Change in cardiovascular risk profile by echocardiography in low- or medium-risk hypertension

ECG Indices Poorly Predict Left Ventricular Hypertrophy and Are Applicable Only in Individuals With Low Cardiovascular Risk

Background: Left ventricular hypertrophy (LVH) is an important risk factor for cardiovascular events. The electrocardiography (ECG) has poor sensitivity, but it is commonly used to detect LVH. Aim: To evaluate the diagnostic efficacy of known ECG indicators to recognize LVH in subgroups with different cardiovascular risk levels. Methods: 676 volunteers were included. Results: We found that 10.2% of the analyzed population had LVH based on echocardiography. Individuals with LVH were older, had a higher body mass index, higher systolic blood pressure, lower heart rate, higher parameters of insulin resistance, higher cardiovascular risk, and android-type obesity. Variables that remained independently associated with LVH were QRS duration, left atrial volume index, troponin T, and hemoglobin A1c. The receiver operating characteristics (ROC) curve analysis of the Sokolow–Lyon index did not show a significant predictive ability to diagnose LVH in the whole study population including all cardiovascular risk classes. The ROC curves analysis of Cornell and Lewis indices showed a modest predictive ability to diagnose LVH in the general population and in a low cardiovascular class. Conclusions: There is a need for new, simple methods to diagnose LVH in the general population in order to properly evaluate cardiovascular risk and introduce optimal medical treatment of concomitant disease.

Echocardiography in Low-Risk Hypertensive Patients

Background

It is debated whether echocardiography should be part of the diagnostic workup in all hypertensive patients. We identified some factors potentially associated with left ventricular hypertrophy (LVH) at echocardiography in untreated hypertensive patients.

Methods and Results

We studied 2150 patients without LVH at ECG. All patients underwent standard 12‐lead ECG and echocardiography. Mean age was 48.7 years, and mean office blood pressure was 154/97 mm Hg. Prevalence of echocardiographic LVH (LV mass >47.0 g/m^2.7 in women and >50.0 g/m^2.7 in men) was 37.1%. We developed a nomogram based on 7 items (age, smoking, body mass index, office systolic and diastolic blood pressure, Cornell voltage, and chronic kidney disease) on the basis of a multivariable logistic regression analysis. We internally validated the model by bootstrap recalibration and obtained a calibration curve to assess agreement in the validation data set. Probability of LVH at echocardiography ranged from <10% (score, ≤100 points) to >90% (score, ≥180 points). Proportion of patients with LVH progressively increased with the total score (χ²=444.8; P<0.001). Prevalence of LVH was <2% and 90% at the lower 5th and upper 95th percentile of its distribution, respectively.

Conclusions

We developed and validated a novel score to assess the probability of LVH at echocardiography in hypertensive patients without LVH at ECG. The score may guide the appropriateness of echocardiographic study in low‐risk hypertensive patients. Echocardiography appears most appropriate for score values >136 in men and >124 in women.

Do Combined Electrocardiographic and Echocardiographic Markers of Left Ventricular Hypertrophy Improve Cardiovascular Risk Estimation?

The authors estimated the risk of cardiovascular mortality associated with echocardiographic (ECHO) left ventricular hypertrophy (LVH) and subtypes of this phenotype in patients with and without electrocardiographic (ECG) LVH. A total of 1691 representatives of the general population were included in the analysis. During a follow-up of 211 months, 89 cardiovascular deaths were recorded. Compared with individuals with neither ECHO LVH nor ECG LVH, fully adjusted risk of cardiovascular mortality increased (hazard ratio [HR], 3.36; 95% confidence interval [CI], 1.51-7.47; P=.003) in patients with both ECHO-LVH and ECG-LVH, whereas the risk entailed by ECHO-LVH alone was of borderline statistical significance (P=.04). Combined concentric nondilated LVH and ECG-LVH, but not concentric nondilated LVH alone, predicted cardiovascular death (HR, 3.79; 95% CI, 1.25-11.38; P=.01). Similar findings were observed for eccentric nondilated LVH (HR, 3.37; 95% CI, 1.05-10.78; P=.04.). The present analysis underlines the value of combining ECG and ECHO in the assessment of cardiovascular prognosis related to abnormal left ventricular geometric patterns.

Recommendations on the Use of Echocardiography in Adult Hypertension: A Report from the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE)

Hypertension remains a major contributor to the global burden of disease. The measurement of blood pressure continues to have pitfalls related to both physiological aspects and acute variation. As the left ventricle (LV) remains one of the main target organs of hypertension, and echocardiographic measures of structure and function carry prognostic information in this setting, the development of a consensus position on the use of echocardiography in this setting is important. Recent developments in the assessment of LV hypertrophy and LV systolic and diastolic function have prompted the preparation of this document. The focus of this work is on the cardiovascular responses to hypertension rather than the diagnosis of secondary hypertension. Sections address the pathophysiology of the cardiac and vascular responses to hypertension, measurement of LV mass, geometry, and function, as well as effects of treatment.

How to identify hypertensive patients at high cardiovascular risk? The role of echocardiography

Scientific authorities recommend that patients with arterial hypertension should be managed not only on the basis of blood pressure (BP) levels, but also on the assemement of total cardiovascular risk. In particular, evaluation of target organ damage (TOD) is of major relevance for identifying hypertensive individuals at high cardiovascular risk independently of clinic BP levels. Evidence of cardiac and extra-cardiac TOD has been consistently associated with worse cardiovascular prognosis. Unfortunately, detection of TOD markedly depends on sensitivity of diagnostic tools, at difference from evaluation of risk factors and associated diseases, usually reliably provided by accurate clinical examination and routine investigation. The purpose of this paper was to provide an updated, comprehensive review on the role of echocardiography in identifying hypertensive patients apparently uncomplicated, but exposed to a high cardiovascular risk due to the presence of subclinical structural and functional cardiac alterations of adverse prognostic significance.

The neglected role of the electrocardiogram in the diagnostic work-up of hypertensive patients: a study in clinical practice

INTRODUCTION

The electrocardiogram (ECG) is listed among the routine diagnostic examinations for hypertensive patients according to international guidelines.

OBJECTIVE

The aim of this survey was to investigate whether an ECG is routinely prescribed before an echocardiographic examination by general practitioners for the evaluation of subclinical cardiac damage in uncomplicated hypertensive patients in a suburban area of Italy.

METHODS

A total of 60 consecutive hypertensive patients (45% men, mean age 60 ± 14 years) referred to a single out-patient cardiology service by their general practitioners for the assessment of cardiac organ damage by echocardiography were enrolled in the study. Patients' demographic data and medical history were collected at the echocardiographic laboratory on a questionnaire administered by the attending physician.

RESULTS

Less than 40% of the study sample had undergone an ECG during the 12-month period preceding the echocardiographic examination. Notably, only 60% of newly diagnosed hypertensive patents had an ECG done after the discovery of their hypertensive status.

CONCLUSIONS

These findings show that an ECG is not routinely prescribed as a first-line examination in the assessment of cardiac organ damage related to hypertension by a large fraction of general practitioners in current clinical practice in a northern area of Italy. This contrasts with available evidence that the combined assessment of left ventricular hypertrophy by ECG and echocardiogram provides the best evaluation of cardiac damage and stratification of cardiovascular risk in hypertension.

Use of diagnostic tests in adolescents with essential hypertension

OBJECTIVE

To describe the use of diagnostic tests in adolescents with essential hypertension.

DESIGN

Longitudinal analysis of administrative claims data.

SETTING

Michigan Medicaid program during 2003 to 2008.

PARTICIPANTS

Adolescents with 3 or more years of Medicaid eligibility (≥ 11 months/y) who had a diagnosis of essential hypertension and 1 or more antihypertensive medication pharmacy claims.

MAIN OUTCOME MEASURES

We examined adolescents' echocardiogram use and compared it with electrocardiogram (EKG) and renal ultrasonography use. We examined timing of the 3 diagnostic tests in relation to the first pharmacy claim. We examined patient demographics and presence of obesity-related comorbidities.

RESULTS

During 2003 to 2008, there were 951 adolescents with essential hypertension who had antihypertensive pharmacy claims; 24% (226) had echocardiograms; 22% (207) had renal ultrasonography; and 50% (478) had EKGs. Males (odds ratio [OR], 1.53; 95% CI, 1.06-2.21), younger adolescents (OR, 1.69; 95% CI, 1.17-2.44), those who had EKGs (OR, 5.79; 95% CI, 4.02-8.36), and those who had renal ultrasonography (OR, 2.22; 95% CI, 1.54-3.20) were more likely to obtain echocardiograms compared with females, older adolescents, and adolescents who did not have EKGs or renal ultrasonography.

CONCLUSIONS

Guideline-recommended diagnostic tests-echocardiograms and renal ultrasonography-were equally poorly used by adolescents with essential hypertension. Sex and age differences exist in the use of echocardiograms by adolescents with essential hypertension. The decision and choice of diagnostic tests to evaluate adolescents with essential hypertension warrant further study to understand the underlying rationale for those decisions and to determine treatment effectiveness.

Cost-effectiveness of electrocardiography vs. electrocardiography plus limited echocardiography to diagnose LVH in young, newly identified, hypertensives

BACKGROUND

In the United States, screening for left ventricular hypertrophy (LVH) in a newly diagnosed hypertensive patient is typically performed using electrocardiography (ECG). Echocardiography (echo) is a more accurate but also more expensive procedure. However, the introduction of limited echo within the past decade has made sonographic imaging of the heart less expensive and more available for routine screening.

METHODS

The cost per additional correct diagnosis of LVH for ECG vs. ECG plus limited echo (with limited echo utilized in patients without ECG evidence of LVH) was analyzed using decision analytic modeling. A structured literature search was used to parameterize model probabilities, and costs are based on the 2008 Medicare Physician Fee Schedule. The study population consisted of black and white cohorts ~50 years of age with new diagnosis of hypertension. Outcomes included short-term results of LVH screening and diagnosis, and the study perspective was health system.

RESULTS

Base-case results indicate each additional correct LVH diagnosis by ECG plus limited echocardiography instead of ECG cost $655 in the black cohort and $829 in the white cohort. Results in both cohorts were most sensitive to the cost of echocardiography. Simulation-generated cost-effectiveness acceptability curves demonstrated costs per additional correct diagnosis have a 90% likelihood of being below $993 and $1,420 in the black and white cohorts, respectively.

CONCLUSIONS

LVH detection by ECG plus limited echocardiography may be an economically feasible alternative to ECG due to increased accuracy. However, final recommendations require analysis of long-term effects on morbidity, mortality, quality of life, and subsequent treatment costs between the diagnostic approaches.

Cardiovascular risk stratification in unselected primary care patients with newly detected arterial hypertension

Cardiovascular risk (CVR) stratification in patients with arterial hypertension is essential. Few data are available on CVR factors (CVRFs), hypertensive target organ damage (TOD) and overall CVR in medical outpatients with newly detected arterial hypertension. General medical patients entering the Medical Outpatient Department of the University Hospital Basel, Switzerland, were screened for elevated office blood pressure (OBP of >140/90 mm Hg). Patients with newly detected arterial hypertension (elevated OBP at two consultations) underwent a work-up that included fundoscopy, urinalysis, ambulatory blood pressure (ABP) monitoring, ECG and echocardiography. CVR was calculated according to the 1999/2003 World Health Organization/International Society of Hypertension (WHO/ISH) guidelines. A total of 2615 outpatients were screened. Of 580 patients with elevated first OPB, 207 were treated for hypertension, 98 refused to participate, 8 were early dropouts and 36 had a normal second OBP. Data from 212 patients were analyzed (mean age 53+/-14 years). The first and second OBP readings were 162+/-6/100+/-6 and 153+/-14/96+/-9 mm Hg, respectively. Mean ABP was 134+/-12/83+/-9 mm Hg, and sustained hypertension was found in 76.9% of patients. Among patients with hypertension according to OPB monitoring, 61.3% had 1 or 2 CVRFs, and 33.0% had >or=3 CVRFs. Evidence of TOD, diabetes or associated clinical conditions (ACCs), such as renal or cardiovascular disease, was found in 26.4, 5.6 and 7.1% of patients, respectively. In terms of CVR, 2.4% of patients were at low risk, 25.9% at medium risk and 71.7% at high risk. No differences existed between white coat and sustained hypertensives regarding CVRFs, TOD or ACCs. Comprehensive analysis in patients with newly detected arterial hypertension revealed a surprisingly high prevalence of CVRFs, TOD and ACCs, indicating high CVR in the majority of these patients.

Echocardiography in clinical practice: the burden of arterial hypertension. A multicenter Italian survey

Little information is available about the burden of hypertension on echo-lab activity in current practice. The aim of the present nation-wide survey in outpatient echo-labs was to investigate the prevalence rates of (1) echo examinations performed for the evaluation of hypertensive cardiac damage; (2) reports providing quantitative data on left ventricular (LV) structure and geometry; (3) LV hypertrophy (LVH) in hypertensives referred to echo labs. The study was carried out in 14 outpatient echo-labs across Italy. Prescriptions written by general practitioners were used to identify the indications for the examinations. Estimates of LVH were derived from original echo reports or were calculated from LV primary measures, when available, with Devereux's formula in a post-analysis. Echo examination was performed in 2449 subjects (1245 men and 1204 women); hypertension was the indication for echo in 745 (30.4%) cases. In this subgroup, LV mass (LVM), LVM indexed to body surface area, LVM indexed to height(2.7) and relative wall thickness ratio were reported in 58, 59, 54 and 52%, respectively. LVH was present in 53% of untreated hypertensives and, among treated patients, in 45 and 65% of those with and without blood pressure control, respectively. Our findings show that (1) hypertension accounts for approximately one-third of echo examinations performed in clinical practice; (2) a large fraction of echo reports do not provide quantitative data on LVM and LV geometry, (3) LVH is highly prevalent in hypertensives referred to echo labs for assessment of cardiac damage.

Carotid atherosclerosis and cardiovascular risk stratification: Role and cost‐effectiveness of echo‐Doppler examination in untreated essential hypertensives

OBJECTIVE

To investigate the impact and cost-effectiveness of carotid ultrasonographic examination on total risk stratification in low-medium risk hypertensive patients in relation to age (< 50 and > 50 years) and gender.

METHODS

Five hundred and eighty untreated hypertensives classified at low-medium risk, after the routine work-up recommended by the 2003 ESH/ ESC guidelines, were included in the study and total risk was reassessed by adding the results of carotid ultrasonography.

RESULTS

According to the stratification based on routine work-up 16.3% of the whole population was considered at low added risk and 83.7% at medium added risk. Carotid subclinical damage was found in 158 patients (27.0%), who were then reclassified in the high-risk stratum. Prevalence rates of patients reclassified in the high-risk stratum as a consequence of carotid damage were as follows: 12.6% in men < 50 years, 14.1% in women < 50 years, 53.0% in men > or = 50 years and 40.1% in women > or = 50 years. The cost per detected case of carotid atherosclerosis was 473 euro in patients < 50 years and 133 euro in those > or = 50 years.

CONCLUSIONS

Our results show that: (i) the use of carotid ultrasonography allows a much more accurate identification of high-risk individuals; (ii) its impact and cost-effectiveness on the risk stratification process differs markedly according to the age and gender; (iii) the selective use of this procedure in subjects at high risk of target organ damage may substantially improve the cost of primary prevention.

Retinal changes and cardiac remodelling in systemic hypertension

The clinical value of left ventricular hypertrophy (LVH), a cardinal manifestation of hypertensive organ damage, in predicting cardiovascular (CV) events, independently of blood pressure (BP) and other accompanying risk factors, has been widely documented and its role in CV stratification indisputability recognized. Although the examination of the fundus oculi provides a unique opportunity to evaluate retinal microvascular abnormalities, which may mirror systemic arteriolar damage due to high BP, no consistent evidence exists, on the prognostic value of mild degrees of retinopathy, encompassing the vast majority of uncomplicated hypertensive subjects. Personal and literature data indicate that: (1) there is a tight association between advanced retinopathy and LVH suggesting the existence of a parallel involvement of retinal tree and cardiac damage in severe untreated or poorly controlled hypertension; (2) in contrast, a firm conclusion about the relationship between early or nonspecific retinal changes (narrowing or arteriovenous crossing) and cardiac damage is not allowed by the majority of the studies; (3) future investigations, based on computer-assisted methods, are further required to document the relation between initial retinal changes with organ damage and more importantly to test their predictive value for clinical outcomes.

Studies on left ventricular hypertrophy regression in arterial hypertension: a clear message for the clinician?

BACKGROUND

Evidence-based medicine should provide clear and unbiased information to clinicians. We conducted an analysis on published randomized trials evaluating the effects of antihypertensive therapy on left ventricular (LV) morphology assessed by echocardiography to investigate (i) the consistency of criteria used for definition of LV hypertrophy (LVH) and (ii) the consistency of the way LVH regression and blood pressure (BP) control were reported.

METHODS

Studies identified by a PubMed search were eligible for inclusion in the analysis, if they fulfilled the following criteria: (i) publication in a peer-reviewed journal within the last 12 years; (ii) double blind, randomized, controlled, parallel-group design; (iii) numerosity of at least 50 adult hypertensive subjects; (iv) follow-up duration of at least 6 months; (v) comparison between single-drugs or association regimens; (vi) LV mass (LVM) or wall thickness measured by echocardiography.

RESULTS

Thirty-nine trials, including 9,162 hypertensive subjects of both genders in 78 active treatment arms or in 6 placebo arms were identified. Definition of LVH was provided by 34 studies (87.1%) according to 19 different criteria. All trials evaluated LVH regression as the absolute or relative changes of continuous variables such as LVM index (LVMI) or LV wall thickness. Data concerning prevalence rates of LVM normalization were reported in 12 studies (30.7%). The percentage of patients reaching BP target (<140/90 mm Hg) was reported in 11 studies (28.2%).

CONCLUSIONS

Our findings indicate that (i) definition of hypertensive LVH phenotype is extremely variable, and (ii) no precise information on LVH regression rates or changes in LV geometrical patterns, as well as on target BP, is provided by the majority of papers.

[High prevalence of left ventricular hypertrophy in patients with hypertension of long course]

BACKGROUND AND OBJECTIVE

Left ventricular hypertrophy (LVH) is the most frequent manifestation of cardiac damage in hypertension. The objective of this study was to evaluate the prevalence of LVH in hypertensive patients of long evolution at Primary Care (PC) and to describe their epidemiological profile.

PATIENTS AND METHOD

915 hypertensive patients treated for more than 5 years with antihypertensive drugs, who were attended in a consecutive way by de PC physicians, were evaluated in a multicentral and descriptive study. Clinical evaluation data together with electrocardiographic (EKG) and laboratory results were recorded. LVH was assessed by the Cornell and/or Sokolow-Lyon criteria.

RESULTS

Study population was characterized by a mean age of 68.7 years, 63% women, 31.6% diabetics, and 37.5% presented controlled blood pressure levels. 30.5% of them presented LVH criteria on EKG, being more prevalent among women, and on the other hand, women with LVH were of a greater age. 30% of patients presented history of cardiovascular disease and heart failure was more frequent among those with LVH. 54% were polymedicated with blood pressure lowering drugs, however there were no differences between groups of patients with and without LVH regarding their treatment. The Cornell criterion and the Sokolow-Lyon criterion alone were presented in a 77% and 12% of patients, respectively, and 11% of them were positive for both criteria. Patients with positivity for only the Cornell criterion were characterized by a greater prevalence of women and obesity.

CONCLUSIONS

The prevalence of LVH assessed by EKG criteria is high among hypertensive population of long evolution. A greater effort is needed to guarantee a periodic EKG performance in hypertensive patients together with a therapeutic strategy improvement.

Intravascular volume dependency of left ventricular mass calculation by two-dimensional guided M-mode echocardiography

BACKGROUND

Increased left ventricular mass (LVM) is an independent risk factor for cardiovascular morbidity and mortality, and may be used for risk stratification. Two-dimensional echocardiography, the most commonly used technique for estimation of LVM, uses the third power of the left ventricular internal diameter (LVID) for the calculation.

OBJECTIVES

To determine whether a decrease in intravascular volume after dialysis may cause inaccurate estimation of LVM by echocardiography.

METHODS

Thirty-eight patients undergoing hemodialysis due to chronic renal failure constituted the study group (14 women [37%] and 24 men [63%], mean age +/- SD 38.7+/-10.9 years). LVID, and interventricular and posterior wall thicknesses were measured by two-dimensionally guided M-mode echocardiography. Stroke volume and cardiac output were calculated using left ventricular outflow tract diameter and the pulsed-wave Doppler time-velocity integral obtained from left ventricular outflow tract. LVM was calculated by using Devereux's formula, and was indexed for body surface area and height. All echocardiographic parameters were measured or calculated before and after dialysis (on the same day), and then compared.

RESULTS

There were no significant changes in wall thickness; however, LVID, LVM, the LVM/body surface index and the LVM/height index significantly decreased after dialysis (P<0.001 for each parameter). There was a significant correlation between the change in LVID and the change in LVM (P<0.001, r=0.59). Stroke volume and cardiac output also decreased significantly after hemodialysis (P<0.001 for each parameter).

CONCLUSIONS

Intravascular volume-dependent change in LVID causes inaccurate estimation of LVM, so volume status should be kept in mind, especially in serial assessment of LVM.

Intensive cardiovascular examination regarding blood pressure levels: evaluation of risk groups. ICEBERG study

OBJECTIVE

Assessment of total cardiovascular risk level is crucial for approaching hypertensive patients. Therefore, the aim of the Intensive/Initial Cardiovascular Examination regarding Blood pressure levels: Evaluation of Risk Groups (ICEBERG) study is to determine cardiovascular risk evaluation and stratification of subjects with high normal and high blood pressure (BP > or = 130/85 mmHg), and to evaluate the impact of laboratory tests on this stratification.

METHODS

ICEBERG was an epidemiological study conducted at 20 university hospitals and 197 primary healthcare centers. A total of 10,313 patients, who were diagnosed with high BP and under antihypertensive treatment or not antihypertensive under treatment at least for the last 3 months were selected. Besides routine clinical evaluation, microalbuminuria (MAU) and high sensitive C-reactive protein (hs-CRP) tests, echocardiography (Echo) and carotid ultrasonography (USG) were performed in selected arms. The patients were stratified into low, moderate, high and very high added risk groups as described by the European Society of Hypertension/European Society of Cardiology Guidelines Committee (2003).

RESULTS

Upon routine evaluation, the percentage of "high and very high added cardiovascular risk" groups was between 51.2% and 60.7% in different study arms. This percentage increased to 62.9% by subsequent serum biochemistry assessment and to 76.2% by hs-CRP test results. Switching upwards to "high and very high added risk" groups was around 6% when MAU results were used, with a 4.9% upwards switch to "high and very high added risk" groups when Echo was performed; this proportion increased by 6.8%, when carotid USG was taken into account.

CONCLUSION

Cardiovascular risk evaluation by intensive cardiovascular examination including Echo and carotid USG provided more accurate risk stratification. Furthermore, a simple test to demonstrate presence of MAU usable at primary healthcare level will also help to evaluate the patient's risk profile better than routine assessment methods alone.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

C-reactive protein and echocardiography have little impact on risk stratification in never-treated hypertensive patients

The aim of this study was to assess the contribution of increased concentrations of high-sensitivity C-reactive protein (hsCRP) and echocardiography to risk stratification according to the 2003 European guidelines for the management of arterial hypertension in patients with untreated hypertension. A total of 207 consecutive medical outpatients with untreated hypertension were included. History and clinical examination, electrocardiography, laboratory analyses including the measurement of hsCRP and echocardiography were performed in all patients. Patients were classified into four risk groups with and without using echocardiography and hsCRP concentrations of at least 10 mg/l according to the 2003 guidelines for the management of hypertension. The majority of the 207 patients (81%) were at moderate or high cardiovascular risk before adding echocardiography and/or hsCRP to the risk stratification process. When echocardiography was included, only three patients were reclassified from the moderate added risk to the high added risk group. Adding hsCRP concentrations of at least 10 mg/l had no impact on risk stratification. Using an hsCRP cutoff level of 3 mg/l, one patient was at moderate instead of low added risk, eight patients were at high instead of moderate added risk and one patient was at very high instead of high added risk. We conclude that hsCRP at the proposed cutoff level of 10 mg/l has no impact on risk stratification in outpatients with untreated hypertension. An hsCRP cutoff level of 3 mg/l may be more suitable for risk stratification. Finally, our data suggest that depending on the population studied, there is minimal impact of echocardiography on risk stratification.

Should we perform an echocardiogram in hypertensive patients classified as having low and medium risk?

BACKGROUND

Left ventricular hypertrophy is an important predictor of cardiovascular risk and its detection contributes to risk stratification. However, echocardiography is not a routine procedure and electrocardiography (ECG) underestimates its prevalence.

OBJECTIVE

To evaluate the prevalence of echocardiographic left ventricular hypertrophy in low and medium risk non-treated hypertensive subjects, in order to find out the percentage of them who would be reclassified as high risk patients.

METHODS

Cross-sectional, multicenter study was performed in hospital located hypertension units. An echocardiogram was performed in 197 previously untreated hypertensive patients, > 18 years, classified as having low (61%) or medium (39%) risk, according to the OMS/ISH classification. The presence of left ventricular hypertrophy was considered if left ventricular mass index was > or = 134 or 110 g/m(2) in men and women, respectively (Devereux criteria). A logistic regression analysis was performed to identify factors associated to left ventricular hypertrophy.

RESULTS

The prevalence of left ventricular hypertrophy was 23.9% (95% CI:17.9-29.9), 25.6% in men and 22.6% in women. In the low risk group its prevalence was 20.7% and in medium risk group 29.5%. Factors associated to left ventricular hypertrophy were: years since the diagnosis of hypertension, OR:1.1 (95% CI:1.003-1.227); systolic blood pressure, OR:1.08 (95% CI:1.029-1.138); diastolic blood pressure, OR:0.9 (95% CI:0.882-0.991); and family history of cardiovascular disease, OR:4.3 (95% CI:1.52-12.18).

CONCLUSIONS

These findings underline the importance of performing an echocardiogram in low and high risk untreated hypertensive patients in which treatment would otherwise be delayed for even one year.

High pulse pressure as a marker of preclinical cardiovascular disease

Increasing attention has been focused on the pathophysiology and prognostic relevance of increased pulse pressure. High systolic pressure increases vascular load whereas low diastolic pressure reduces coronary perfusion pressure, both of which provide pathophysiological explanations for the prognostic value of pulse pressure. In a recent study we have demonstrated that in the presence of either normal or high peripheral resistance, brachial pulse pressure is associated with an increase in left ventricular mass and in arterial stiffness. As indicated in our study, a brachial pulse pressure over 63 mmHg represents a sign of established cardiovascular damage in the setting of arterial hypertension. Accordingly, we suggest elevated brachial pulse pressure should be considered a marker of established preclinical cardiovascular disease rather than a risk factor for the development of arterial disease.

Influence of target organ lesion detection (assessment of microalbuminuria and echocardiogram) in cardiovascular risk stratification and treatment of untreated hypertensive patients

European guidelines indicate the importance of the evaluation of global cardiovascular risk (CVR) to determine the management of the hypertensive patients (EH). However, in primary care, the diagnostic work-up (PCD) only includes the metabolic risk factors. The aim of this study was to assess the importance of microalbuminuria (MA) and echocardiogram (ECHO) in the process of risk stratification, and the number of patients to be treated with drugs at diagnosis. In total, 155 nontreated EH were included in the study. Blood pressure, a lipid profile and plasma glucose (LG) were determined after an overnight fast. MA was evaluated with dipstick MICRALTEST, and in those patients with two positive results, it was measured again in two 24-h urine samples and was considered positive (MA+) if the average was >30 mg/24 h. Left ventricular mass index was calculated and values>125 g/m2 were considered as LV hypertrophy (LVH+). When the patients were stratified according to PCD, 22 had to be treated with drugs. When MA, ECHO and both tests used together were added to the risk evaluation, the number of patients to be treated were 42, 51 and 64, respectively (P<0.001 vs PCD). It is mainly in patients who have moderate cardiovascular risk that risk changes, whereas risk hardly changes in those having low and very high risk. In conclusion, in EH with moderate risk, measurement of MA, due to its easy availability and low cost, seems to be a cost effective screening test to avoid the underestimation of the CVR.

Cardiac structural and functional changes during long-term antihypertensive treatment with lacidipine and atenolol in the European Lacidipine Study on Atherosclerosis (ELSA)

OBJECTIVES

To evaluate and correlate the effects of long-term antihypertensive treatment on left ventricular (LV) mass and carotid structural changes in a large group of essential hypertensive patients, participating in the European Lacidipine Study on Atherosclerosis (ELSA).

DESIGN

In four (Brescia, Glasgow, Naples and Pisa) of 23 centres participating in the ELSA study, an echocardiographic examination was performed at baseline and repeated, until the end of the 4-year study, in essential hypertensive patients, followed-up for carotid quantitative ultrasound examination of intima-media thickness (IMT), after random allocation to treatment with either lacidipine or atenolol (and added hydrochlorothiazide, as required for control of blood pressure).

METHODS

M-mode, two-dimensional guided echocardiography was used to measure left ventricular (LV) wall thickness and dimensions, from which LV mass was calculated, using an anatomically validated formula (Penn Convention) and indexed to body surface area (left ventricular mass index, LVMI). The echocardiographic tracings were blindly evaluated in a single reading centre (Brescia). Bilateral IMT was measured at the site of common carotid and bifurcation far walls (CBMmax).

RESULTS

At baseline, cardiac and carotid ultrasound scans were available in 278 patients (mean age 54 +/- 7 years, 57% males, 22% obese). A significant correlation was observed between baseline LVMI and CBMmax (r = 0.22, P < 0.001), independent of age. In multivariate analysis, CBMmax and mean 24-h pulse pressure were most strongly associated with baseline LVMI. A significant reduction in LVMI was observed both during lacidipine (n = 96) (-12.5% reduction) and atenolol (n = 78) (-13.9% reduction) treatments (up to 4 years) (P < 0.001 for both, without significant differences between treatments). Changes in LVMI were not related to changes in carotid wall thickness. In multivariate analysis, baseline LV mass and mean 24-h systolic blood pressure changes were significantly associated with changes in LV mass.

CONCLUSIONS

In this large, long-term controlled study, antihypertensive treatment with atenolol or lacidipine was accompanied by a similar and significant decrease in LV mass. Treatment-induced changes in LV mass were related to baseline LV mass and changes in 24-h mean systolic blood pressure, without any correlation with changes in carotid structure. In the whole ELSA population, carotid IMT changes have been shown to be unrelated to blood pressure reduction, but significantly influenced by the type of antihypertensive treatment.

Hypertensive retinopathy: there's more than meets the eye

Hypertension is associated with increased cardiovascular risk, leading to systemic end-organ damage, including retinopathy. However, the recent European Society of Hypertension-European Society of Cardiology and World Health Organization-International Society of Hypertension 2003 guidelines propose new prognostic indications for the classification of hypertensive retinopathy. In particular, grades I and II are no longer included among signs of end-organ damage, and only grades III and IV are retained as associated clinical conditions for the stratification of global cardiovascular risk. This review article will focus on the wider implications of clinical markers of microvascular damage in the retina, with specific reference to hypertension and end-organ damage. Early recognition of retinal changes remains an important step in the risk stratification of hypertensive patients.

Relationship between left ventricular geometry and left atrial size and function in patients with systemic hypertension

BACKGROUND

Arterial hypertension determines distinct adaptive left ventricular geometric responses, which may differently affect left ventricular function and left atrial performance.

OBJECTIVES

In this study, the effect of left ventricular geometry on left atrial size and function, and the relationship between left atrial size and left ventricular mass were assessed in 336 patients with systemic arterial hypertension who had undergone Doppler echocardiography.

METHODS AND RESULTS

Patients were classified into concentric (110 patients with concentric left ventricular geometry defined as relative wall thickness > or = 0.44) and eccentric groups (226 patients with relative wall thickness < 0.44). Comparison to the latter, the former had greater left atrial size, left atrial ejection force, left ventricular mass and lower left ventricular midwall fractional shortening. Left ventricular concentric, rather than eccentric, geometry emerged by multivariate analysis as a factor independently associated with the highest degree of left atrial ejection force. Left atrial size was positively related to left ventricular mass in the whole population (r = 0.65, SEE = 6 ml, P < 0.00001). This relationship was maintained in the subgroups with concentric (r = 0.65, SEE = 6 ml, P < 0.00001) or eccentric geometry (r = 0.59, SEE = 6 ml, P < 0.00001).

CONCLUSIONS

Our results indicate that the relationship of left ventricular geometry to both left atrial size and ejection force in hypertensive patients is relevant. Concentric left ventricular geometry is associated with greater left atrial size and ejection force than eccentric geometry, suggesting that increased left ventricular stiffness has a greater effect in stimulating left atrial performance than left ventricular end-systolic stress. The degree of left atrial enlargement similarly depends on left ventricular mass in patients with concentric and eccentric geometry.

Usefulness of microalbuminuria in cardiovascular risk stratification of essential hypertensive patients

BACKGROUND/AIMS

To evaluate the influence of microalbuminuria (albumin excretion rate--AER) determination and echocardiography (ECHO) on cardiovascular risk stratification, initially performed according the 1999 WHO/ISH guidelines by using only routine diagnostic procedures with or without fundal examination.

METHODS

312 essential hypertensives attending our institution were studied retrospectively. Cardiovascular risk was assessed in a semiquantitative way using four categories of absolute cardiovascular disease risk (low, medium, high and very high risk), as proposed by the 1999 WHO/ISH guidelines, on the basis of data on the average 10-year risk of cardiovascular events among participants in the Framingham Study.

RESULTS

Without the retinal data, estimating the level of global cardiovascular risk on the basis of routine work-up alone, 14% were classified as low-risk patients, 48% were as medium-risk, 20% as high-risk and 18% at very-high-risk patients. The combined use of AER and ECHO, in line with the newer ESH-ESC guidelines, determined a statistically significant reclassification of the hypertensive patients. Only 10% remained in the low-risk category, 28% were classified in the medium-, 42% in the high- and 20% in the very-high-risk classes. The overall percentage of patients that changed risk stratum (mostly shifting from the medium- to the high-risk class) was significantly different from the proportion of subjects reclassified after the addition of either microalbuminuria or echocardiography alone. No change in the distribution of risk categories was observed when AER assay and ECHO were added to routine procedures including funduscopic examination.

CONCLUSIONS

Considering the questionable prognostic value of qualitative retinal examination, our results suggest that cardiovascular risk evaluation based only on simple routine work-up, ignoring the information provided by AER determination and ECHO, may underestimate the level of absolute risk.

Risk stratification by guidelines compared with risk assessment by risk equations applied to a MONICA sample

BACKGROUND

The World Health Organization/International Society of Hypertension (WHO/ISH) Hypertension Guidelines from 1999 propose a risk stratification scheme for estimating absolute risk for cardiovascular disease (CVD). Risk equations estimated by statistical methods are another way of predicting cardiovascular risk.

OBJECTIVE

We studied the differences between these two approaches when applied to the same set of individuals with high blood pressure.

DESIGN AND METHODS

The two northernmost counties in Sweden (NSW) constitute one of the centres in the WHO MONICA (monitoring trends and determinants in cardiovascular disease) Project. Three population surveys have been carried out in 1986, 1990 and 1994, and were used to estimate a risk equation for predicting the 10-year risk of fatal/non-fatal stroke and myocardial infarction. Another MONICA sample from 1999, a total of 5997 subjects, was classified according to the recent WHO/ISH risk stratification scheme. A risk assessment was also performed, by using the risk equations from the NSW MONICA sample and Framingham risk equations.

RESULTS

The agreement between the two methods was good when the values obtained from the risk equation were averaged for each risk group obtained from the risk classification by guidelines. However, if the predicted risk for each individual was considered, the agreement was poor for the medium and high-risk groups. Although the average risk for all individuals is the same, many subjects have a higher risk or a lower risk than predicted by guidelines.

CONCLUSIONS

Risk classification by the 1999 WHO/ISH Hypertension Guidelines is not accurate and detailed enough for medium- and high-risk patients, which could be of clinical importance in the medium risk group.

Change in cardiovascular risk profile by echocardiography in medium-risk elderly hypertensives

It has been clearly demonstrated that ageing and arterial hypertension are both associated with an increased prevalence of left ventricular hypertrophy (LVH), which is a powerful risk factor for cardiovascular (CV) events. The objective of this study was to assess the impact of echocardiographic LVH in profiling the absolute CV risk stratification according to the 1999 World Health Organization-International Society of Hypertension (WHO/ISH) guidelines in elderly hypertensive patients. A total of 223 never-treated elderly patients (> or =65 years) with essential hypertension (98 men, 125 women, mean age 72+/-5 years) referred to our outpatient hospital clinic were included in the study. They underwent the following procedures: (1) medical history, physical examination, and clinic blood pressure; (2) routine blood chemistry and urine analysis and (3) electrocardiogram. The risk was initially stratified according to the routine procedures suggested by WHO/ISH guidelines and subsequently reassessed by adding the results of echocardiography (LVH as left ventricular mass index >51 g/m(2.7) in men and >47g/m(2.7) in women). According to routine classification, 56% (n=125) were medium-risk patients, 29% (64) high-risk and 15% (34) very-high-risk patients. The overall prevalence of LVH was 56% (48% in medium-risk and 62% in high-risk or very-high-risk patients, P<0.01). A marked change in risk stratification was observed when echocardiographic LVH was taken into consideration: medium-risk patients decreased to 29% and high-risk patients rose to 56% (P<0.01). In conclusion, ultrasound assessment of cardiac target organ damage is extremely useful in obtaining a more valid assessment of global cardiovascular risk in elderly hypertensives, because stratification based on diagnostic routine procedures can underestimate the overall risk in a large fraction (48%) of medium-risk subjects.