Relation of left ventricular hypertrophy and geometry to asymptomatic cerebrovascular damage in essential hypertension

Left Ventricular Hypertrophy and Cerebral Small Vessel Disease: A Systematic Review and Meta-Analysis

Background and Purpose

Left ventricular hypertrophy (LVH) is associated with the risk of stroke and dementia independently of other vascular risk factors, but its association with cerebral small vessel disease (CSVD) remains unknown. Here, we employed a systematic review and meta-analysis to address this gap.

Methods

Following the MOOSE guidelines (PROSPERO protocol: CRD42018110305), we systematically searched the literature for studies exploring the association between LVH or left ventricular (LV) mass, with neuroimaging markers of CSVD (lacunes, white matter hyperintensities [WMHs], cerebral microbleeds [CMBs]). We evaluated risk of bias and pooled association estimates with random-effects meta-analyses.

Results

We identified 31 studies (n=25,562) meeting our eligibility criteria. In meta-analysis, LVH was associated with lacunes and extensive WMHs in studies of the general population (odds ratio [OR]_lacunes, 1.49; 95% confidence interval [CI], 1.12 to 2.00) (OR_WMH, 1.73; 95% CI, 1.38 to 2.17) and studies in high-risk populations (OR_lacunes: 2.39; 95% CI, 1.32 to 4.32) (OR_WMH, 2.01; 95% CI, 1.45 to 2.80). The results remained stable in general population studies adjusting for hypertension and other vascular risk factors, as well as in sub-analyses by LVH assessment method (echocardiography/electrocardiogram), study design (cross-sectional/cohort), and study quality. Across LV morphology patterns, we found gradually increasing ORs for concentric remodelling, eccentric hypertrophy, and concentric hypertrophy, as compared to normal LV geometry. LVH was further associated with CMBs in high-risk population studies.

Conclusions

LVH is associated with neuroimaging markers of CSVD independently of hypertension and other vascular risk factors. Our findings suggest LVH as a novel risk factor for CSVD and highlight the link between subclinical heart and brain damage.

Additional prognostic value of electrocardiographic left ventricular hypertrophy in traditional cardiovascular risk assessments in chronic kidney disease

BACKGROUND

Left ventricular hypertrophy (LVH) is a common predictor of the cardiovascular prognosis in chronic kidney disease (CKD). However, whether or not electrocardiography-derived LVH (ECG-LVH) has prognostic value in patients with various degrees of CKD and improves the cardiovascular risk stratification based on traditional risk factors remains unclear.

METHODS

A total of 7206 participants at least 40 years of age who were free from cardiovascular events in a general population were followed for the incidence of cardiovascular events. CKD was confirmed by either the presence of a reduced estimated glomerular filtration rate (eGFR) (<60 ml/min per 1.73 m) or albuminuria, defined as a urinary albumin-to-creatinine ratio (UACR) of at least 30 mg/g Cr.

RESULTS

A total of 1886 (26.2%) had CKD, of which 1471 (78.0%) had a preserved eGFR (CKD stage 1-2). After an average 11.3 years of follow-up, the adjusted hazard ratio for the incidence of cardiovascular events significantly increased for ECG-LVH according to the Sokolow--Lyon voltage, Cornell voltage, or Cornell voltage product among participants with CKD (hazard ratio 1.47, P = 0.002), in contrast to those without CKD (hazard ratio 1.15, P = 0.210). The inclusion of any ECG-LVH parameters improved the accuracy of reclassification in any risk prediction model based on the eGFR, UACR, or Framingham 10-year risk score in the CKD participants (net reclassification improvement = 0.13-0.32, all P values <0.040).

CONCLUSION

In patients with CKD stage 1-5, ECG-LVH is useful for predicting the risk of future cardiovascular events and adds prognostic information to traditional cardiovascular risk assessments.

Detecting cerebrovascular changes in the brain caused by hypertension in atrial fibrillation group using acoustocerebrography

Acoustocerebrography is a novel, non-invasive, transcranial ultrasonic diagnostic method based on the transmission of multispectral ultrasound signals propagating through the brain tissue. Dedicated signal processing enables the estimation of absorption coefficient, frequency-dependent attenuation, speed of sound and tissue elasticity. Hypertension and atrial fibrillation are well known factors correlated with white matter lesions, intracerebral hemorrhage and cryptogenic stroke numbers. The aim of this study was to compare the acoustocerebrography signal in the brains of asymptomatic atrial fibrillation patients with and without hypertension. The study included 97 asymptomatic patients (40 female and 57 male, age 66.26 ± 6.54 years) who were clinically monitored for atrial fibrillation. The patients were divided into two groups: group I (patients with hypertension) n = 75, and group II (patients without hypertension) n = 22. Phase and amplitude of all spectral components for the received signals from the brain path were extracted and compared to the phase and amplitude of the transmitted pulse. Next, the time of flight and the attenuation of each frequency component were calculated. Additionally, a fast Fourier transformation was performed and its features were extracted. After introducing a machine learning technique, the ROC plot of differentiations between group I and group II with an AUC of 0.958 (sensitivity 0.99 and specificity 0.968) was obtained. It can be assumed that the significant difference in the acoustocerebrography signals in patients with hypertension is due to changes in the brain tissue, and it allows for the differentiating of high-risk patients with asymptomatic atrial fibrillation and hypertension.

Increased Left Ventricular Mass Index Is Associated With Compromised White Matter Microstructure Among Older Adults

BACKGROUND

Left ventricular (LV) hypertrophy is associated with cerebrovascular disease and cognitive decline. Increased LV mass index is a subclinical imaging marker that precedes overt LV hypertrophy. This study relates LV mass index to white matter microstructure and cognition among older adults with normal cognition and mild cognitive impairment.

METHODS AND RESULTS

Vanderbilt Memory & Aging Project participants free of clinical stroke, dementia, and heart failure (n=318, 73±7 years, 58% male, 39% mild cognitive impairment) underwent brain magnetic resonance imaging, cardiac magnetic resonance, and neuropsychological assessment. Voxelwise analyses related LV mass index (g/m2) to diffusion tensor imaging metrics. Models adjusted for age, sex, education, race/ethnicity, Framingham Stroke Risk Profile, cognitive diagnosis, and apolipoprotein E-ε4 status. Secondary analyses included a LV mass index×diagnosis interaction term with follow-up models stratified by diagnosis. With identical covariates, linear regression models related LV mass index to neuropsychological performances. Increased LV mass index related to altered white matter microstructure (P<0.05). In models stratified by diagnosis, associations between LV mass index and diffusion tensor imaging were present among mild cognitive impairment participants only (P<0.05). LV mass index was related only to worse visuospatial memory performance (β=-0.003, P=0.036), an observation that would not withstand correction for multiple testing.

CONCLUSIONS

In the absence of prevalent heart failure and clinical stroke, increased LV mass index corresponds to altered white matter microstructure, particularly among older adults with clinical symptoms of prodromal dementia. Findings highlight the potential link between subclinical LV remodeling and cerebral white matter microstructure vulnerability.

Echocardiographic characteristics of hypertensive patients affected by transient ischemic attack: a cross-sectional study

Atrial septal aneurysm (ASA), common finding in normal echocardiographies, has been described in association with transient ischemic attacks (TIAs)/strokes, as well as hypertensive end-organ damage such as left ventricular (LV) hypertrophy. Aim of this study was to assess if a cluster of echocardiographic aspects could characterize TIA hypertensive patients. A cross-sectional study on patients with history of TIA, referring to a Hypertension Center echolab, has been performed. A total of 5223 patients received transthoracic echocardiography. TIA patients were 292 (5.6%). A total of 102 age/sex-matched patients without TIA have been collected as controls. The main characteristic of TIA patients resulted ASA/bulging (B) (TIA 61%, controls 6%, P = .0001). Other aspect was LV concentric remodeling (TIA 32.3%, controls 20.8%, P = .029) and mitral flow aspects of diastolic dysfunction. After adjustment for age and hypertension, ASA/B (odds ratio [OR] = 62.4, 95% confidence interval [CI]: 13.6-73.9, P < .001), followed by LV concentric hypertrophy (OR = 2.1, 95% CI: 1.1-4.3, P = .043), was associated with a positive TIA history. A binary logistic regression performed in ASA/B patients, identified relative wall thickness as the strongest TIA-associated aspect (OR = 53.4, 95% CI: 11.9-74.18, P = .001). ASA/B, common finds in general population, could carry a significant incremental possibility of association with TIA when concentric geometry, frequent hypertensive aspect, is present as well.

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 geometry and white matter lesions in ischemic stroke patients

Abnormal left ventricular (LV) geometry is associated with extracardiac organ damage in patients with hypertension. The aim of this study was to determine the relationship between LV geometry and white matter lesions (WMLs) in ischemic stroke patients. We retrospectively analyzed data from 155 patients (median age 62; 49.8% male) with mild ischemic stroke (median National Institutes of Health Stroke Scale score 4) who underwent brain magnetic resonance imaging and echocardiography. Patients were categorized into four groups: normal LV geometry, concentric remodeling, eccentric left ventricular hypertrophy (LVH) and concentric LVH. WMLs were graded using the Fazekas scale on fluid-attenuated inversion recovery images. Extensive WMLs were defined as a Fazekas score > 2. Extensive WMLs were more prevalent in patients with concentric LVH, eccentric LVH and concentric remodeling than in those with normal LV geometry. After adjusting for hypertension, age, diabetes mellitus, hypercholesterolemia, glomerular filtration rate and ischemic heart disease, patients with concentric remodeling [odds ratio (OR) 3.94, 95% confidence interval (CI) 1.26-12.31, p = 0.02] and those with concentric LVH (OR 3.69, 95% CI 1.24-10.95, p = 0.02), but not patients with eccentric LVH (OR 2.44, 95% CI 0.72-8.29, p = 0.15), had higher risk of extensive WMLs than patients with normal LV geometry.

Association of postural instability with asymptomatic cerebrovascular damage and cognitive decline: the Japan Shimanami health promoting program study

BACKGROUND AND PURPOSE

Asymptomatic cerebral small-vessel disease (cSVD) in elderly individuals are potent risk factors for stroke. In addition to common clinical risk factors, postural instability has been postulated to be associated with cSVD in older frail patients. Here, we conducted a cross-sectional study to understand the possible link between postural instability and asymptomatic cSVD further, namely periventricular hyperintensity, lacunar infarction, and microbleeds, as well as cognitive function, in a middle-aged to elderly general population (n=1387).

METHODS

Postural instability was assessed based on one-leg standing time (OLST) and posturography findings. cSVD was evaluated by brain MRI. Mild cognitive impairment was assessed using a computer-based questionnaire, and carotid intima-media thickness as an index of atherosclerosis was measured via ultrasonography.

RESULTS

Frequency of short OLST, in particular <20 s, increased linearly with severity of cSVD (lacunar infarction lesion: none, 9.7%; 1, 16.0%; >2, 34.5%; microbleeds lesion: none, 10.1%; 1, 15.3%; >2, 30.0%; periventricular hyperintensity grade: 0, 5.7%; 1, 11.5%; >2, 23.7%). The association of short OLST with lacunar infarction and microbleeds but not periventricular hyperintensity remained significant even after adjustment for possible covariates (lacunar infarction, P=0.009; microbleeds, P=0.003; periventricular hyperintensity, P=0.601). In contrast, no significant association was found between posturographic parameters and cSVD, whereas these parameters were linearly associated with OLST. Short OLST was also significantly associated with reduced cognitive function independent of covariates, including cSVD (P=0.002).

CONCLUSIONS

Postural instability was found to be associated with early pathological changes in the brain and functional decline, even in apparently healthy subjects.

Task force on: 'Early markers of atherosclerosis: influence of age and sex'

Atherosclerosis and its complications are the most important causes of death all over the world, especially in Western countries. Diet habits, modern stress life, smoking, sedentary way of life and an involvement of genetic pattern of individuals lead to a sure degeneration of quality of life increasing the risk of atherosclerosis development. For this reason, the main purpose of actual medicine is to identify all the markers that could allow the physicians to evaluate the first moments of the development of this dangerous pathological process. The aim is to reduce the speed of its evolution, trying to delay indefinitely the risk coming from the morphological alterations of the vessels. 'Endothelium function' could allow physicians to detect the first moment of the natural history of atherosclerosis process. Its impairment is the first step in the degeneration of vascular structures. Many methods [flow-mediated vasodilatation (FMD); antero-posterior abdominal aorta diameter (APAO); intima-media thickness of the common carotid artery (CCA-IMT); arterial stiffness; and so on] try to evaluate its function, but many limitations come from general population characteristics. A standardization of the methods should take into account individuals' peculiarities. Two elements, not modifiable, should be taken into account for vascular evaluation: age and sex. The aim of this review is to outline the linkage among age, sex and instrumental evaluation of patients considered for a noninvasive assessment of their cardiovascular risk profile.

Associations of durations of antiplatelet use and vascular risk factors with the presence of cerebral microbleeds

The association of the presence of cerebral microbleeds with antiplatelet use remains controversial. Long durations of antiplatelet use and vascular risk factors may have a greater impact on the development of cerebral microbleeds than short durations. The aim of this study was to determine whether the durations of antiplatelet use and vascular risk factors were associated with the presence of cerebral microbleeds in patients with ischemic cerebrovascular disease, who are frequently treated with antiplatelet agents. Two hundred twenty outpatients with ischemic cerebrovascular lesions (eg, cerebral infarcts and/or white matter lesions) detected by magnetic resonance imaging were examined. Patients with a history of cerebral hemorrhage were excluded. Cerebral microbleeds were observed in 71 (32.3%) patients. Deep or infratentorial microbleeds and strictly lobar microbleeds were observed in 53 (24.1%) patients and 18 (8.2%) patients, respectively. Aspirin use (odds ratio, 2.14; 95% confidence interval [CI], 1.02-4.73; P = .04) and a long duration (≥10 years) of aspirin use (odds ratio, 3.75; 95% CI, 1.31-10.86; P = .01) were significantly associated with deep or infratentorial microbleeds in the crude analysis, but this became nonsignificant after adjustment for hypertension and other confounding factors. The prevalence of antiplatelet use was significantly higher in the patients with hypertension than in those without hypertension (72.5% versus 49.1%, P = .002). Hypertension (odds ratio, 2.50; 95% CI, 1.11-6.41; P = .04) was significantly associated with the development of deep or infratentorial microbleeds even after adjustment for confounding factors and the association increased with the duration of hypertension. In conclusion, we found a significant association between aspirin use and deep or infratentorial microbleeds, but this association may reflect the presence of hypertension as a confounding factor.

Independent association of cognitive dysfunction with cardiac hypertrophy irrespective of 24-h or sleep blood pressure in older hypertensives

BACKGROUND

Our aim was to assess whether cardiac hypertrophy is associated with cognitive function independently of office, 24-h, or sleep blood pressure (BP) levels in older hypertensive patients treated with antihypertensive medications.

METHODS

In this cross-sectional study, we recruited 443 hypertensive patients aged over 60 years (mean age: 73.0 years; 41% men) who were ambulatory, lived independently, and were without clinically overt dementia. They underwent measurements of 24-h BP monitoring, echocardiographic left ventricular mass index (LVMI), and cognitive function (mini-mental state examination, MMSE).

RESULTS

MMSE score was inversely associated with office, 24-h, awake, and sleep systolic BP (SBP) (each, P < 0.05). There was a close association between MMSE score and LVMI (ρ = -0.32; P < 0.001). Using multiple logistic regression analysis including numerous covariates (i.e., age, sex, obesity, current smoking, educational level, duration of antihypertensive medications, renal dysfunction, statin use, and previous history of cardiovascular disease), the odds ratio (OR) for the presence of cognitive dysfunction, defined as the lowest quartile of MMSE score (median MMSE score: 23 points; n = 115), was estimated; the presence of cardiac hypertrophy (LVMI ≥125 kg/m(2) in men and ≥110 kg/m(2) in women) as well as uncontrolled 24-h BP (mean 24-h SBP/diastolic BP (DBP) ≥130/80 mm Hg) or sleep BP (mean sleep SBP/DBP ≥120/70 mm Hg), but not uncontrolled office BP (mean office SBP/DBP ≥140/90 mm Hg), were independently associated with cognitive dysfunction (all P < 0.05).

CONCLUSIONS

Among older hypertensive patients with antihypertensive medications, those who had echocardiographically determined cardiac hypertrophy may be at high risk for cognitive dysfunction, irrespective of their office BP and 24-h BP levels.

Different pattern of carotid and myocardial changes according to left ventricular geometry in hypertensive patients

The relation between left ventricular (LV) hypertrophy and LV function is well known. However, less is known about the vascular changes influenced by LV geometry. We sought to investigate the relationship of LV geometry to carotid arterial and LV function. A total of 476 hypertensive patients were prospectively recruited. All subjects underwent echocardiography and carotid ultrasound. LV geometry is categorized into four groups according to relative wall thickness (RWT) and LV mass index (LVMI). Concentric LV geometry was associated with increased carotid intima-media thickness (IMT), β-stiffness, and lower strain. All of the carotid parameters showed a stepwise change according to RWT of LV, whereas LV function was worse in hypertrophic geometry, as reflected by significantly lower systolic mitral annular velocity, higher left atrial volume index and E/E' ratio (P<0.001). By multivariate analysis after adjustment for clinical and laboratory parameters, IMT was independently associated with RWT, whereas myocardial function was independently associated with LVMI. Carotid arterial function and IMT showed worse values in concentric geometry, whereas LV systolic and diastolic function were worse in hypertrophic geometry, suggesting a discrepancy between carotid arterial and LV function in hypertensive patients.

Connecting cerebral white matter lesions and hypertensive target organ damage

Chronic hypertension leads to concomitant remodeling of the cardiac and vascular systems and various organs, especially the brain, kidney, and retina. The brain is an early target of organ damage due to high blood pressure, which is the major modifiable risk factor for stroke and small vessel disease. Stroke is the second leading cause of death and the number one cause of disability worldwide and over 80% of strokes occur in the elderly. Preclinical hypertensive lesions in most target organs are clearly identified: left ventricular hypertrophy for the heart, microalbuminuria for the kidney, fundus abnormalities for the eye, and intima-media thickness and pulse wave velocity for the vessels. However, early hypertensive brain damage is not fully studied due to difficulties in access and the expense of techniques. After age, hypertension is the most-important risk factor for cerebral white matter lesions, which are an important prognostic factor for stroke, cognitive impairment, dementia, and death. Studies have shown an association between white matter lesions and a number of extracranial systems affected by high BP and also suggest that correct antihypertensive treatment could slow white matter lesions progression. There is strong evidence that cerebral white matter lesions in hypertensive patients should be considered a silent early marker of brain damage.

Correlations between left ventricular mass index and cerebrovascular lesion

Left ventricular (LV) mass and LV geometry are well-established measures of hypertension chronicity and severity, have a prognostic value on cardiovascular morbidity and mortality, and are related to asymptomatic cerebral small-artery disease (SAD) and largeartery disease (LAD). The aim of the present study was to clarify the different effects of LV mass and LV geometry on underlying SAD compared with its effects on underlying LAD in ischemic stroke patients. Four hundred three ischemic stroke patients underwent echocardiography to determine LV mass index and relative wall thickness. Brain magnetic resonance imaging, angiography, and carotid magnetic resonance angiography were preformed to detect LAD (≥50% stenosis) and SAD (leukoaraiosis, microbleeds, and old lacunar infarction) in the brain. Multivariate analyses showed that the LV mass index was highly associated with underlying SAD but not with underlying LAD. Among the various subtypes of SAD, only cerebral microbleeds were closely related to the LV mass index. Concentric LV hypertrophy was not related to the presence of either SAD or LAD. Subgroup analyses revealed that, among the various subtypes of SAD, only cerebral microbleeds were associated with concentric LV hypertrophy. In conclusion, cerebral microbleeds may imply more advanced target organ damage than underlying LAD and ischemic subtypes of SAD.

Cardiovascular risk in subjects with left ventricular concentric remodeling at baseline examination: a meta-analysis

It is debated whether subjects with concentric remodeling (CR, normal left ventricular mass index (LVMI) and increased relative wall thickness (RWT)) are at higher cardiovascular risk than those with normal geometry (NG, normal LVMI and RWT). The aim of this study was to perform a meta-analysis of studies evaluating cardiovascular events in subjects with CR and NG according to baseline classification. We searched for articles evaluating cardiovascular outcome in subjects with CR compared with those with NG, and reporting adjusted hazard ratio (HR) and 95% confidence interval (CI). Six studies were included in the meta-analysis. The pooled population consisted of 7465 subjects with CR and NG. During the follow-up, they experienced 852 events. When compared with NG, the overall adjusted HR was 1.36 (95% CI 1.03-1.78) for CR, P<0.03. There was some heterogeneity between studies. Subgroup meta-analysis showed that increased cardiovascular risk in subjects with CR was more relevant in studies evaluating hypertensive and Caucasian subjects and reporting both fatal and non-fatal events. Cardiovascular risk is significantly higher in subjects with CR than in those with NG. This aspect is more evident in studies including hypertensive patients and Caucasian populations and reporting global cardiovascular risk.

Heart failure in acute ischemic stroke

Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Due to the aging of the population it has become a growing public health problem in recent decades. Diagnosis of HF is clinical and there is no diagnostic test, although some basic complementary testing should be performed in all patients. Depending on the ejection fraction (EF), the syndrome is classified as HF with low EF or HF with normal EF (HFNEF). Although prognosis in HF is poor, HFNEF seems to be more benign. HF and ischemic stroke (IS) share vascular risk factors such as age, hypertension, diabetes mellitus, coronary artery disease and atrial fibrillation. Persons with HF have higher incidence of IS, varying from 1.7% to 10.4% per year across various cohort studies. The stroke rate increases with length of follow-up. Reduced EF, independent of severity, is associated with higher risk of stroke. Left ventricular mass and geometry are also related with stroke incidence, with concentric hypertrophy carrying the greatest risk. In HF with low EF, the stroke mechanism may be embolism, cerebral hypoperfusion or both, whereas in HFNEF the mechanism is more typically associated with chronic endothelial damage of the small vessels. Stroke in patients with HF is more severe and is associated with a higher rate of recurrence, dependency, and short term and long term mortality. Cardiac morbidity and mortality is also high in these patients. Acute stroke treatment in HF includes all the current therapeutic options to more carefully control blood pressure. For secondary prevention, optimal control of all vascular risk factors is essential. Antithrombotic therapy is mandatory, although the choice of a platelet inhibitor or anticoagulant drug depends on the cardiac disease. Trials are ongoing to evaluate anticoagulant therapy for prevention of embolism in patients with low EF who are at sinus rhythm.

Relation of pulse pressure and arterial stiffness to concentric left ventricular hypertrophy in young men (from the Bogalusa Heart Study)

Differences in geometric adaptation of the left ventricle and associated cardiovascular risk may reflect the differential effects of classic risk factors and arterial stiffness on the left ventricle. In the present study, the influence of cardiovascular risk factors and arterial stiffness indexes on left ventricular (LV) geometry types were studied in a large community-based cohort of young adults. As part of the Bogalusa Heart Study, echocardiographic examinations of the heart were performed on 786 black and white adults (age range 24 to 43 years, average 36; 42% men, 70% white). Arterial stiffness indexes of the study cohort included aorta-femoral pulse wave velocity, carotid artery elastic modulus, and arterial compliance using tonometry. Pulse pressure in young adults with concentric LV hypertrophy (47 +/- 11 mm Hg) was significantly higher than in those with eccentric LV hypertrophy (40 +/- 8 mm Hg) and normal geometry (37 +/- 7 mm Hg). Multinomial logistic regression analysis showed that widened pulse pressure, the presence of diabetes mellitus, and increased body mass index were associated with concentric LV hypertrophy compared with normal geometry. Similarly, higher Peterson's and Young's elastic modulus of the carotid arteries and lower large- and small-artery compliance, in addition to increased body mass index, diabetes mellitus, and black race, were associated with concentric LV hypertrophy in young adults. In conclusion these data suggested that concentric LV hypertrophy was associated with widened pulse pressure, increased arterial stiffness, and decreased arterial compliance in young adults.

Silent cerebral microbleeds associated with arterial stiffness in an apparently healthy subject

Silent cerebral microbleeds (MBs) are a common finding in stroke patients, especially those with intracerebral hemorrhage, and are thought to be a marker of future cerebral hemorrhage. Clinically, two distinct forms of MBs have been documented, those observed with either or both stroke or small vessel disease (SVD) and those associated with cerebral amyloid angiopathy. We investigated a possible association between MBs and arterial stiffness in a general population. Subjects were 443 apparently healthy individuals with a mean age of 67.1+/-8.1 years. The presence of MBs, lacunar infarcts and periventricular hyperintensity (PVH) was determined by 3-tesla magnetic resonance imaging. Carotid intima-media thickness (IMT) was measured by ultrasonography. Arterial stiffness was evaluated by brachial-to-ankle pulse wave velocity (baPWV), and the Framingham stroke risk score (FSRS) was obtained as an integrated cerebrovascular risk factor. The prevalence of MBs was 5.0%. Both baPWV and FSRS were significantly higher in subjects with MBs (1820+/-308 vs. 1645+/-325 cm/s, P=0.014 and 12.1+/-8.6 vs. 8.9+/-7.5%, P=0.047, respectively). Odds ratio of a high baPWV, defined as >or=1500 cm/s, for the presence of MBs was 6.05 even after correction for confounding parameters, including age and hypertension. This association with high baPWV remained irrespective of MBs location, whether strictly located in the lobes or in the basal ganglia and infratentorial regions. These findings indicate an association between arterial stiffness and the presence of MBs. Assessment of arterial stiffness may be useful in identifying subjects at high risk for the presence of MBs.

Relation of left ventricular hypertrophy to regional cerebral blood flow: single photon emission computed tomography abnormalities in essential hypertension

Several reports have shown that left ventricular hypertrophy (LVH) is an independent predictor of acute cerebrovascular events. The aim of the present study was to investigate the relationship between LVH and cerebral blood flow in middle-aged patients with essential hypertension. Forty never-treated hypertensive patients (24 men, 16 women, aged 50-60 years) without clinical evidence of target organ damage were studied. Regional cerebral blood flow was measured by means of single photon emission computed tomography of the brain. Twenty-nine patients showed echocardiographic criteria of LVH; 11 patients did not show this feature. No differences were found in regional cerebral blood flow ratio of all brain areas studied between hypertensives with or without LVH except for the striatum area. The regional cerebral blood flow ratio was significantly reduced in the striatum region of hypertensive patients with LVH, compared with patients without LVH (91.5+/-7.4 vs 98.1+/-8.3; P=.023). This relationship remained significant after adjusting for blood pressure. The authors conclude that the presence of LVH in middle-aged patients with essential hypertension is associated with a reduction of regional cerebral blood flow in the striatum area.

Silent Cerebral White Matter Lesions and Their Relationship With Vascular Risk Factors in Middle-Aged Predialysis Patients With CKD

BACKGROUND

Silent cerebral white matter lesions are observed on magnetic resonance imaging (MRI) scans in elderly people, and they are related to vascular risk factors, particularly hypertension. No data on the prevalence and risk factors of white matter lesions in patients with chronic kidney disease (CKD) are available. The aim is to analyze the prevalence of white matter lesions and their determinants in this population.

METHODS

We studied 52 patients without diabetes with CKD (stage 3 or 4) aged 30 to 60 years (average, 49 years) and a group of 32 normotensive control subjects. MRI studies were performed and subcortical and periventricular white matter lesions were evaluated by using semiquantitative measures. Patients were classified into 2 groups depending on the presence or absence of white matter lesions. Echocardiographic studies and measures of markers of systemic inflammation (C-reactive protein and interleukin 6) also were performed.

RESULTS

White matter lesions were more prevalent in patients with CKD than controls (33% versus 6%; P = 0.008). Patients with CKD who had white matter lesions were older; had a greater history of cardiovascular disease and vascular nephropathy as a primary cause of renal disease and greater levels of systolic blood pressure, pulse pressure, left ventricular mass index, and C-reactive protein; and were administered more antihypertensive drugs than patients with CKD without white matter lesions. Stage and duration of CKD were not related to the presence of white matter lesions. After adjusting for several factors, only vascular nephropathy (odds ratio, 15.6; 95% confidence interval, 1.27 to 191.54; P = 0.03) independently predicted an increased risk for white matter lesions.

CONCLUSION

One third of middle-aged patients with CKD have silent cerebral white matter lesions. Vascular nephropathy seems to be the most important factor related to the presence of these lesions, suggesting that white matter lesions reflect ischemic brain damage caused by generalized vascular damage.

Left Ventricular Concentric Geometry During Treatment Adversely Affects Cardiovascular Prognosis in Hypertensive Patients

Left ventricular (LV) mass and geometry predict risk for cardiovascular events in hypertension. Regression of LV hypertrophy (LVH) may imply an important prognostic significance. The relation between changes in LV geometry during antihypertensive treatment and subsequent prognosis has not yet been determined. A total of 436 prospectively identified uncomplicated hypertensive subjects with a baseline and follow-up echocardiogram (last examination 72+/-38 months apart) were followed for an additional 42+/-16 months. Their family doctor gave antihypertensive treatment. After the last follow-up echocardiogram, a first cardiovascular event occurred in 71 patients. Persistence of LVH from baseline to follow-up was confirmed as an independent predictor of cardiovascular events. Cardiovascular morbidity and mortality were significantly greater in patients with concentric (relative wall thickness > or =0.44) than in those with eccentric geometry (relative wall thickness <0.44) in patients presenting with LVH (P=0.002) and in those without LVH (P=0.002) at the follow-up echocardiogram. The incidence of cardiovascular events progressively increased from the first to the third tertile of LV mass index at follow-up (partition values 91 and 117 g/m2), but for a similar value of LV mass index it was significantly greater in those with concentric geometry (OR: 4.07; 95% CI: 1.49 to 11.14; P=0.004 in the second tertile; OR: 3.45; 95% CI: 1.62 to 7.32; P=0.001 in the third tertile; P<0.0001 in concentric versus eccentric geometry). Persistence or development of concentric geometry during follow-up may have additional prognostic significance in hypertensive patients with and without LVH.

Comparative analysis of the spatial distribution and severity of cerebral microbleeds and old lacunes

BACKGROUND

Cerebral microbleeds, which result from microangiopathic changes following chronic hypertension, may reflect bleeding-prone microangiopathy. However, the distribution of these lesions has not been compared with that of lacunes, which represent occlusive type microangiopathy.

OBJECTIVES

To compare the cerebral distribution of microbleeds and lacunes and correlate their severity.

METHODS

The study population comprised 129 hypertensive patients who underwent brain magnetic resonance imaging (MRI), including gradient echo (GE) sequences. Cerebral microbleeds were counted using GE-MRI data, and lacunes were also counted by comparing T1 and T2 weighted MRI. To investigate the distributions, the number of patients with each type of lesion was compared, and the occurrence index (the total number of the specific lesions divided by the total number of patients) was examined statistically. Correlation analyses were done on the relations between the different grades of microbleeds, lacunes, and leukoaraiosis.

RESULTS

Cerebral microbleeds and lacunes were found at various foci in the brain, with a preference for the cortico-subcortical region and the deep grey matter. The occurrence index of microbleeds, but not of lacunes, was significantly higher in the cortico-subcortical region than in the deep grey matter. The severity of the microbleeds was positively correlated with the severity of lacunes, and both types of lesion were closely correlated with the degree of leukoaraiosis.

CONCLUSIONS

These data suggest that microbleeds and lacunes tend to occur to a similar extent in long standing hypertension, but not necessarily in the same locations.

Reversal of left ventricular hypertrophy: what have recent trials taught us?

Regression of left ventricular hypertrophy (LVH) is an important intermediate target for antihypertensive therapy. Thus, several trials and meta-analyses have attempted to compare the effects of different antihypertensive agents on LVH, but flawed study designs and methodologic problems have limited the utility of these studies. PRESERVE (Prospective Randomized Enalapril Study Evaluating Regression of Ventricular Enlargement), LIVE (LVH: Indapamide Sustained Release Versus Enalapril) and LIFE (Losartan Intervention For Endpoint reduction in hypertension) represent a new generation of large well designed trials with the power to compare different antihypertensive drugs. These studies have shown that treatment regimens based on enalapril and a nifedipine gastrointestinal therapeutic system are of similar efficacy (PRESERVE), that indapamide sustained release (SR) is superior to enalapril (LIVE), and that a regimen based on losartan is superior to a regimen based on atenolol (LIFE) in reversing hypertensive LVH. LIVE incorporated on-treatment echocardiographic quality control, with centralized readers blinded for both treatment and sequence of recording. The findings of these rigorous studies, to some extent in disagreement with results of previous meta-analyses, support the notion that antihypertensive drugs need to be judged on their individual effects on important intermediate endpoints such as LVH in well designed and adequately sized studies. However, extrapolation of the results of these studies in terms of class effects could be misleading and should be made with caution.

Statins Induce the Regression of Left Ventricular Mass in Patients With Angina

Background There is evidence that statins induce the regression of cardiac hypertrophy in a transgenic rabbit model of hypertrophic cardiomyopathy. Methods and Results The association between treatment with statins and the regression of cardiac mass (left ventricular mass index, LVMI) was investigated in a case - control study using transthoracic echocardiography in 304 patients with angina who underwent coronary angiography. Those who received pravastatin or simvastatin were defined as cases (n=66), and age, sex and body mass index-matched controls (n=127) were selected. The cases showed a significant decrease in LVMI compared with the controls. Although the cases included a significantly higher percentage of patients with hypertension and calcium antagonist (CaA) treatment than the controls, there were no relationships between LVMI and either hypertension or CaA treatment. Because the cases had a significantly higher number of stenosed vessels than the controls, LVMI for each number of stenosed vessels was analyzed, and a significant interaction effect between the association of LVMI with statin and the number of stenosed vessels was found. Conclusions Treatment with statins was associated with a lower cardiac mass in patients with angina, suggesting that this is one of the drugs' pleiotropic effects.

Left ventricular mass and geometry and the risk of ischemic stroke

BACKGROUND AND PURPOSE

Left ventricular hypertrophy (LVH) is a risk factor for cardiovascular events, but its effect on ischemic stroke risk is established mainly in whites. The effect of LV geometry on stroke risk has not been defined. The aim of the present study was to evaluate whether LVH and LV geometry are independently associated with increased ischemic stroke risk in a multiethnic population.

METHODS

A population-based case-control study was conducted on 394 patients with first ischemic stroke and 413 age-, sex-, and race-ethnicity-matched community control subjects. LV mass was measured by transthoracic echocardiography. LV geometric patterns (normal, concentric remodeling, concentric or eccentric hypertrophy) were identified. Stroke risk associated with LVH and different LV geometric patterns was assessed by conditional logistic regression analysis in the overall group and age, sex, and race-ethnic strata, with adjustment for established stroke risk factors.

RESULTS

Concentric hypertrophy carried the greatest stroke risk (adjusted odds ratio [OR], 3.5; 95% confidence interval [CI], 2.0 to 6.2), followed by eccentric hypertrophy (adjusted OR, 2.4; 95% CI, 2.0 to 4.3). Concentric remodeling carried slightly increased stroke risk (adjusted OR, 1.7; 95% CI, 1.0 to 2.9). Increased LV relative wall thickness was independently associated with stroke after adjustment for LV mass (OR, 1.6; 95% CI, 1.1 to 2.3).

CONCLUSIONS

LVH and abnormal LV geometry are independently associated with increased stroke risk. LVH is strongly associated with ischemic stroke in all age, sex, and race-ethnic subgroups. Increased LV relative wall thickness imparts an increased stroke risk after adjustment for LV mass and is of additional value in stroke risk prediction.

Prospective Study of Single and Multiple Lacunar Infarcts Using Magnetic Resonance Imaging

BACKGROUND AND PURPOSE

We investigated whether lacunar infarct (LI) patients with >1 lacune have different vascular risk factors, a different prognosis, and poorer functional outcome than those with a single lacune.

METHODS

The study included 175 first-ever LI patients. The group was divided according to the presence of multiple (n=136) or single (n=39) LI. The association of single or multiple LI with the principal vascular risk factors, leukoaraiosis, outcome, and recurrence was investigated with logistic regression models that included age, sex, and cardiac disease.

RESULTS

No significant differences were found between single and multiple LI with respect to age, hypertension, hyperlipidemia, smoking, and heavy alcohol drinking. Diabetes mellitus (odds ratio [OR], 2.43; 95% CI, 1.09 to 5.4), high levels of hematocrit (>0.47) (OR, 1.09; 95% CI, 1.04 to 1.21), and leukoaraiosis (OR, 3.58; 95% CI, 1.77 to 7.51) were significantly related to multiple but not to single LI. Stroke recurrence rate was 7.7% in patients with single LI and 24.3% in the multiple LI group (OR, 3.84; 95% CI, 1.1 to 13.3). During a median follow-up of 12 months (range, 6 to 156 months), 94% of the single LI patients and 77.2% of the multiple LI patients had favorable outcomes (Rankin Scale score 0 to 2) (OR, 5.4; 95% CI, 1.25 to 23.9).

CONCLUSIONS

Diabetes mellitus, leukoaraiosis, and high levels of hematocrit are important risk factors in patients with >1 LI. The presence of multiple LI may be an important prognostic indicator not only for functional recovery but also for a higher rate of recurrence.

Left ventricular hypertrophy is associated with asymptomatic cerebral damage in hypertensive patients

BACKGROUND AND PURPOSE

It has been demonstrated that left ventricular hypertrophy (LVH) confers an increased risk for major cerebrovascular events. However, it is still uncertain whether there is an association between LVH and asymptomatic cerebrovascular damage in hypertensive patients. In this study, we investigated the relation between LVH, evaluated by both echocardiography (Echo-LVH) and electrocardiography (ECG-LVH), and preclinical cerebral damage, as identified by magnetic resonance imaging.

METHODS

One hundred ninety-five consecutive patients were enrolled in the study. We evaluated other risk factors such as age, sex, presence of diabetes, cholesterol levels, smoking status, heart rate, and systolic and diastolic blood pressure. Asymptomatic cerebrovascular damage was considered silent cerebral lesions: punctate lesions, lacunes, and territorial lesions. Patients were divided into 2 groups according to the presence of asymptomatic brain lesions.

RESULTS

The 2 groups of patients differed only in terms of age and systolic pressure. More importantly, the prevalence of Echo-LVH (83% versus 47.7%, P<0.001) and ECG-LVH (56% versus 22%, P<0.001) was significantly higher in patients with asymptomatic brain lesions. A multivariate analysis allowed us to recognize LVH as the only independent predictor for the presence of ischemic lacunes (P<0.001). Moreover, we evaluated the impact of left ventricular geometry on asymptomatic cerebrovascular damage, and we found that hypertensives with concentric hypertrophy displayed more pronounced asymptomatic cerebrovascular damage compared with patients with eccentric hypertrophy.

CONCLUSIONS

Our study demonstrates that LVH is associated with cerebral damage even in the absence of clinical symptoms. Thus, the presence of cardiac damage provides important prognostic clues about the presence of asymptomatic cerebral damage.

MTHFR gene polymorphism as a risk factor for silent brain infarcts and white matter lesions in the Japanese general population: The NILS-LSA Study

BACKGROUND AND PURPOSE

Silent brain infarcts (SBI) and white matter lesions are relatively common neuroimaging findings, especially in the elderly population. The genetic background for SBI and white matter lesions in a large Japanese general population was investigated.

METHODS

Subjects were recruited from participants in the National Institute for Longevity Sciences, Longitudinal Study of Aging. Genotyping of methylenetetrahydrofolate reductase (MTHFR) C677T gene mutation and brain MRI examination were performed in 1721 subjects free of any history of stroke. SBI and white matter lesions were diagnosed from MRI findings.

RESULTS

Of 1721 MRI examinations, SBI was observed in 178 (10.3%). The prevalence of SBI and white matter lesions increased with age. The prevalence of SBI was significantly higher in subjects with the MTHFR TT genotype compared with the TC+CC genotype (14.6% versus 9.5%; 42 of 288 versus 136 of 1433; chi2=6.71; P=0.010). The stage of white matter lesions was not significantly different. In subjects >or=60 years of age (n=849), the prevalence of SBI was significantly higher in TT than TC+CC (27.7% versus 16.6%; 36 of 130 versus 119 of 719; chi2=9.16; P=0.002). The prevalence of moderately advanced white matter lesions was also significantly higher in TT than TC+CC (60.7% versus 49.0%; 79 of 130 versus 352 of 719; chi2=9.16; P=0.002). After correction for other risk factors, the MTHFR TT genotype was independently associated with SBI (odds ratio [OR], 1.72; 95% CI, 1.10 to 2.68; P=0.018) and moderately advanced white matter lesions (OR, 1.58; 95% CI, 1.07 to 2.33; P=0.02).

CONCLUSIONS

These findings indicate that the MTHFR TT genotype is an independent risk factor for SBI and white matter lesions in the general Japanese population, especially in elderly subjects.

Low concentration of serum total cholesterol is associated with multifocal signal loss lesions on gradient-echo magnetic resonance imaging: analysis of risk factors for multifocal signal loss lesions

BACKGROUND AND PURPOSE

Multifocal signal loss lesions (MSLLs) on T2*-weighted gradient-echo (GE) MRI are believed to be microbleeds histopathologically. Previous epidemiological studies suggested that low serum cholesterol is associated with the increased risk of intracerebral hemorrhage. We investigated risk factors of MSLLs and the relationship between lipid profiles and MSLLs on GE-MRI.

METHODS

We included consecutively 172 patients who underwent brain MRI. MSLLs on GE-MRI were counted by 2 neurologists separately and graded by consensus. The concentrations of lipid profiles were categorized as quartiles, and the MSLLs were graded as absent (total count, 0), mild (1 to 2), moderate (3 to 10), and severe (>10).

RESULTS

The mean concentrations of total cholesterol and low-density lipoprotein cholesterol were significantly lower in patients with a severe degree of MSLLs than in those without MSLL (P<0.05). By multivariate analysis, MSLLs were significantly correlated with hypertension (odds ratio [OR], 3.42; 95% CI, 1.17 to 9.97), leukoaraiosis (OR, 4.62; 95% CI, 2.87 to 7.41), the lowest quartile of serum total cholesterol (<4.27 mmol/L; OR, 10.91; 95% CI, 3.98 to 25.57), and the highest quartile of high-density lipoprotein (>1.47 mmol/L; OR, 3.5; 95% CI, 1.45 to 8.29).

CONCLUSIONS

Our results suggest that both the lipid profile levels and the severity of hypertension may be closely associated with MSLLs on GE-MRI.

Correlation between silent cerebral white matter lesions and left ventricular mass and geometry in essential hypertension

BACKGROUND

It has been proposed that concentric left ventricular hypertrophy (LVH) is related to a worse degree of target organ damage in hypertensives with this feature than in those without. Moreover, the presence of cerebral white matter lesions (WMLs) is considered to be an early marker of brain damage in essential hypertension. The aim of this study was to assess the association between the presence of silent WMLs and left ventricular mass and geometry in middle-aged individuals with hypertension that had never been treated.

METHODS

A total of 62 patients (39 men, 23 women, aged 50 to 60 years, mean age 54.4 +/- 3.2 years) with never-treated essential hypertension and without clinical evidence of target organ damage were studied. All patients underwent brain magnetic resonance imaging and were classified into two groups according to the presence or absence of WMLs. Echocardiography measuring posterior wall thickness (PWT), interventricular septum thickness (IVST) and left ventricular end-diastolic diameter (LVEDD) was also performed. Left ventricular mass index (LVMI) was calculated using the Penn convention criteria, and relative wall thickness ratio (RWT) was estimated by the standard formula: 2 x PWT/LVEDD.

RESULTS

Hypertensive patients with WMLs exhibited significantly higher PWT, IVST, LVMI, and RWT when compared with hypertensive patients without WMLs. In addition, 23 of 26 hypertensive patients with WMLs showed echocardiographic criteria for LVH that was significantly higher than that observed in hypertensive patients without WMLs (21 of 36; P = .01). Concentric hypertrophy (LVH and RWT > or = 0.45) was present in 14 hypertensive patients with WMLs and in only four patients without WMLs (P = .002).

CONCLUSION

There is a close association between cerebral WMLs and concentric LVH in asymptomatic middle-aged hypertensive patients, independent of blood pressure values.

Left ventricular hypertrophy as an independent predictor of acute cerebrovascular events in essential hypertension

BACKGROUND

It is uncertain whether left ventricular hypertrophy (LVH) confers an increased risk for cerebrovascular disease in apparently healthy patients with essential hypertension.

METHODS AND RESULTS

A total of 2363 initially untreated hypertensive patients (mean age 51+/-12 years, 47% women) free of previous cardiovascular disease were followed up for up to 14 years (mean 5 years). At entry, all patients underwent diagnostic tests, including ECG, echocardiography, and 24-hour ambulatory blood pressure (BP) monitoring. At entry, the prevalence of LVH was 17.6% by ECG (Perugia score) and 23.7% by echocardiography (LVM >125 g/m(2)). Over the subsequent years, 105 patients experienced a first stroke or transient ischemic attack. The cerebrovascular event rate was higher among patients with LVH at entry, diagnosed by either ECG or echocardiography, than among those without hypertrophy (both P<0.01). After control for the significant influence of age, sex, diabetes, and 24-hour mean ambulatory BP, LVH by ECG conferred an increased risk for cerebrovascular events (relative risk [RR] 1.79; 95% CI 1.17 to 2.76). LVH by echocardiography also conferred a higher risk for cerebrovascular events (RR 1.64; 95% CI 1.07 to 2.68). For each increase in LV mass of 1 SD (29 g/m(2)), there was a significant independent increase in the risk for cerebrovascular events (RR 1.31; 95% CI 1.09 to 1.58).

CONCLUSIONS

In apparently healthy patients with essential hypertension, LVH diagnosed by ECG or echocardiography confers an excess risk for stroke and transient ischemic attack independently of BP and other individual risk factors.

Cerebral white matter lesions in essential hypertension

The pathogenesis and clinical significance of cerebral white matter lesions (WML) remain controversial. Most studies have shown that age, hypertension, diabetes mellitus, and a history of stroke or heart disease are the most important factors related to the presence of cerebral WML. Moreover, some studies suggest that the presence of WML are closely related to cerebrovascular disease and cognitive impairment in elderly patients with vascular risk factors, particularly hypertension. In this review, different points of view about cerebral WML are discussed, with special focus on the presence of WML in essential hypertension. Some authors suggest that the presence of WML in hypertensive patients could be considered an early marker of brain damage.

Low wall shear stress in carotid arteries in subjects with left ventricular hypertrophy

Left ventricular hypertrophy (LVH) is an independent risk factor for cardiovascular complications including atherosclerosis. The close linkage between LVH and carotid atherosclerosis has been the focus of much research. However, the underlying mechanism linking the two conditions is not fully understood. Low wall shear stress contributes to intimal thickening and atherosclerosis development as a local mechanism. In the present study, we investigated the relationship between wall shear stress and LVH in subjects with risk factors for atherosclerosis. Eighty subjects with at least one risk factor for atherosclerosis; ie, hypertension, diabetes mellitus, hyperlipidemia, or smoking, were enrolled. Intimal-medial thickness (IMT), number of plaques, internal dimensions, and blood flow velocity in the common carotid artery were evaluated. Wall shear stress was calculated using a Poiseuillean parabolic model of velocity distribution: shear stress = 4 x blood viscosity x central flow velocity/internal dimension. Subjects were divided into two groups; LVH(-) (n = 36) and LVH(+) (n = 44), according to their left ventricular mass index (LVMI). Mean shear stress and systolic peak shear stress were significantly lower in subjects with LVH compared with subjects without LVH. Furthermore, mean shear stress (r = -0.42, P < .0001) and peak shear stress (r = -0.31, P < 0.01) were significantly inversely related to LVMI. Stepwise regression analysis revealed that wall shear stress independently correlated with LVMI as well as IMT. These results indicate that low shear stress could function as a local factor in the development of atherosclerosis in subjects with LVH.