Whether SLE alters left ventricular (LV) structure and function in the absence of valvular and clinical coronary artery disease is unknown.

METHODS AND RESULTS

SLE patients without clinical or echocardiographic evidence of valvular or coronary disease were age and gender matched to a reference group (n=173 in both groups). Subjects underwent echocardiography to quantify LV structure and function and carotid ultrasonography to detect atherosclerosis. Disease characteristics and radial applanation tonometry to measure arterial stiffness were evaluated in SLE patients. The 2 groups were similar in subjects' body size, hypertension and diabetes status, smoking status, and cholesterol levels. LV mass (38.3 versus 32.8 g/m(2.7)), ejection fraction (71% versus 67%), and prevalence of LV hypertrophy (17.9% versus 6.4%) were higher in SLE patients than in referent subjects (all P<0.001). The combination of SLE and hypertension further increased LV mass. In multivariable analysis, LV mass was associated with SLE (P<0.001) in addition to body mass index, diabetes mellitus, and hypertension. Among SLE patients, LV mass was associated with arterial stiffness (P<0.001). Carotid atherosclerosis, SLE duration, damage index, serum creatinine, and homocysteine were significantly related to LV mass in univariate but not multivariable analyses.

CONCLUSIONS

SLE predicts increased LV mass, possibly because of inflammation-related arterial stiffening. Excess LV hypertrophy may contribute to the increased cardiac morbidity and mortality observed in SLE patients.

Left ventricular hypertrophy and cardiovascular risk stratification: impact and cost-effectiveness of echocardiography in recently diagnosed essential hypertensives

BACKGROUND

Echocardiography is more accurate than electrocardiography in the assessment of cardiac target organ damage related to hypertension, thus leading to a more precise stratification of total cardiovascular risk. However, ultrasound examination of the heart on a routine basis remains a matter of debate.

OBJECTIVE

To evaluate the impact and cost-effectiveness of echocardiographic examination on global risk stratification in low and medium-risk hypertensive patients in relation to age and sex.

METHODS

A total of 580 untreated hypertensive individuals (355 men and 225 women, mean age 47.8 +/- 11.4 years), classified at low to medium risk, according to routine clinical work-up suggested by the 2003 European Society of Hypertension/European Society of Cardiology guidelines, were included in the study. Total risk was reassessed by adding the results of ultrasound examination of the heart. Left ventricular hypertrophy (LVH) was defined as a left ventricular mass index of 125 g/m2 or more in men and 110 g/m2 or more in women. The impact of LVH in stratifying risk was assessed according to age (< 50 and > or = 50 years) and sex.

RESULTS

According to routine classification, 16.3% (n = 93) of the 580 patients were considered to be at low added risk and 83.7% (n = 487) at medium added risk. In the whole population, echocardiographic LVH was found in 86 patients (14.8%) who were then reclassified in the high-risk stratum. The prevalence rates of patients reclassified in the high-risk class as a consequence of LVH detection, according to age and sex, were as follows: 8.9% in men under 50 years, 12.3% in women under 50 years, 26.7% in men aged 50 years and over and 15.3% in women aged 50 years and over. The cost per detected case of LVH was 595 euros in patients under 50 years of age and 290 euros in those 50 years of age and older.

CONCLUSIONS

Our findings indicate that the prevalence of LVH, and consequently the probability of upgrading the total cardiovascular risk profile, is highest in the group of old hypertensive men; echocardiography has a limited impact on the risk reclassification in younger patients and an unfavourable cost-effectiveness profile. Our data thus do not support the systematic ultrasound assessment of the heart in all uncomplicated hypertensive individuals.

Operative contractility: A functional concept of the inotropic state

1. Initial unsuccessful attempts to evaluate ventricular function in terms of the 'heart as a pump' led to focusing on the 'heart as a muscle' and to the concept of myocardial contractility. However, no clinically ideal index exists to assess the contractile state. The aim of the present study was to develop a mathematical model to assess cardiac contractility. 2. A tri-axial system was conceived for preload (PL), afterload (AL) and contractility, where stroke volume (SV) was represented as the volume of the tetrahedron. Based on this model, 'operative' contractility ('OperCon') was calculated from the readily measured values of PL, AL and SV. The model was tested retrospectively under a variety of different experimental and clinical conditions, in 71 studies in humans and 29 studies in dogs. A prospective echocardiographic study was performed in 143 consecutive subjects to evaluate the ability of the model to assess contractility when SV and PL were measured volumetrically (mL) or dimensionally (cm). 3. With inotropic interventions, OperCon changes were comparable to those of ejection fraction (EF), velocity of shortening (Vcf) and dP/dt-max. Only with positive inotropic interventions did elastance (Ees) show significantly larger changes. With load manipulations, OperCon showed significantly smaller changes than EF and Ees and comparable changes to Vcf and dP/dt-max. Values of OperCon were similar when AL was represented by systolic blood pressure or wall stress and when volumetric or dimensional values were used. 4. Operative contractility is a reliable, simple and versatile method to assess cardiac contractility.

Prevalence of ventricular diastolic dysfunction in asymptomatic, normotensive patients with diabetes mellitus

To determine the prevalence of left ventricular diastolic dysfunction in asymptomatic, normotensive patients with type 2 diabetes mellitus, we studied 61 consecutive normotensive patients with type 2 diabetes using conventional Doppler echocardiography at rest (deceleration time, isovolumic relaxation time, early diastolic velocity [E]/peak atrial systolic velocity [A] ratio), and during the Valsalva maneuver. In addition, mitral annular velocity and velocity of flow propagation were assessed in all patients using tissue Doppler imaging (TDI) and color M-mode echocardiography. A standard resting echocardiogram excluded significant valvular disease and stress echocardiography excluded significant coronary artery disease in those with diastolic dysfunction. Diastolic dysfunction was found in 43 of 57 patients (75%) when all of the above echocardiographic techniques were used. TDI detected diastolic dysfunction more often (63%) than any other echocardiographic approach. Thus, the prevalence of left ventricular diastolic dysfunction in asymptomatic, normotensive patients with type 2 diabetes without significant coronary artery disease is much higher than previously suspected. TDI markedly improved the echocardiographic detection of diastolic dysfunction in asymptomatic patients with type 2 diabetes.

The Influence of Ambulatory Blood Pressure Profile on Left Ventricular Geometry

Besides causing a hypertrophy in the left ventricle, hypertension results in a change in the geometry of the left ventricle. The blood pressure, which does not decrease enough during the night, leads to structural changes in the left ventricle. In this study, the influence of 24-hour blood pressure profile on the left ventricular geometry was examined. Ambulatory blood pressure monitoring was applied to 60 patients with mild to moderate hypertension who had never been treated and standard echocardiographic evaluation was conducted thereafter. The patients were divided into two groups with respect to the ambulatory blood pressure profiles: the patients whose night blood pressure levels decreased by more than 10% compared to their daytime blood pressure levels (dipper) and those whose levels did not decrease that much (nondipper). The left ventricle mass index and the relative wall thickness of the patients were calculated. With respect to the left ventricle geometry, mass index and relative wall thickness of the patients were determined as: having normal geometry, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy. Age, gender, systolic, and diastolic blood pressure were similar within the dipper and nondipper groups. Normal geometry, concentric remodeling, and concentric hypertrophy ratios were similar in both groups. Eccentric hypertrophy was higher in the nondipper group compared to the dipper group (42.9% vs 6.3%, P < 0.03). Patients with mild to moderate hypertension, whose blood pressure does not decrease enough, develop eccentric hypertrophy.

Long-term left ventricular echocardiographic follow-up of SHR and WKY rats: effects of hypertension and age

Long-term follow-up of left ventricular (LV) function using echocardiography has not been reported and, in this study, was carried out in normotensive (WKY) rats and spontaneously hypertensive rats (SHR). In 10 WKY rats and SHR, LV diastolic and systolic diameter (LVEDD and LVSD), shortening fraction (SF), and weight (LVW) were determined at 8, 15, 20, 35, and 80 wk of age. The ratio of early to late mitral flow and mitral annulus velocity (VE/VA and Em/Am), isovolumic relaxation time (IVRT), deceleration time of the E wave (DTE), Tei index, and mitral flow propagation velocity (Vp) were measured. No difference in LVEDD was found between SHR and WKY rats; however, LVEDD was increased at 80 wk in both strains. SF decreased slightly in old WKY rats. LVW progressively increased from 20 to 80 wk in both strains and was greater in SHR. VE/VA and Em/Am decreased at 80 wk in WKY rats. LV relaxation (IVRT, Tei index, and Vp) was progressively impaired in SHR compared with WKY rats. LV compliance (DTE) was altered in old SHR. Echocardiography permitted a long follow-up of LV function in SHR and WKY rats. Ventricular relaxation was impaired early in the life of SHR and progressed with aging. Furthermore, LV compliance was altered, but systolic function remained unchanged, in old SHR. In contrast, relaxation and SF were only slightly altered in old WKY rats, suggesting that pressure-related changes in LV function were the dominant features in the SHR.

Left ventricular remodeling impairs coronary flow reserve in hypertensive patients

BACKGROUND

In arterial hypertension, changes in both left ventricular mass and geometry may occur. Concentric left ventricular remodeling (i.e. an increased wall thickness relative to end diastolic diameter) has been implicated as an independent cardiovascular risk factor in hypertensive patients. The influence of concentric remodeling on the coronary microcirculation is not known.

OBJECTIVE

To investigate the impact of left ventricular geometry on coronary flow reserve in patients with arterial hypertension and angiographically normal coronary arteries.

METHODS

Following exclusion of coronary artery disease by cardiac catheterization, coronary flow reserve (dipyridamole, 0.5 mg/kg body weight intravenously; argon gas-chromatographic method) was measured in 49 patients with arterial hypertension and in six age-matched controls. Hypertensive patients were grouped by echocardiographic findings according to left ventricular mass and relative left ventricular wall thickness (i.e. left ventricular posterior wall plus septal thickness divided by end diastolic diameter): seven patients had normal left ventricular mass and geometry, 19 had eccentric hypertrophy (i.e. normal relative wall thickness but increased mass), concentric remodeling (i.e. normal mass but increased relative wall thickness) was present in nine patients, and 14 patients had concentric hypertrophy.

RESULTS

There was a marked reduction in coronary flow reserve in all hypertensive groups as compared with control values (4.2 +/- 0.5). Within the hypertensive subgroups, the coronary flow reserve was differentially reduced in the following rank order: concentric remodeling (2.0 +/- 0.7) approximately concentric hypertrophy (2.3 +/- 0.8) < eccentric hypertrophy (2.9 +/- 0.6) mu normal geometry (2.7 +/- 0.4). Multi-factorial regression analysis showed that the relative wall thickness but not left ventricular mass was independently linked to the coronary flow reserve.

CONCLUSIONS

Concentric left ventricular remodeling is an independent predictor of the coronary flow reserve in hypertensive patients with chest pain and normal coronary angiogram. The impairment of the coronary microcirculation may contribute to the excess cardiovascular event rate associated with hypertensive concentric left ventricular remodeling.

Impact of coronary artery disease on left ventricular systolic function and geometry in hypertensive patients with left ventricular hypertrophy (the LIFE study)

Hypertensive patients with left ventricular (LV) hypertrophy have a higher incidence of cardiovascular events than those without it. We hypothesized that a close relation exists between clinical evidence of coronary artery disease (CAD) and alterations in LV structure and function that contribute to their higher risk. Echocardiograms were recorded in 963 hypertensive patients (mean age 66 +/- 7 years, 41% women) with electrocardiographic LV hypertrophy, and divided into 149 with and 814 without clinical (prior myocardial infarction or angina pectoris) or electrocardiographic (Minnesota codes 1.1, 1.2) evidence of CAD. Patients with CAD had larger LV internal dimensions (5.5 +/- 0.6 vs 5.2 +/- 0.5 cm), increased LV mass (136 +/- 31 vs 122 +/- 24 g/m(2), and 62.4 +/- 19.4 vs 55.5 +/- 12.1 g/m(2.7)), lower ejection fraction (58 +/- 10% vs 62 +/- 8%), higher circumferential end-systolic wall stress (cESS) (198 +/- 59 vs 181 +/- 47 kdynes/cm(2), all p <0.001), and higher total peripheral resistances (2,088 +/- 628 vs 1,963 +/- 553 dynes x s x m(2)/cm(3), p = 0.02). Although eccentric LV hypertrophy predominated, the CAD group had a greater prevalence of this geometric pattern than the non-CAD group (56% vs 47%, p <0.02). An index of myocardial oxygen demand per beat--the LV mass x cESS x ejection time--was 20% higher in patients with CAD. In conclusion, clinical evidence of CAD in hypertensive patients with electrocardiographic evidence of LV hypertrophy identifies subjects with structural and functional abnormalities at high risk for cardiovascular events. LV mass. cESS. ejection time, a noninvasive index that parallels myocardial oxygen demand per beat, is especially high in hypertensive patients with CAD.

Effect of regression of left ventricular hypertrophy from systemic hypertension on systolic function assessed by midwall shortening (HOT echocardiographic study)

Depressed midwall shortening has been shown to be an independent predictor of cardiovascular morbid events in hypertensive patients with left ventricular (LV) hypertrophy despite normal endocardial fractional shortening. The effects of LV mass changes in hypertensive patients on midwall shortening are unclear. To determine the impact of LV hypertrophy regression on LV systolic function assessed at the endocardium and the midwall level, 508 patients (58% men, 57% Caucasians, mean age 60 +/- 7 years) participating in the Hypertension Optimal Treatment study were prospectively studied by serial echocardiography at baseline, year 1, year 2, and at the end of the study. The Hypertension Optimal Treatment study was designed to challenge the existence of the J-curve phenomenon in hypertension. This study enrolled men and women between 50 and 80 years of age with mild to moderate hypertension. Patients were treated with a regimen based on felodipine with the addition of other antihypertensive drug classes as needed to reduce the diastolic blood pressure to a predefined target of < or =80, < or =85, or < or =90 mm Hg. From baseline to year 1, year 2, and end of the study, body mass index was unchanged (30.4, 30.1, 30.2, and 30.5 kg/m(2)); however, diastolic blood pressure was significantly reduced (99, 83, 80, and 80 mm Hg, p <0.0001), as was systolic blood pressure (161, 139, 137, and 134 mm Hg, p <0.0001) and LV mass index (117, 119, 107, and 106 g/m(2), p <0.0001). Over the same period of observation the endocardial fractional shortening did not change significantly (40%, 42%, 43%, and 44%); however, shortening at the midwall level showed improvement (20%, 21%, 22%, and 30%, p <0.001). In conclusion, midwall shortening is a more sensitive index of systolic function in subjects with pressure-overload hypertrophy, and it identifies high-risk patients who may benefit from a more aggressive antihypertensive program. The disparity between midwall and endocardial shortening suggests reduced myofibril function in patients with hypertension-induced hypertrophy.

Assessment of the left ventricular diastolic reserve in essential hypertension: the acute saline load test

OBJECTIVE

The aim of this study was to evaluate the significance of the development of a restrictive response to an acute saline load, defined as an increase in the ratio of peak early to peak late diastolic transmitral flow velocity (E/A ratio) associated with a decrease in the deceleration time, in patients with mild to moderate untreated hypertension.

BACKGROUND

Recognised abnormal patterns of transmitral diastolic flow include, from 'best' to 'worst': prolonged relaxation, pseudonormalisation, and restrictive physiology. The common denominator of these transitions is the constellation of an increase in the E/A ratio associated with a decrease in deceleration time.

PATIENTS AND METHODS

Sixteen normal control subjects (6 males, 10 females, age 51.6 +/- 6.9 years) and 24 patients with mild to moderate untreated hypertension (12 males, 12 females, age 46.8 +/- 7.5 years) underwent supine blood pressure measurement with sphygmomanometry, biochemical studies, and transthoracic M-mode, 2D, and Doppler echocardiography before and after an acute saline load (7 mL kg(-1), maximum 500 mL, NaCl 0.9% within 15 min IV).

RESULTS

The baseline E/A ratio was lower (0.90 +/- 0.14 vs. 1.04 +/- 0.18; P < 0.01) and the deceleration time was longer (158.8 +/- 19.4 vs. 135 +/- 8.9 ms; P < 0.01) in patients with hypertension compared with normotensive controls. However, no patient with hypertension exhibited a transmitral flow velocity pattern compatible with typical prolonged relaxation. A restrictive response to the acute saline load was observed in 12 (50%) of the hypertensive and none of the control subjects. Hypertensive patients with a restrictive response to the acute saline load had a lower baseline E velocity (54.8 +/- 8.7 cm s(-1) vs. 66 +/- 6.4 cm s(-1); P = 0.003), a lower baseline E/A ratio (0.83 +/- 0.13 vs. 0.97 +/- 0.12; P = 0.015), and a longer deceleration time (167.5 +/- 15.4 ms vs. 150 +/- 19.5; P = 0.03) than hypertensive patients without such a response.

CONCLUSION

A restrictive response to an acute saline load is indicative of a limited diastolic reserve in patients with mild to moderate untreated hypertension. Further studies are required in order to evaluate the significance of such a response with regards to risk stratification and efficacy of medical treatment in this patient population.

Gender differences in systolic left ventricular function in hypertensive patients with electrocardiographic left ventricular hypertrophy (the LIFE study)

Echocardiography was performed in 944 untreated hypertensive patients (391 women and 553 men, mean age 66 years) who had electrocardiographic left ventricular (LV) hypertrophy at baseline in the Losartan Intervention For End point reduction in hypertension (LIFE) study to evaluate gender-associated differences in systolic LV function. Women had significantly lower diastolic blood pressure (175/97 vs 173/99 mm Hg) and body surface area and a higher body mass index (all p < 0.01). Women also had higher LV ejection fraction (EF), endocardial and midwall fractional shortening (63% vs 60%, 35% and 33%, and 16% vs 15%, respectively, all p < 0.01), higher stress-corrected midwall fractional shortening (98% vs 96%, p < 0.05), and lower circumferential end-systolic wall stress (178 vs 187 kdynes/cm(2), p < 0.01). There was no difference in age or LV mass indexed for height(2.7), but relative wall thickness was higher in women (0.42 vs 0.41, p < 0.05). In multiple regression analyses: (1) EF and endocardial fractional shortening were 2% to 3% higher in women than men, independent of the effects of LV stress, body mass index, and height (multiple r = 0.77 and 0.75, respectively, gender p < 0.02 in both models); (2) midwall fractional shortening was 0.5% higher in women, independent of the effects of age, body mass index, circumferential end-systolic stress, and absence of diabetes (multiple r = 0.36, p = 0.014 for gender); and (3) stress-corrected LV midwall fractional shortening was 2% higher (p = 0.004) in women, independent of the effects of age, height, heart rate, body mass index, and diabetes (multiple r = 0.33). Thus, female gender is an independent predictor of higher systolic LV function in hypertensive patients with electrocardiographic LV hypertrophy.

Prevalence of diastolic dysfunction in normotensive, asymptomatic patients with well-controlled type 2 diabetes mellitus

To evaluate the prevalence of left ventricular (LV) diastolic dysfunction in patients with type 2 diabetes mellitus free of cardiovascular disease, we studied 86 normotensive men and women (mean age 46 +/- 6 years) with Doppler echocardiography. All subjects were asymptomatic for ischemic heart disease or heart failure. The traditional transmitral filling patterns were used to characterize diastolic physiology. The Valsalva maneuver was used to differentiate normal from pseudonormal LV filling pattern. All patients had a normal electrocardiogram at rest and a negative result on exercise echocardiography for inducible wall motion abnormalities. Global LV systolic function was normal (mean LV ejection fraction 58%, range 53% to 76%). Diastolic dysfunction was found in 41 subjects (47%) of which 26 (30%) had impaired relaxation and 15 (17%) had a pseudonormal filling pattern. The mean LV mass index was 101 g/m2 (range 86 to 122). All patients with a normal-filling physiology had gender-adjusted normal LV mass index (mean 93 +/- 11 g/m2), whereas 62% of those with either abnormal relaxation (mean 103 +/- 12 g/m2, p <0.001) or a pseudonormal pattern (mean 110 +/- 12 g/m2, p <0.001) had increased LV mass index. No subject in this cohort had restrictive diastolic physiology. In conclusion, diastolic dysfunction in type 2 diabetes mellitus patients is often found despite adequate metabolic control and freedom from clinically detectable heart disease. The Valsalva maneuver can unmask an additional 17% of patients with subclinical abnormal LV filling pattern, who otherwise would be classified as having a normal diastolic physiology. Increased LV mass index is closely associated with abnormal LV filling characteristics.

Hypertension and the heart

Sustained increase in arterial pressure causes left ventricular hypertrophy and adversely affects all myocardial compartments: myocytes, interstitium, and coronary vasculature. Ventricular hypertrophy significantly increases the risk for cardiovascular morbidity and mortality in hypertensive disease. Impairments in coronary circulation and ventricular fibrosis, which are an essential part of hypertensive disease, contribute to that increased risk. This report discusses the mechanisms of hypertension-induced myocardial collagen accumulation and impairments in coronary hemodynamics. Particular attention is given to the interaction of hypertension and aging because aging aggravates hypertensive changes and the incidence of hypertension increases with aging. The effect of therapy on hypertension-induced ventricular fibrosis and impairment in coronary hemodynamics and the risk associated with these changes are also discussed.

Relation of left ventricular diastolic properties to systolic function in arterial hypertension

BACKGROUND

It is unclear whether impairment of left ventricular (LV) diastolic characteristics is independent of systolic dysfunction.

METHODS AND RESULTS

To address this issue, 159 consecutive hypertensive patients (44+/-11 years, 78 obese, 96 women) and 165 normotensive subjects (32+/-11 years, 84 obese, 110 women) were studied with the use of Doppler echocardiography. After adjustment for age, body mass index (BMI), and sex, we found that ejection fraction (EF; M-mode, z-derived) was higher in hypertensive (66. 6+/-5.2%) than in normotensive (63.9+/-4.4%, P<0.0001) subjects, whereas midwall shortening (MS) was lower (hypertensive patients 16. 9+/-2.0%, normotensive subjects 17.8+/-2.2%, P<0.02), even after correction for end-systolic wall stress (P<0.05). Isovolumic relaxation time (IVRT) was greater in hypertensive patients (103+/-14 ms) than in normotensive subjects (78+/-19 ms), as was deceleration time of E velocity and peak A velocity (all P<0.0001). In multivariate analysis, IVRT was unrelated to EF, but a negative relation was found with MS (P<0.001), independent of age, BMI, presence of arterial hypertension, LV geometry, and load (multiple R(2)=0.58). For comparable age, sex distribution, BMI, and blood pressure values, hypertensive patients with lower afterload-adjusted MS exhibited longer IVRT than patients with normal MS (P<0.005). However, IVRT remained higher than in normotensive control subjects after control for LV geometry and load.

CONCLUSIONS

Doppler indices of delayed LV relaxation can be detected in the presence of normal or supranormal EF but are independently related to impaired MS. A less severely abnormal relaxation, however, can be also detected in the presence of normal midwall function, independent of LV geometry and load. Thus, diastolic abnormalities may occur before systolic dysfunction even when it is measured at the midwall.