Role of hypertension, diabetes, obesity, and race in the development of symptomatic myocardial dysfunction in a predominantly minority population with normal coronary arteries

Mexican immigrants' and Mexican Americans' perceptions of hypertension

Although the rate of hypertension (HTN) is no higher for Mexican-origin clients than for non-Hispanic Whites, their rate of blood pressure (BP) control is lower. To effectively assist clients with their BP, health care providers must first understand barriers and facilitators to BP control from the clients' perspectives. The purpose of this study was to describe the experience of living with HTN for Mexican immigrants and Mexican Americans. A phenomenological method was appropriate to describe their lived experience. We conducted one-time interviews with 26 adults who self-identified as Mexican-origin. Some participants did not know what caused HTN and others believed in causes they could control. Many believed HTN was of short duration. Some participants forgot to take medication or were not able to afford it. Mexican-origin clients need more assistance with BP control, and need it in both English and Spanish.

Out-of-proportion pulmonary hypertension and heart failure with preserved ejection fraction

BACKGROUND

A subset of patients with heart failure with preserved ejection fraction (HFpEF) will have a marked increase in pulmonary artery pressure (PAP).

OBJECTIVE

To evaluate the clinical and hemodynamic characteristics of these patients in comparison to patients with idiopathic pulmonary arterial hypertension (IPAH).

METHODS

We reviewed the clinical and hemodynamic data of patients with HFpEF with out-of-proportion pulmonary hypertension (HFpEF-PH) and compared it to the corresponding data of age-matched patients with IPAH.

RESULTS

Twenty consecutive patients with HFpEF-PH and 20 patients with IPAH were included in the study. The mean age (±SD) was 71.3 ± 7.8 and 70.2 ± 6.7 years, respectively. The majority of the HFpEF-PH patients were postmenopausal females with at least two features of the metabolic syndrome and atrial fibrillation. Although HFpEF-PH patients fulfilled the criteria for out-of-proportion PH, with transpulmonary gradient (TPG) >12 mm Hg, the difference between the diastolic PAP and the pulmonary capillary wedge pressure (PCWP) was significantly lower compared to IPAH (6.3 ± 6.2 vs. 27.5 ± 4.8, p < 0.00001).

CONCLUSIONS

Our results suggest that a diagnosis of HFpEF-PH should be suspected when severe PH occurs in an elderly postmenopausal female with one or more features of the metabolic syndrome and atrial fibrillation. Interestingly, these patients had significantly lower differences between diastolic PAP and PCWP, suggesting that the increase in TPG is mainly caused by an elevated systolic PAP, possibly as a result of increased pulmonary vascular stiffness, and not pulmonary vascular remodeling.

Contribution of comorbidities to functional impairment is higher in heart failure with preserved than with reduced ejection fraction

BACKGROUND

Comorbidities negatively affect prognosis more strongly in heart failure with preserved (HFpEF) than with reduced (HFrEF) ejection fraction. Their comparative impact on physical impairment in HFpEF and HFrEF has not been evaluated so far.

METHODS AND RESULTS

The frequency of 12 comorbidities and their impact on NYHA class and SF-36 physical functioning score (SF-36 PF) were evaluated in 1,294 patients with HFpEF and 2,785 with HFrEF. HFpEF patients had lower NYHA class (2.0 ± 0.6 vs. 2.4 ± 0.6, p < 0.001) and higher SF-36 PF score (54.4 ± 28.3 vs. 54.4 ± 27.7, p < 0.001). All comorbidities were significantly (p < 0.05) more frequent in HFrEF, except hypertension and obesity, which were more frequent in HFpEF (p < 0.001). Adjusting for age and gender, COPD, anemia, hyperuricemia, atrial fibrillation, renal dysfunction, cerebrovascular disease and diabetes had a similar (p for interaction > 0.05) negative effect in both groups. Obesity, coronary artery disease and peripheral arterial occlusive disease exerted a significantly (p < 0.05) more adverse effect in HFpEF, while hypertension and hyperlipidemia were associated with fewer (p < 0.05) symptoms in HFrEF only. The total impact of comorbidities on NYHA (AUC for prediction of NYHA III/IV vs. I/II) and SF-36 PF (r(2)) in multivariate analyses was approximately 1.5-fold higher in HFpEF, and also much stronger than the impact of a 10% decrease in ejection fraction in HFrEF or a 5 mm decrease in left ventricular end-diastolic diameter in HFpEF.

CONCLUSION

The impact of comorbidities on physical impairment is higher in HFpEF than in HFrEF. This should be considered in the differential diagnosis and in the treatment of patients with HFpEF.

Molecular determinants of the cardiometabolic phenotype

The metabolic syndrome represents a clustering of risk factors that has been shown to predict adverse cardiovascular outcomes. Although the precise mechanisms contributing to the cardiometabolic syndrome (CMS) remain poorly defined, accumulating evidence identifies two intersecting candidate pathways responsible for inflammation and energy homeostasis in the pathophysiology that underlie cardiometabolic traits. Although currently no pharmacologic interventions specifically target CMS, future drug development efforts should attempt to capitalize on molecular nodes at the intersections of these pathways in the CMS.

Pericardial fat and echocardiographic measures of cardiac abnormalities: the Jackson Heart Study

OBJECTIVE

Pericardial adipose tissue (PAT), a regional fat depot adjacent to the myocardium, may mediate the complex relation between obesity and cardiac left ventricular (LV) abnormalities. We sought to evaluate the association of PAT with echocardiographic measures of LV abnormalities in the Jackson Heart Study (JHS).

RESEARCH DESIGN AND METHODS

A total of 1,414 African Americans (35% men; mean age 58 years) from the JHS underwent computed tomographic assessment of PAT and abdominal visceral adipose tissue (VAT) from 2007 to 2009 and echocardiography examination between 2000 and 2004. Echocardiographic measures of left atrial (LA) internal diameter, LV mass, LV ejection fraction (LVEF), and E-wave velocity-to-A-wave velocity ratio (E/A ratio) were examined in relation to PAT, VAT, BMI, and waist circumference (WC).

RESULTS

All adiposity measures were positively correlated with LA diameter and LV mass and negatively correlated with E/A ratio (P = 0.02 to 0.0001) and were not with LVEF (P = 0.36-0.61). In women, per 1-SD increment of PAT, we observed association with higher LV mass (9.0 ± 1.7 gm, P = 0.0001) and LA diameter (1.0 ± 0.1 mm, P = 0.0001). However, the magnitude of the association between PAT and cardiac measures was similar compared with VAT (P = 0.65 [LV mass]; P = 0.26 [LA diameter]) and was smallercompared with BMI (P = 0.002 [LV mass]; P = 0.01 [LA diameter]) and WC (P = 0.009 [LA diameter]).

CONCLUSIONS

PAT is correlated with echocardiographic measures of cardiac LV abnormalities, but the association is not stronger than other adiposity measures.

Left ventricular structure and function in prediabetic adults: Relationship with insulin resistance

INTRODUCTION

Several studies have shown that ventricular dysfunction is increased in individuals with diabetes. Insulin resistance (IR) may precede type 2 diabetes, and is a pathogenic factor for it. Furthermore, IR has been shown to be an independent predictor of cardiovascular disease in diabetes. Given that glucose intolerance and IR precede the development of overt diabetes, these factors would be associated with abnormal myocardial performance.

AIM OF THE WORK

To evaluate the state of left ventricular structure and function in prediabetic adults in relation with IR.

PATIENTS AND METHODS

A case-control study was performed. One hundred and twenty-one consecutive adults with prediabetes were enrolled for the study. Forty-two of the adults had IR (group A) and 79 had insulin sensitivity (group B). Forty-three healthy (with normal blood glucose) adults matched for age and gender were considered as a control group. All groups were subjected to full medical history and clinical examination and biochemical and echocardiographic studies.

RESULTS

There were no statistically significant differences between the insulin-sensitive prediabetic group and the control group in all parameters of left ventricular structure and systolic and diastolic functions. Significant differences were observed between group A and control group in the parameters of left ventricular diastolic function (both isovolumetric relaxation time and E/A ratio). Regarding correlation between the parameters of diastolic function and different variables of IR prediabetic group, there was a statistically significant coefficient correlation with HOMA IR, waist circumference and triglycerides. No correlation was observed with fasting glucose, Hb A1c, body mass index, blood pressure (BP) and total lipids.

CONCLUSION

In prediabetic adults, IR is associated with impaired left ventricular diastolic function, and this association appears to be independent of BP, ventricular geometry, glucose tolerance status, total plasma lipids and obesity.

The economic consequences of diabetes and cardiovascular disease in the United States

Diabetes-related care and complications constitute a significant proportion of the United States' (US) health care expenditure. Of these complications, cardiovascular disease (CVD) is a major component. Higher morbidity and mortality rates translate to higher costs of care in patients with diabetes compared to those who do not have the disease. Minorities bear a disproportionate burden of diabetes and CVD. We review this disparity and examine potential etiologies for it in Hispanics and African-Americans, the two largest minority groups in the US. We examine strategies in these populations that may improve outcomes in diabetes and CVD, potentially decreasing health care costs.

Fasting plasma glucose is an independent determinant of left ventricular diastolic dysfunction in nondiabetic patients with treated essential hypertension

Left ventricular (LV) hypertrophy and LV diastolic dysfunction are common cardiac changes in hypertensive patients, and these changes are modified by various factors other than blood pressure. The present study was conducted to investigate the influence of mild abnormalities in glucose metabolism on LV structure and function in essential hypertension. In 193 nondiabetic patients with treated essential hypertension, two-dimensional and Doppler echocardiographic examinations were performed, and relative wall thickness (RWT), LV mass index (LVMI), fractional shortening, and the ratio of the peak velocity of atrial filling to early diastolic filling (A/E) were calculated. Fasting plasma glucose (FPG) and HbA1c levels were positively correlated with the A/E ratio and the deceleration time of the E wave. However, these plasma levels had no correlation with RWT, LVMI, or fractional shortening. Peak A wave velocity and the A/E ratio were significantly higher in patients who had FPG of > or = 100 mg/dl (and <126 mg/dl) than those who had FPG of <100 mg/dl, although age, blood pressure, RWT, LVMI, and fractional shortening did not differ between the two groups. In a multiple regression analysis of all subjects, only FPG and age were independent determinants of the A/E ratio. These observations suggest that FPG is a sensitive predictor for LV diastolic dysfunction in nondiabetic patients with treated hypertension. Since a slight increase in plasma glucose levels is associated with abnormalities in diastolic function independent of LV hypertrophy, an early stage of impaired glucose metabolism in hypertensive patients may specifically deteriorate cardiac diastolic function.