High-density lipoprotein cholesterol and left ventricular hypertrophy in essential hypertension

Association between Sleep Duration and Left Ventricular Hypertrophy for Patients with Type 2 Diabetes Mellitus

Objective

In this study, we aimed to estimate the impact of sleep duration on left ventricular hypertrophy (LVH) in type 2 diabetes mellitus (T2DM).

Methods

Consecutive patients with T2DM undergoing transthoracic echocardiography (TTE) in our center from October 2017 to February 2021 were analyzed. The association of the risk of LVH in T2DM patients was evaluated using univariable and multivariable logistic regression analyses.

Results

This study finally included 2689 adult patients (mean age 51.8 ± 12.5 years, 56.2% men, mean sleep duration 7.6 ± 1.4 hours per day). Of all patients, 655 (24.4%) patients were diagnosed with LVH and 2034 did not have LVH. All patients were adults and were diagnosed with T2DM. In the univariate and multivariate regression analyses, gender, sleep duration, body mass index (BMI), waist, hemoglobin (Hb), blood creatinine (Cr), and high-density lipoprotein cholesterol (HDL-c) were associated with LVH. In the restricted cubic spline (RCS) model, the cut-off points of sleep duration given refer to the group of patients with T2DM and LVH were 8 hours per day. With the cut-off points, the multivariable analysis demonstrated that, for diabetic patients, LVH was significantly correlated with a sleep duration of 8 hours per day, hemoglobin, blood urea nitrogen (BUN), and HDL-c.

Conclusion

For patients with T2DM, long sleep duration (>8 hours per day), hemoglobin, BUN, and HDL-c were independently associated with LVH. This trial is registered with NCT03811470.

Lipid Levels and New-Onset Atrial Fibrillation in Patients with Acute Myocardial Infarction

AIM

In acute myocardial fraction (AMI) patients, the association between lipid parameters and new-onset atrial fibrillation (NOAF) remains unclear due to limited evidence.

METHODS

A total of 4282 participants free from atrial fibrillation (AF) at baseline were identified in Beijing Friendship Hospital. Fasting levels of total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) were measured at baseline. The study population was stratified based on tertiles of lipid profile and lipid ratios. Incidence of NOAF was observed at the follow-up visits. The associations between different lipid parameters and the incidence of NOAF were assessed by multivariate Cox regression analysis.

RESULTS

Over a median follow-up period of 42.0 months (IQR: 18.7, 67.3 months), 3.1% (N=132) AMI patients developed NOAF. After multivariable adjustment, higher TC (hazard ratios (HR): 0.205, 95% confidence intervals (CI): 0.061-0.696) levels were inversely associated with NOAF development. However, higher HDL-C (HR: 1.892, 95% CI: 1.133-3.159) levels were positively associated with NOAF development. LDL-C levels, TG levels, non-HDL-C levels, and lipid ratios showed no association with NOAF development.

CONCLUSION

TC levels were inversely associated with incidence of NOAF; this was mainly reflected in the subgroups of male gender and older patients (65 years or older). HDL-C levels were positively associated with incidence of NOAF; this was mainly reflected in the subgroups of male gender and younger patients (age ＜65 years). There was no significant association of NOAF with LDL-C, TG, or non-HDL-C levels.

Determinants of Left Atrial Compliance in the Metabolic Syndrome: Insights from the "Linosa Study"

The association between left atrial (LA) impairment and cardiovascular diseases (CVD) and between dyslipidaemia and CVD are well known. The present study aims to investigate the relationships between metabolic factors and LA dimensions and compliance, as well as test the hypothesis that metabolic factors influence LA function independent from hemodynamic mechanisms. Arterial blood pressure (BP), waist and hip circumference, metabolic indices, and a complete echocardiographic assessment were obtained from 148 selected inhabitants (M/F 89/59; age 20−86 years) of Linosa Island, who had no history of CVD. At enrollment, 27.7% of the subjects met the criteria for metabolic syndrome (MetS) and 15.5% for arterial hypertension (HTN). LA compliance was reduced in subjects with MetS compared to those without (53 ± 27% vs. 71 ± 29%, p = 0.04) and was even lower (32 ± 17%, p = 0.01) in those with MetS and HTN. At multiple regression analysis, the presence of MetS independently determined LA maximal area (r = 0.56, p < 0.001), whereas systolic BP and the total cholesterol/HDL cholesterol ratio determined LA compliance (r = 0.41, p < 0.001). In an apparently healthy population with a high prevalence of MetS, dyslipidaemia seems to independently influence LA compliance. At a 5-year follow-up, LA compliance was reduced in both all-cause and CVD mortality groups, and markedly impaired in those who died of CVD. These findings may contribute to understanding the prognostic role of LA function in CVD and strengthen the need for early and accurate lipid control strategies.

Combined superposition effect of hypertension and dyslipidemia on left ventricular hypertrophy

BACKGROUND

Hypertension and dyslipidemia are considered reversible risk factors for cardiovascular disease. The purpose of this study was to explore the impact of traditional and nontraditional blood lipid profiles on the risk of left ventricular hypertrophy (LVH) and to explore the superposition effect of dyslipidemia combined with hypertension.

METHODS

Data on 9134 participants (53.5 ± 10.3 years old) from the Northeast China Rural Cardiovascular Health Study (NCRCHS) were statistically analyzed. The blood lipid profile was measured by total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total glyceride (TG), and calculated nontraditional blood lipid indices including non-HDL-C, atherosclerosis index (AI), TC/HDL-C, and residual cholesterol (RC).

RESULTS

After the adjustment of age and gender, the odds ratios (ORs) of LVH in patients with hypertension, high LDL-C, high non-HDL-C, high AI, and high TC/HDL-C were 3.97 (3.31-4.76), 1.27 (1.02-1.59), 1.21 (1.04-1.39), 1.33 (1.15-1.53), and 1.42 (1.22-1.65), respectively. After full adjustment of potential confounding factors, high AI and TC/HDL-C were associated with LVH rather than traditional blood lipid indices. The combination of hypertension and nontraditional dyslipidemia (defined by high AI and TC/HDL-C) was associated with the highest risk of LVH, especially in participants under 45 years of age. The risk was more significant in men, 5.09-fold and 6.24-fold, respectively, compared with 3.66-fold and 4.01-fold in women.

CONCLUSIONS

People with dyslipidemia defined by nontraditional blood lipid indices (high AI and high TC/HDL-C) and hypertension were more likely to develop LVH.

Insulin Resistance and Vitamin D Deficiency: A Link Beyond the Appearances

Vitamin D is a steroid hormone that plays a key role in the regulation of body homeostasis, including cardiovascular function. Although the chronic deficiency of vitamin D is associated with cardiovascular risk factors, as well as with an adverse prognosis, randomized controlled trials have failed in demonstrating that dietary vitamin D supplementation could ameliorate the prognosis of patients with cardiovascular diseases, and suggested that vitamin D deficiency is the expression of the effects of other determinants of cardiovascular risk. Thus, the supplementation of vitamin D is not sufficient to improve the cardiovascular risk profile and prognosis. Insulin resistance is a complex phenomenon that plays a key role in the pathogenesis of conventional cardiovascular risk factors. Interestingly, defects of vitamin D and insulin resistance have a superimposable epidemiological distribution. According to the common view, Insulin resistance is considered the direct or indirect consequence of vitamin D deficiency. However, it is also reasonable to speculate that the deficit or the impaired action of vitamin D, in some circumstances, could be the result of the same pathogenic mechanisms responsible of insulin resistance development. In this case, vitamin D deficiency could be considered an epiphenomenon of insulin resistance. Insulin resistance is a reversible condition, being possibly ameliorated by physical activity and hypocaloric diets. Notably, both physical exercise and energy-restricted dietary regimens are associated with an increase of vitamin D levels. These findings indicate that improving insulin resistance condition is a necessary step to ameliorate vitamin D supplementation-based strategies in cardiovascular prevention.

The role of metabolic syndrome in sudden cardiac death risk: Recent evidence and future directions

Metabolic syndrome (MetS) is a frequent condition whose deleterious effects on the cardiovascular system are often underestimated. MetS is nowadays considered a real pandemic with an estimated prevalence of 25% in general population. Individuals with MetS are at high risk of sudden cardiac death (SCD) as this condition accounts for 50% of all cardiac deaths in such a population. Of interest, recent studies demonstrated that individuals with MetS show 70% increased risk of SCD even without previous history of coronary heart disease (CHD). However, little is known about the interplay between the two conditions. MetS is a complex disease determined by genetic predisposition, unhealthy lifestyle and ageing with deleterious effects on different organs. MetS components trigger a systemic chronic low-grade pro-inflammatory state, associated with excess of sympathetic activity, cardiac hypertrophy, arrhythmias and atherosclerosis. Thus, MetS has an important burden on the cardiovascular system as demonstrated by both preclinical and clinical evidence. The aim of this review is to summarize recent evidence concerning the association between MetS and SCD, showing possible common aetiological processes, and to indicate prospective for future studies and therapeutic targets.

Assessment of Carotid Intima Media Thickness and Left Ventricular Mass Index in Children with Idiopathic Nephrotic Syndrome

BACKGROUND

Children with nephrotic syndrome (NS) are at a greater risk of atherosclerosis due to recurrent exposures to hyperlipidemia, hypertension, and immunosuppressive medications. CIMT (carotid intima media thickness) is a reliable marker for assessment of atherosclerosis of large and medium-sized blood vessels; endothelial dysfunction and increased CIMT usually precede the development of cardiovascular diseases. Some manifestations of NS, like proteinuria and hyperlipidemia, are associated with an increased risk of cardiac morbidity and mortality. The aim of the current study was to evaluate the carotid intima media thickness and LVM (left ventricular mass) thickness in children with nephrotic syndrome.

SUBJECTS AND METHODS

Eighty-one children with nephrotic syndrome and 100 healthy children as controls were enrolled in the study. The inclusion criteria were: disease duration of minimum of 12 months, glomerular filtration rate >60mL/min/1.73m 2 and children aged two years or more at the time of study. CIMT and left ventricular mass index, lipid profile, protein/creatinine ratio in urine and kidney function tests were done for cases and controls after approval of internal ethical committee.

RESULTS

The mean CIMT (mm) was significantly higher in NS (0.51± 0.12) compared to controls (0.42± 0.09) (P <0.001). LVM and LVM Index were significantly higher in NS than controls (p< 0.001, for both). Subsequently, CIMT was significantly correlated to duration of the disease (p< 0.001), LVM index was significantly correlated with duration of the disease, body mass index (BMI), blood pressures and triglycerides level (p< 0.05).

CONCLUSION

Children with NS are at increasing risk to develop atherosclerosis as measured by CIMT. LVM was significantly higher in NS and positively correlated to BP, disease duration, triglyceride levels and BMI.

The Effect of Blood Lipids on the Left Ventricle: A Mendelian Randomization Study

Background

Cholesterol and triglycerides are among the most well-known risk factors for cardiovascular disease.

Objectives

This study investigated whether higher low-density lipoprotein (LDL) cholesterol and triglyceride levels and lower high-density lipoprotein cholesterol level are causal risk factors for changes in prognostically important left ventricular (LV) parameters.

Methods

One-sample Mendelian randomization (MR) of 17,311 European individuals from the UK Biobank with paired lipid and cardiovascular magnetic resonance data was performed. Two-sample MR was performed by using summary-level data from the Global Lipid Genetics Consortium (n = 188,577) and UK Biobank Cardiovascular Magnetic Resonance substudy (n = 16,923) for sensitivity analyses.

Results

In 1-sample MR analysis, higher LDL cholesterol was causally associated with higher LV end-diastolic volume (β = 1.85 ml; 95% confidence interval [CI]: 0.59 to 3.14 ml; p = 0.004) and higher LV mass (β = 0.81 g; 95% CI: 0.11 to 1.51 g; p = 0.023) and triglycerides with higher LV mass (β = 1.37 g; 95% CI: 0.45 to 2.3 g; p = 0.004). High-density lipoprotein cholesterol had no significant association with any LV parameter. Similar results were obtained by using 2-sample MR. Observational analyses were frequently discordant with those derived from MR.

Conclusions

MR analysis demonstrates that LDL cholesterol and triglycerides are associated with adverse changes in cardiac structure and function, in particular in relation to LV mass. These findings suggest that LDL cholesterol and triglycerides may have a causal effect in influencing cardiac morphology in addition to their established role in atherosclerosis. (J Am Coll Cardiol 2020;76:2477-88).

Triglycerides are related to left ventricular mass in hypertensive patients independently of other cardiometabolic risk factors: the effect of gender

Given the inconsistent results on the prognostic significance of triglycerides (TGs), the purpose of the present study was to investigate the association of plasma TGs with left ventricular mass (LVM) in hypertensive patients. We studied 760 never treated, non diabetic, hypertensive patients. Τransthoracic echocardiography was performed and LVMI was calculated according to the Devereux formula, adjusted to body surface area. Triglycerides were associated with LVMI after adjustment for age, gender, systolic blood pressure (SBP), smoking and fasting glucose (b = 0.08, p = 0.009). This relationship remained significant even after adjustment for BMI, LDL-C and ApoB/ApoA1 ratio (b = 0.07, p = 0.04). Gender-stratified analysis indicated that TGs were related to LVMI in men (p = 0.001) but not in women (p = NS). In addition, TGs were related with LV hypertrophy (LVH) in men, increasing the odds by 7% to present LVMI over 115 g/m² (OR = 1.07 per 10 mg/dl increase in TGs, p = 0.01). In conclusion, TGs are associated with LVMI in hypertensive patients, independently of other risk factors, including LDL-C. Given the prognostic significance of LVH, it might be suggested that TGs may serve as a useful marker for indentifying hypertensive patients at high risk. The gender discrepancy may suggest a possible gender-specific modulatory effect of TGs on LV structure.

A nutraceutical combination reduces left ventricular mass in subjects with metabolic syndrome and left ventricular hypertrophy: A multicenter, randomized, double-blind, placebo-controlled trial

BACKGROUND & AIMS

Increased left ventricular mass (LVM) is often present in metabolic syndrome (MS), also in the setting of well-controlled blood pressure (BP). Aim of the present study was to evaluate the efficacy of a nutraceutical combination of berberine, red yeast rice extract and policosanol (Armolipid Plus™, AP) in reducing LVM in patients with MS and left ventricular hypertrophy (LVH).

METHODS

In this multicenter, randomized, double-blind, placebo-controlled trial, 158 patients with MS (IDF criteria) and LVH (LVM > 48 g/m^2.7 in men and > 44 g/m^2.7 in women), were randomized 1:1 to receive AP or placebo for 24 weeks. Reduction of LVM, regression of LVH, and changes in lipids were analysed.

RESULTS

One-hundred-and-forty-five patients (AP n = 74, placebo n = 71) completed the study. A significant percentage reduction in LVM was observed in AP group vs baseline (-2.7%, p < 0.0001), and compared to placebo (-4.1%, p < 0.0001), and remained significant after adjustment for age, sex, baseline systolic BP and BMI and their changes during the study period. The proportion of subjects showing LVM reduction was higher in AP group than in the placebo group (57% vs 28%, adjusted p = 0.007). Treatment with AP was associated with improvement of lipid profile.

CONCLUSIONS

24-week of treatment with AP is associated with a significant reduction in LVM in subjects with MS and LVH, in addition to favourable effects on lipid profile, and could represent an effective strategy aiming at reducing the associated cardiovascular risk. The trial was registered at clinicaltrials.gov with ID NCT02295176.

Association Between Blood Lipid Profiles and Atrial Fibrillation: A Case-Control Study

Background

Dyslipidemia is the most frequent comorbidity in patients with cardiovascular disease. However, studies examining the relationship between blood lipid profiles and AF have produced inconsistent results.

Material/Methods

A total of 651 patients were enrolled into 3 groups: Healthy controls (n=64), Paroxysmal AF (PAF; n=270), and Continuous AF (CAF; n=317). All enrolled patients underwent routine baseline 12-lead electrocardiography (ECG) and 24-h dynamic ECG along with blood testing, which included the following: complete metabolic panel, hepatic function, renal function, circulating thyroxine, fasting high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), and total cholesterol (TC).

Results

Patients with AF had significantly higher levels of triglycerides (TG), lower levels of LDL-C-c, and lower levels of HDL-C (p<0.05). TC (OR 0.979, p<0.9247) and TG (OR 0.945, p<0.6496) were negatively and linearly associated with PAF, while TG (OR 0.807, p=0.2042), LDL-C (OR 0.334, p=0.0036), and HDL-C (OR 0.136, p=0.0002) were negatively and linearly associated with CAF.

Conclusions

Compared to healthy controls, patients with AF had lower blood lipid levels, especially LDL-c and HDL-c levels. Hypolipoproteinemia may increase patient susceptibility to developing AF.

The impact of nontraditional lipid profiles on left ventricular geometric abnormalities in general Chinese population

BACKGROUND

Despite current interest in the unfavorable impact of nontraditional lipid profiles on cardiovascular disease, information regarding its relations to abnormal left ventricular (LV) geometry has not been systemically elucidated. This study sought to understand predictive implication of nontraditional lipid profiles in specific LV geometric patterns in the general population of rural China.

METHODS

Analyses were based upon a cross-sectional study of 10,756 participants (mean age 53.8 years; 54.0% females) who underwent assessment of biochemical, anthropometric, and blood pressure variables in rural areas of China. Participants were classified into four groups of LV morphologic pattern according to left ventricular mass index (LVMI) and relative wall thickness with quantitative echocardiographic data.

RESULTS

By multivariable-adjusted linear regression models, nontraditional lipid profiles were positive determinants of concentricity index and LV wall thickness (all P < 0.05), with modest effects on LVMI. Non-high-density lipoprotein cholesterol (non-HDL-C) emerged as an independent correlate of concentric LV hypertrophy (LVH) (adjusted odds ratio [OR]: 1.174 per 1 SD increment in non-HDL-C, 95% confidence interval [CI]: 1.075-1.281), followed by low-density lipoprotein cholesterol (LDL-C)/HDL-C ratio (1.158 [1.059-1.266]), total cholesterol (TC)/HDL-C ratio (1.150 [1.050-1.260]), and triglyceride (TG)/HDL-C ratio (1.134 [1.030-1.249]). The ORs for concentric LVH by tertiles further provided insight into that excess risk was associated with the highest tertile of nontraditional lipid profiles. The areas under the ROC curves to predict concentric LVH were statistically identical among nontraditional lipid parameters.

CONCLUSION

Nontraditional lipid profiles, easily measured in the everyday routine examination, were responsible for increased risk of concentric LVH, potentially providing enhanced clinical utility at no additional cost, which emphasized the beneficial effect of these markers to supplement and improve CVD risk stratification.

Cholesterol remnants and triglycerides are associated with decreased myocardial function in patients with type 2 diabetes

BACKGROUND

Recently, genetic studies have suggested a causal relationship between cholesterol remnants and ischemic heart disease. We aimed to determine whether cholesterol remnants and its marker, triglyceride levels, are associated with cardiac function as determined by sensitive echocardiographic measures in a population of patients with type 2 diabetes.

METHODS

Comprehensive echocardiography including 2D-speckle tracking echocardiography was performed on a representative sample of 924 patients with type 2 diabetes-730 of whom were treated with statins. These were recruited from two large secondary care centers.

RESULTS

In multivariable analyses, triglycerides and cholesterol remnants were not associated with left ventricular ejection fraction, but with subtle measures of systolic function, including global longitudinal strain by speckle tracking and longitudinal displacement by tissue Doppler echocardiography: global longitudinal strain [0.33 % (0.14), p = 0.02 per doubling in cholesterol remnants and 0.28 % (0.13), p = 0.03 per doubling in triglyceride levels] and with longitudinal displacement [-0.25 mm (0.10), p = 0.01 per doubling in cholesterol remnants and -0.25 mm (0.09), p = 0.005 per doubling in triglyceride levels]. Subgroup analyses of patients receiving statin therapy and patients without known heart disease revealed similar results, but the association was not present in patients with known heart disease.

CONCLUSION

In patients with type 2 diabetes, subtle decrease in left ventricular function is present with increasing levels of cholesterol remnants and triglyceride levels indicating an effect of these on cardiac function that is not detectable by conventional echocardiography.

Impact of duration and dosage of statin treatment and epicardial fat thickness on the recurrence of atrial fibrillation after electrical cardioversion

The purpose of this study was to investigate the time-dependent effect of statin treatment and echocardiographic epicardial fat thickness (EFT) on the maintenance of sinus rhythm (SR) in atrial fibrillation (AF) patients after electrical cardioversion (EC). One hundred sixty-three AF patients without previous statin treatment who underwent EC were consecutively enrolled. The maintenance rate of SR after EC (1, 3, 6, and 12 months) as documented by electrocardiogram and EFT were compared between patients with statin treatment (statin group, n = 63) and those without (no statin group, n = 100). There was no significant difference in the maintenance rate of SR between the groups soon after EC (statin group; 85.7 % vs. no statin; 84.8%, p = 0.535), after 1 month (71.0 vs. 59.1%, p = 0.091), and after 3 months (63.2 vs. 50.0%, p = 0.086). However, the maintenance rate of SR was significantly higher in the statin group compared to no statin group (61.8 vs. 42.9%, p = 0.024) after 6 months, and this significant difference persisted up to 12 months of follow up (60.1 vs. 36.4%, p = 0.001). Patients with recurrence showed higher baseline EFT (7.4 ± 2.7 vs. 8.5 ± 3.0 mm, p = 0.014). Multivariate linear regression analysis indicated that EFT, left atrial diameter, high-density lipoprotein cholesterol, statin treatment, and dose were the significant contributors to the maintenance of SR for all periods after EC. Statin treatment and low EFT were associated with a higher maintenance rate of SR in AF patients after EC. Significant benefit of statin was realized 6 months after EC, and this benefit was shown to be maintained over time.

Dysregulation of the autonomic nervous system predicts the development of the metabolic syndrome

CONTEXT

Stress is suggested to lead to metabolic dysregulations as clustered in the metabolic syndrome. Although dysregulation of the autonomic nervous system is found to associate with the metabolic syndrome and its dysregulations, no longitudinal study has been performed to date to examine the predictive value of this stress system in the development of the metabolic syndrome.

OBJECTIVE

We examined whether autonomic nervous system functioning predicts 2-year development of metabolic abnormalities that constitute the metabolic syndrome.

DESIGN

Data of the baseline and 2-year follow-up assessment of a prospective cohort: the Netherlands Study of Depression and Anxiety was used.

SETTING

Participants were recruited in the general community, primary care, and specialized mental health care organizations.

PARTICIPANTS

A group of 1933 participants aged 18-65 years.

MAIN OUTCOME MEASURES

The autonomic nervous system measures included heart rate (HR), respiratory sinus arrhythmia (RSA; high RSA reflecting high parasympathetic activity), pre-ejection period (PEP; high PEP reflecting low sympathetic activity), cardiac autonomic balance (CAB), and cardiac autonomic regulation (CAR). Metabolic syndrome was based on the updated Adult Treatment Panel III criteria and included high waist circumference, serum triglycerides, blood pressure, serum glucose, and low high-density lipoprotein (HDL) cholesterol.

RESULTS

Baseline short PEP, low CAB, high HR, and CAR were predictors of an increase in the number of components of the metabolic syndrome during follow-up. High HR and low CAB were predictors of a 2-year decrease in HDL cholesterol, and 2-year increase in diastolic and systolic blood pressure. Short PEP and high CAR also predicted a 2-year increase in systolic blood pressure, and short PEP additionally predicted 2-year increase in diastolic blood pressure. Finally, a low baseline RSA was predictive for subsequent decreases in HDL cholesterol.

CONCLUSION

Increased sympathetic activity predicts an increase in metabolic abnormalities over time. These findings suggest that a dysregulation of the autonomic nervous system is an important predictor of cardiovascular diseases and diabetes through dysregulating lipid metabolism and blood pressure over time.

Atrial fibrillation and diabetes mellitus. Correlation, co-existence, and coagulation therapy

Epidemiological studies have reported on the association between diabetes mellitus (DM) and subsequent risk of atrial fibrillation (AF) with inconsistent results. Individuals with DM present with an increased risk (approximate 40%) of subsequent AF compared with unaffected individuals, but the mechanisms underlying the relationship between DM and AF remains speculative. Both entities share common risk factors and, thus, seem to be closely associated with each other. Obviously, the quality of glycemic control is directly related with the risk for AF; the risk is higher with longer duration of treated diabetes and poorer glycemic control. Future research should identify approaches to reduce the risk of AF in people with diabetes by means of consequent screening and anti-coagulation therapy.

Thyroid function and left ventricular structure and function in the Framingham Heart Study

BACKGROUND

Thyroid hormone acts on the heart and peripheral vasculature in multiple ways. Even in patients with subclinical hypo- or hyperthyroidism, subclinical alterations in left ventricular (LV) structure and function may be associated with important clinical effects. Our objective was to determine whether thyroid function is related to echocardiographic indices of LV structure and function.

METHODS

Cross-sectional association of serum thyroid-stimulating hormone (TSH) with two-dimensional-guided M-mode echo LV dimensions and function. Participants were 1376 Framingham Heart Study participants (61% women, mean age 69 years) who attended a routine examination 1979-1981. We excluded participants with myocardial infarction or heart failure, renal insufficiency, and missing data, and those using thyroid hormone or antithyroid medications. Serum TSH was measured 1977-1979. The following echocardiographic measurements were analyzed both as continuous variables and dichotomized at the top quintile: LV end-diastolic dimensions, LV wall thickness, LV mass, LV fractional shortening (an indicator of systolic function), and left atrial diameter. Sex-specific multiple regression models were adjusted for age, height, weight, blood pressure, heart rate, total to high-density lipoprotein cholesterol ratio, and the presence of diabetes, hypertension treatment, and valve disease.

RESULTS

In multivariable linear models, log-TSH was not related to LV mass, LV wall thickness, or left atrial size in either sex, or to LV systolic function in men. Log-TSH had a borderline inverse association with fractional shortening (p = 0.06) in women. In multivariable logistic models, women with TSH <0.5 mU/L (n = 81) had a greater odds of being in the highest quintile of fractional shortening compared to euthyroid subjects (odds ratio 2.2, 95% confidence interval 1.3-3.8, p = 0.01).

CONCLUSIONS

In our moderate-sized community-based sample, TSH concentration was not associated with LV structure in either sex, but was inversely related to LV contractility, consistent with the known inotropic effects of thyroid hormone.

Relations of lipid concentrations to heart failure incidence: the Framingham Heart Study

BACKGROUND

The relations of lipid concentrations to heart failure (HF) risk have not been elucidated comprehensively.

METHODS AND RESULTS

In 6860 Framingham Heart Study participants (mean age, 44 years; 54% women) free of baseline coronary heart disease, we related high-density lipoprotein cholesterol (HDL-C) and non-HDL-C to HF incidence during long-term follow-up, adjusting for clinical covariates and myocardial infarction at baseline and updating these at follow-up examinations. We evaluated dyslipidemia-specific population burden of HF by calculating population attributable risks. During follow-up (mean of 26 years), 680 participants (49% women) developed HF. Unadjusted HF incidence in the low (<160 mg/dL) versus high (> or =190 mg/dL) non-HDL-C groups was 7.9% and 13.8%, respectively, whereas incidence in the high (> or =55 [men], > or =65 [women] mg/dL) versus low (<40 [men], <50 [women] mg/dL) HDL-C groups was 6.1% and 12.8%, respectively. In multivariable models, baseline non-HDL-C and HDL-C, modeled as continuous measures, carried HF hazards (confidence intervals) of 1.19 (1.11 to 1.27) and 0.82 (0.75 to 0.90), respectively, per SD increment. In models updating lipid concentrations every 8 years, the corresponding hazards (confidence intervals) were 1.23 (1.16 to 1.31) and 0.77 (0.70 to 0.85). Participants with high baseline non-HDL-C and those with low HDL-C experienced a 29% and 40% higher HF risk, respectively, compared with those in the desirable categories; the population attributable risks for high non-HDL-C and low HDL-C were 7.5% and 15%, respectively. Hazards associated with non-HDL-C and HDL-C remained statistically significant after additional adjustment for interim myocardial infarction.

CONCLUSIONS

Dyslipidemia carries HF risk independent of its association with myocardial infarction, suggesting that lipid modification may be a means for reducing HF risk.

Impact of waist circumference on cardiac phenotype in hypertensives according to gender

Our aim was to assess the differential effect of waist circumference on left-ventricular (LV) structural and functional alterations, in hypertensive males and females. One thousand seven hundred and eighty nine consecutive, nondiabetic, essential hypertensives (aged 55.8 +/- 13.5 years, 966 females), included in the 3H Study, an ongoing registry of hypertension-related-target-organ damage, were classified to obese and nonobese groups according to Adult Treatment Panel III criteria. All participants underwent complete echocardiographic study including LV diastolic function evaluation by means of conventional and tissue Doppler imaging (TDI) methods, averaging early and late diastolic mitral annular peak velocities (Em, Am, Em/Am) from four separate sites of measurement. Hypertensive obese women compared with nonobese exhibited significantly greater LV mass index and prevalence of LV hypertrophy (by 5.5 g/m(2), P = 0.003, and 8.8%, P = 0.005, respectively), while such differences were not present among men. Obese women compared to nonobese ones were accompanied by lower transmitral E/A (by 0.08, P < 0.001), TDI-derived Em/Am (by 0.12, P < 0.001), and higher E/Em ratio (by 0.8, P = 0.016). In contrast, hypertensive obese men compared to nonobese ones exhibited lower E and Em (by 0.04 m/s and 0.6 cm/s, both P < 0.05). A significant interaction between sex and abdominal obesity was observed only regarding TDI-derived Am and Em/Am. Furthermore, waist circumference was a predictor of E/A (beta = -0.097, P = 0.002) and Em/Am (beta = -0.116, P = 0.001), independently of body size, in females but not in males. The adverse effect of abdominal obesity on LV alterations is more pronounced among female hypertensives, suggesting that routine measurement of waist circumference provides additional information on cardiac phenotype especially in women.

High-Density Lipoprotein Cholesterol and Left Ventricular Mass Index in Peritoneal Dialysis

Objective

The prevalence of left ventricular hypertrophy (LVH) reaches 75% in patients with end-stage renal disease. In patients on peritoneal dialysis (PD), some factors, such as hypertension, volume overload, serum albumin, and residual renal function, have been reported to be related to LVH. Dyslipidemia often occurs in PD but it remains unclear whether dyslipidemia is related to LVH. We investigated the relationship between clinical parameters, including lipid profile, and left ventricular mass index (LVMI).

Methods

In this cross-sectional study, 34 patients undergoing PD for more than 1 year without combined therapy with hemodialysis were included. We recorded the patients’ clinical data and related those parameters with LVMI as evaluated by echocardiography.

Results

The patients included 23 males and 11 females (age 62.2 ± 12.1 years, duration on PD 31.6 ± 15.6 months). Mean LVMI was 142 ± 37 g/m2. In univariate analysis, urine volume ( r = -0.493, p = 0.003), total cholesterol ( r = -0.418, p = 0.01), high-density lipoprotein cholesterol (HDL-C; r = -0.374, p = 0.02), and human atrial natriuretic peptide (hANP; r = 0.600, p < 0.001) significantly correlated with LVMI. Stepwise multiple regression analysis showed that hANP (β= 0.524, p = 0.001) and HDL-C (β= -0.422, p = 0.007) were independently associated with LVMI ( r2 = 0.32).

Conclusion

Strict volume control and salt restriction is essential for prevention of LVH. The role of HDL-C in the development of LVH in PD patients remains to be determined.

Vascular permeability, blood pressure, and organ damage in primary hypertension

Sub-clinical organ damage is a strong independent predictor of cardiovascular mortality in primary hypertension, and its changes over time parallel those in risk of cardiovascular events. A better understanding of the pathogenetic mechanisms underlying the development of target organ damage may help us devise more effective therapeutic strategies. We therefore investigated the relationship between the presence of organ damage and some of its potential determinants, such as blood pressure severity and early atherosclerotic abnormalities. Thirty-seven untreated, non-diabetic hypertensive patients were enrolled. Target organ damage was assessed by albuminuria and left ventricular mass index; systemic vascular permeability was evaluated by transcapillary escape rate of albumin (TERalb); and blood pressure was measured by 24h ambulatory blood pressure monitoring. The albumin-to-creatinine ratio and left ventricular mass index were directly related to TERalb (r = 0.48, p = 0.003 and r = 0.39, p < 0.020, respectively) and 24-h systolic blood pressure values (r = 0.54, p < 0.001; r = 0.60, p < 0.001). The simultaneous occurrence of increased blood pressure load and TERalb was associated with higher left ventricular mass index values (p = 0.012) and entailed an increased risk of having at least one sign of damage (chi2 = 17.4; p < 0.001). Logistic regression analysis showed that the risk of presenting at least one sign of organ damage increased more than ten-fold when TERalb was above the median and more than five-fold with each 10 mmHg increase in 24-h systolic blood pressure. Blood pressure load and vascular permeability are potentially modifiable factors that are independently associated with the occurrence of sub-clinical signs of renal and cardiac damage in hypertensive patients.

Prevention of heart failure: a scientific statement from the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group

The increase in heart failure (HF) rates throughout the developed and developing regions of the world poses enormous challenges for caregivers, researchers, and policymakers. Therefore, prevention of this global scourge deserves high priority. Identifying and preventing the well-recognized illnesses that lead to HF, including hypertension and coronary heart disease, should be paramount among the approaches to prevent HF. Aggressive implementation of evidence-based management of risk factors for coronary heart disease should be at the core of HF prevention strategies. Questions currently in need of attention include how to identify and treat patients with asymptomatic left ventricular systolic dysfunction (Stage B HF) and how to prevent its development. The relationship of chronic kidney disease to HF and control of chronic kidney disease in prevention of HF need further investigation. Currently, we have limited understanding of the pathophysiological basis of HF in patients with preserved left ventricular systolic function and management techniques to prevent it. New developments in the field of biomarker identification have opened possibilities for the early detection of individuals at risk for developing HF (Stage A HF). Patient groups meriting special interest include the elderly, women, and ethnic/racial minorities. Future research ought to focus on obtaining a much better knowledge of genetics and HF, especially both genetic risk factors for development of HF and genetic markers as tools to guide prevention. Lastly, a national awareness campaign should be created and implemented to increase public awareness of HF and the importance of its prevention. Heightened public awareness will provide a platform for advocacy to create national research programs and healthcare policies dedicated to the prevention of HF.

Echocardiographic left ventricular hypertrophy in hypertension: marker for future events or mediator of events?

PURPOSE OF REVIEW

To discuss the most relevant studies on the prognostic impact of echocardiographic left ventricular hypertrophy in hypertension.

RECENT FINDINGS

There is abundant evidence from epidemiological studies that increased left ventricular mass identifies hypertensive patients at increased risk of major cardiac and cerebrovascular events. Looking at the geometric patterns of the left ventricle, concentric remodelling and concentric left ventricular hypertrophy carry the highest risk for adverse events. Patients with left ventricular hypertrophy reversal as an effect of treatment are exposed to a lesser risk of events as compared with patients with persistence of left ventricular hypertrophy. Reversal of concentric remodelling predicts a lesser risk of adverse events compared with persistence of remodelling. Experimental evidence is accumulating that several haemodynamic and nonhaemodynamic factors which are able to promote progression of atherosclerosis through plaque growth and destabilization may also induce left ventricular hypertrophy by acting on myocyte and interstitium. Increased left ventricular mass may also be a causative factor for reduced pumping performance and arrhythmias.

SUMMARY

Increased left ventricular mass is a marker of cardiovascular risk because it reflects and integrates the long-term level of activity of factors inducing progression of atherosclerosis. Increased left ventricular mass may also mediate myocardial ischaemia with potential evolution towards heart failure and arrhythmias.

High-density lipoprotein cholesterol and insulin resistance are independent and additive markers of left ventricular hypertrophy in essential hypertension

We examined whether plasma high-density lipoprotein-cholesterol (HDL-C) levels and glucose metabolism parameters are independent or additive predictors of left ventricular hypertrophy (LVH) in patients with untreated essential hypertension. The study group consisted of 41 Japanese patients with untreated essential hypertension and LVH (left ventricular mass index [LVMI] >125 g/m2; age 58+/-6 years, mean+/-SD), and the control group consisted of 39 age-matched patients with untreated essential hypertension without LVH (LVMI <or=125 g/m2; age 58+/-7 years). The following metabolic parameters were higher in the group with LVH: fasting plasma glucose (FPG) (p<0.01), fasting insulin concentration (F-IRI) (p<0.0001), and homeostasis model assessment (HOMA)-index (p<0.0001). Among the laboratory parameters investigated, plasma HDL-C levels were lower (p<0.0001), and triglyceride and uric acid levels were higher in the group with LVH (p<0.05 for both). The nighttime systolic and diastolic ambulatory blood pressure (ABP) (p<0.0001, p<0.01, respectively) and nighttime heart rate (p<0.01) were higher in patients with LVH. Multivariate logistic analysis identified HDL-C (odds ratio [OR]=0.92, 95% confidence interval [CI]=0.87-0.98, p<0.05), HOMA-index (OR=3.83, 95% CI=1.28-11.5, p<0.05) and nighttime systolic ambulatory blood pressure (ABP) (OR=1.06, 95% CI=1.00-1.13, p<0.05) as independent significant risk factors for LVH. Our findings suggest that HDL-C, HOMA-index and nighttime systolic ABP are independent predictors for the presence of LVH in Japanese patients with essential hypertension.

Different impact of the metabolic syndrome on left ventricular structure and function in hypertensive men and women

Metabolic syndrome (MS) is increasingly recognized as an important cardiovascular risk factor in hypertension, but its influence on left ventricular (LV) mass and function in the 2 genders has not been specifically addressed. Among 618 nondiabetic, untreated hypertensive subjects, echocardiographically detected LV mass was significantly greater in subjects with MS. A significant interaction was observed between sex and the MS (P<0.003 for the multiplicative interaction term). Compared with women without the MS, those with the syndrome had a 24% greater LV mass (49.5+/-12 versus 40.0+/-10 g x m(-2.7); P<0.001), whereas the difference was only 9% in men (50.3+/-12 versus 46.1+/-10 g x m(-2.7); P=0.003). A greater prevalence of LV hypertrophy was found in women (37% versus 14%; P<0.001) but not in men (39% versus 29%; P=0.09) with the MS. After adjustment for the effect of age, body mass index, 24-hour systolic blood pressure, and several confounders, the MS was independently associated with a greater LV mass index in women (regression coefficient, 4.80; P<0.001) but not in men. Women with the MS also had a greater LV relative wall thickness (0.42+/-0.07 versus 0.39+/-0.07; P=0.004) and a depressed afterload-corrected midwall fractional shortening (94.0+/-12% versus 101.0+/-13%; P<0.001) than women without the syndrome, whereas no differences emerged in men. We conclude that, in untreated hypertension, MS has a different impact on LV hypertrophy and function in men and women. The effect of MS is more pronounced in women and is partly independent from the effect of several hemodynamic and nonhemodynamic determinants of LV mass.

Prevalence and determinants of electrocardiographic left ventricular hypertrophy among a multiethnic population of postmenopausal women (The Women's Health Initiative)

Our objectives were to determine the prevalence and factors related to left ventricular hypertrophy (LVH) among older women for commonly used electrocardiographic criteria. LVH is a potent risk factor for cardiovascular disease, especially among women. However, its value has been limited, in part, by the use of different electrocardiographic criteria and the lack of a clearly defined standard for the general population. A total of 3,613 eligible women, aged 50 to 79 years, underwent medical history, physical measurements, and biochemical determinations and had behavioral factors recorded at baseline. Three LVH indexes were derived from computer measurement of the electrocardiogram: hypertrophied left ventricular mass > or =171.04 g (HLVM); Cornell voltage > or =2,200 microV; and Minnesota Code items. The prevalence of LVH ranged from <1% to 13% when stratified by age, ethnicity, and scoring technique. Baseline traits differed significantly for those meeting the LVH criteria. Predictors (p <0.01) of HLVM were age (odds ratio 0.66), height (odds ratio 1.47), waist/hip ratio (odds ratio 1.30), systolic blood pressure (odds ratio 1.18); low-density lipoprotein cholesterol (odds ratio 0.97), log insulin (odds ratio 2.10), dietary kilocalories (odds ratio 1.16), weekly energy expenditure (odds ratio 0.53), hypertension (odds ratio 1.61), current estrogen use (odds ratio 0.60), and current smoker (odds ratio 0.47). The presence of the metabolic syndrome was related to all LVH indexes, with odds ratios of 4.95, 2.24, and 2.35, respectively, for HLVM, Cornell voltage, and Minnesota Code. In conclusion, the prevalence of LVH varied by ethnicity and the electrocardiographic index used. However, the baseline traits, especially the factors associated with the metabolic syndrome, were consistently and strongly related to all LVH indexes, particularly HLVM. Intervention on these factors may provide strategies for reducing LVH, a strong independent risk factor for cardiovascular morbidity and mortality among women.

Risk factors for heart failure

Despite remarkable therapeutic advances in the management of patients with heart failure (HF), the mortality due to this syndrome remains high. Identifying free-living individuals who are at high risk for developing HF may allow implementing strategies that can prevent HF. Prospective epidemiologic studies have identified several risk factors and risk markers for HF. This article reviews current knowledge regarding conventional and newer risk markers for HF, outlines possible underlying mechanisms for the increased HF risk, and provides a framework for clinical multivariate risk prediction using HF risk factors.

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.

Lipid lowering: another method of reducing blood pressure?

Modern management of cardiovascular risk depends on assessment of cardiovascular risk factors. Hypertension and hyperlipidaemia are synergistic risk factors for cardiovascular events. Both show a degree of cross-correlation through sharing mechanisms of pathogenesis including insulin resistance and endothelial dysfunction. This article reviews the common pathways leading to dyslipidaemia and hypertension and the effects diet and lipid-lowering drug therapies have had on correcting blood pressure in patients with essential hypertension. Both statins and fibrates have shown a capability to lower blood pressure by up to 8/5 and 15/10 mmHg respectively, in some small-scale clinical trials and have effects on arterial wall structure and hence pulse wave velocity. This blood pressure action may account for some of the clinical effects of lipid-lowering drugs on cardiovascular risk. Thus, lipid lowering may provide an additional method of correcting hypertension in some high-risk patients. However, data from large-scale intervention trials are either absent or ambiguous. Definitive large-scale trials to investigate the antihypertensive effects of lipid-lowering drugs are required, although end point studies examining the interaction of lipid-lowering and antihypertensive drugs to determine optimum combinations are already under way.