Value of a simple echocardiographic linear predictor of left ventricular mass in systemic hypertension

Unravelling the role of sex in the pathophysiology, phenotypic expression and diagnosis of cardiac amyloidosis

Sex-related differences in amyloid transthyretin (ATTR) amyloidosis.

The Progetto Ipertensione Umbria Monitoraggio Ambulatoriale (PIUMA) Study

BACKGROUND

the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale (PIUMA) study is a prospective registry of morbidity and mortality in initially untreated patients with essential hypertension whose initial diagnostic evaluation included 24-hour ambulatory blood pressure monitoring according to a standardized protocol. The present article summarizes the main results of the PIUMA study.

METHODS

the PIUMA study is conducted in three Hospitals in Umbria, Central Italy. After their initial assessment at entry, patients are followed in the outpatient clinic of the referring hospital and in collaboration with their family doctors. Telephone interviews with patients and meetings with family doctors are periodically conducted to ascertain the incidence of major complications of hypertension.

RESULTS

the PIUMA study gave us a tremendous opportunity to investigate several aspects related to hypertension: (1) Cross sectional studies focused on the association between clinic and 24-hour ABP and organ damage; (2) Longitudinal studies focused on the association between 24-hour ABP and hypertensive organ damage at cardiac level and other levels with the subsequent incidence of major cardiovascular events and mortality; (3) Longitudinal studies exploring the prognostic impact of other risk factors in hypertensive patients (i.e., diabetes, dyslipidemia, atrial fibrillation, left ventricular dysfunction, etc). The PIUMA study provided the first ever evidence of the prognostic value of (a) 24-hour ambulatory blood pressure monitoring; (b) regression of echocardiographic left ventricular hypertrophy in hypertensive patients.

CONCLUSIONS

the PIUMA registry gave us an enormous opportunity for investigating several pathophysiologic, diagnostic and therapeutic aspects related to management of hypertensive patients. Some of our studies have been mentioned in several Hypertension Guidelines to support some specific statements.

Obesity, Echocardiographic Changes and Framingham Risk Score in the Spectrum of Gout: A Cross-Sectional Study

Objectives

This study aims to establish cardiovascular risk in obese and non-obese patients in stages of gout by using Framingham risk score (FRS) and transthoracic echocardiography.

Patients and methods

This single-center cross-sectional study encompassed 201 patients (160 males, 41 females; mean age 56.9±13 years; range 20 to 89 years) including 52 asymptomatic hyperuricemia, 86 gouty arthritis without tophi, and 63 gouty tophi patients. Body Mass Index (BMI) and FRS were calculated. Left atrium (LA), interventricular septum, posterior wall (PW) of the left ventricle, fractional shortening (FS), mitral annular systolic velocity (S'), mitral annular early diastolic velocity (E') and transmitral to mitral annular early diastolic velocity ratio (E/E') were measured. Data were analyzed by Kolmogorov-Smirnov test, Shapiro-Wilk test, t-test, Mann-Whitney U test, analysis of variance test and multiple linear regression models.

Results

There was no significant difference in FRS, FS, S', E' and E/E' between obese and non-obese patients with asymptomatic hyperuricemia, gouty arthritis without tophi or gouty tophi. Obese patients in the three disease gradations had larger LA (p=0.007, p=0.004, p=0.039) and thicker PW (p=0.002, p=0.037, p=0.007). Increased BMI independently predicted the thickening of the PW in asymptomatic hyperuricemia (R2=0.319), gouty arthritis without tophi (R2=0.093) and gouty tophi (R2=0.068).

Conclusion

Despite the lack of difference in FRS and functional systolic and diastolic parameters between obese and non-obese patients in the spectrum of gout, morphological heart changes were more pronounced in obese patients. In gouty tophi, it is possible that higher urate load together with chronic inflammation contribute for the alterations, as obesity worsens them.

Validation of Left Atrial Volume Estimation by Left Atrial Diameter from the Parasternal Long-Axis View

BACKGROUND

Measurement of left atrial (LA) volume (LAV) is recommended for quantification of LA size. Only LA anteroposterior diameter (LAd) is available in a number of large cohorts, trials, or registries. The aim of this study was to evaluate whether LAV may be reasonably estimated from LAd.

METHODS

One hundred forty consecutive patients referred to our outpatient clinics were prospectively enrolled to measure LAd from the long-axis view on two-dimensional echocardiography. LA orthogonal dimensions were also taken from apical four- and two-chamber views. LAV was measured using the Simpson, area-length, and ellipsoid (LAV_e) methods. The first 70 patients were the learning series and the last 70 the testing series (TeS). In the learning series, best-fitting regression analysis of LAV-LAd was run using all LAV methods, and the highest values of F were chosen among the regression equations. In the TeS, the best-fitting regressions were used to estimate LAV from LAd.

RESULTS

In the learning series, the best-fitting regression was linear for the Spearman method (r² = 0.62, F = 111.85, P = .0001) and area-length method (r² = 0.62, F = 112.24, P = .0001) and powered for the LAV_e method (r² = 0.81, F = 288.41, P = .0001). In the TeS, the r² value for LAV prediction was substantially better using the LAV_e method (r² = 0.89) than the Simpson (r² = 0.72) or area-length (r² = 0.70) method, as was the intraclass correlation (ρ = 0.96 vs ρ = 0.89 and ρ = 0.89, respectively). In the TeS, the sensitivity and specificity of LA dilatation by the estimated LAV_e method were 87% and 90%, respectively.

CONCLUSIONS

LAV can be estimated from LAd using a nonlinear equation with an elliptical model. The proposed method may be used in retrospective analysis of existing data sets in which determination of LAV was not programmed.

Prognostic impact of the indexation of left ventricular mass in patients undergoing dialysis

Left ventricular hypertrophy (LVH) is exceedingly frequent in patients undergoing dialysis. Cardiac mass is proportional to body size, but the influence of various indexing methods has not been studied in patients with end-stage renal disease. The issue is important because malnutrition and volume expansion would both tend to distort the estimate of LV mass (LVM) in these patients. In a cohort of 254 patients, the prognostic impact on all-cause mortality and cardiovascular outcomes of LVH values, calculated according to two established methods of indexing, either body surface area (BSA) or height(2.7), was assessed prospectively. When LVM was analyzed as a categorical variable, the height(2.7)-based method identified a larger number of patients with LVH than the corresponding BSA-based method. One hundred and thirty-seven fatal and nonfatal cardiovascular events occurred during the follow-up period. Overall, 90 patients died, 51 of cardiovascular causes. In separate Cox models, both the LVM/height(2.7) and the LVM/BSA index independently predicted total and cardiovascular mortality (P < 0.001). However, the height(2.7)-based method coherently produced a closer-fitting model (P < or = 0.02) than did the BSA-based method. The height(2.7) index was also important for the subcategorization of patients according to the presence of concentric or eccentric LVH because the prognostic value of such subcategorization was apparent only when the height(2.7)-based criterion was applied. In conclusion, LVM is a strong and independent predictor of survival and cardiovascular events in patients undergoing dialysis. The indexing of LVM by height(2.7) provides more powerful prediction of mortality and cardiovascular outcomes than the BSA-based method, and the use of this index appears to be appropriate in patients undergoing dialysis.