Impact of overweight and obesity on cardiac benefit of antihypertensive treatment

Concomitant hypertension is associated with abnormal left ventricular geometry and lower systolic myocardial function in overweight participants: the FAT associated CardiOvasculaR dysfunction study

OBJECTIVE

We studied the impact of concomitant hypertension on left ventricular (LV) systolic myocardial function and geometry in apparently healthy women and men with increased BMI.

MATERIAL AND METHODS

We performed a cross-sectional analysis of 535 participants (59% women) with BMI greater than 27 kg/m without known cardiovascular disease enrolled in the FAT associated CardiOvasculaR dysfunction (FATCOR) study. Hypertension was defined as use of antihypertensive treatment or elevated 24-h ambulatory blood pressure. Abnormal LV geometry was identified as increased relative wall thickness and/or LV mass index. Systolic myocardial function was assessed by midwall shortening (MWS) and speckle tracking peak global longitudinal strain (GLS).

RESULTS

Hypertensive participants were older (49 vs. 46 years), had higher BMI and waist circumference, higher prevalences of diabetes and abnormal LV geometry (29 vs. 16%), and lower GLS (-19 vs. -20%) and MWS (16.3 vs. 17.1%) compared with normotensive participants (all P < 0.01). In multivariable linear regression analyses, hypertension was associated with lower GLS (β=0.11, P = 0.035) and lower MWS (β=0.09, P = 0.029) independent of sex, diabetes, LV hypertrophy, ejection fraction, and waist circumference. Hypertension was also associated with presence of abnormal LV geometry [odds ratio 1.74 (95% confidence interval 1.04-2.89), P = 0.035) independent of the same confounders. When replacing waist circumference with BMI in the models, hypertension retained its association with lower myocardial function, whereas the association with abnormal LV geometry was attenuated.

CONCLUSION

In participants with increased BMI without known clinical cardiovascular disease, concomitant hypertension was associated with lower systolic myocardial function and more abnormal LV geometry.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov NCT02805478.

Obesity cardiomyopathy: evidence, mechanisms, and therapeutic implications

The prevalence of heart failure is on the rise and imposes a major health threat, in part, due to the rapidly increased prevalence of overweight and obesity. To this point, epidemiological, clinical, and experimental evidence supports the existence of a unique disease entity termed “obesity cardiomyopathy,” which develops independent of hypertension, coronary heart disease, and other heart diseases. Our contemporary review evaluates the evidence for this pathological condition, examines putative responsible mechanisms, and discusses therapeutic options for this disorder. Clinical findings have consolidated the presence of left ventricular dysfunction in obesity. Experimental investigations have uncovered pathophysiological changes in myocardial structure and function in genetically predisposed and diet-induced obesity. Indeed, contemporary evidence consolidates a wide array of cellular and molecular mechanisms underlying the etiology of obesity cardiomyopathy including adipose tissue dysfunction, systemic inflammation, metabolic disturbances (insulin resistance, abnormal glucose transport, spillover of free fatty acids, lipotoxicity, and amino acid derangement), altered intracellular especially mitochondrial Ca²⁺ homeostasis, oxidative stress, autophagy/mitophagy defect, myocardial fibrosis, dampened coronary flow reserve, coronary microvascular disease (microangiopathy), and endothelial impairment. Given the important role of obesity in the increased risk of heart failure, especially that with preserved systolic function and the recent rises in COVID-19-associated cardiovascular mortality, this review should provide compelling evidence for the presence of obesity cardiomyopathy, independent of various comorbid conditions, underlying mechanisms, and offer new insights into potential therapeutic approaches (pharmacological and lifestyle modification) for the clinical management of obesity cardiomyopathy.

Left ventricular myocardial oxygen demand and subclinical dysfunction in patients with severe obesity referred for bariatric surgery

BACKGROUND AND AIMS

Increased myocardial oxygen (O₂) demand carries higher cardiovascular risk in hypertension. We hypothesized that myocardial O₂ demand is increased in severe obesity and linked to early left ventricular (LV) dysfunction.

METHODS AND RESULTS

Baseline data from 106 severely obese subjects referred for gastric bypass surgery (42 ± 11 years, 74% women, body mass index [BMI] 41.9 ± 4.8 kg/m², 32% with hypertension) in the prospective FatWest (Bariatric Surgery on the West Coast of Norway) study was used. LV systolic function was assessed by biplane ejection fraction (EF), midwall shortening (MWS) and endocardial global longitudinal strain (GLS), and LV diastolic function by mitral annular early diastolic velocity (e'). Myocardial O₂ demand was estimated from the LV mass-wall stress-heart rate product (high if > 1.62 × 10⁶/2.29 × 10⁶ g kdyne/cm² bpm in women/men). High myocardial O₂ demand was found in 33% and associated with higher BMI and high prevalence of low GLS (65%) and low MWS (63%) despite normal EF. In ROC analyses, higher myocardial O₂ demand discriminated between patients with low vs. normal MWS and GLS (area under curve 0.71 and 0.63, p < 0.05). In successive multiple regression analyses, higher myocardial O₂ demand was associated with lower LV MWS, GLS and average e', respectively, independent of age, gender, BMI, pulse pressure, diabetes mellitus, and EF (all p < 0.05).

CONCLUSION

In obese patients without known heart disease and with normal EF referred for bariatric surgery, high myocardial O₂ demand is associated with lower myocardial function whether assessed by GLS or MWS independent of confounders. CLINICALTRIALS.

GOV IDENTIFIER

NCT01533142.

The Impact of Obesity on Left Ventricular Hypertrophy and Diastolic Function in Caucasian Children

Background: Left ventricular hypertrophy (LVH) and diastolic dysfunction are correlated with obesity and hypertension in adult patients, but few studies have investigated the association between obesity itself and left ventricular function in children. The aim of this study was to evaluate the effect of obesity and LVH on left ventricular diastolic function in pediatric subjects compared with children without obesity. Methods: A number of 454 patients from an outpatient cardiology service were enrolled in a prospective study, 33 children with obesity, 20 overweight children, and 401 children without obesity. The subjects were assigned to three groups according to age and school grade. A standardized two-dimensional echocardiography analysis was performed in all children. The evaluated echocardiographic parameters included thickness of the interventricular septum (IVS), thickness of the posterior wall of the left ventricle, and left atrium size. The left ventricular diastolic function was analyzed by the classic pulsed-wave Doppler technique, tissue Doppler technique, and continuous Doppler technique. Results: The number of children with obesity was higher in the school and adolescent groups. The median age of children with obesity was 9 years. The subjects were classified according to blood pressure values in hypertensive, with high-normal blood pressure/prehypertension and with normal blood pressure values. Standard echocardiography showed that children with obesity had significantly increased thickness of the IVS and of the posterior wall compared with nonobesity subjects (P < 0.001). Left ventricular systolic function was preserved in both groups. Diastolic function was normal in the obesity group and in the non-obesity group, respectively. Conclusions: The results of this study demonstrate that childhood obesity is associated with significant changes in the myocardial structure consisting of LVH, but we did not find an early alteration in the left ventricular diastolic function of the subjects with obesity compared with patients with a normal weight.

Adiposity, Sex, and Cardiovascular Disease Risk in Children With CKD: A Longitudinal Study of Youth Enrolled in the Chronic Kidney Disease in Children (CKiD) Study

RATIONALE & OBJECTIVE

Traditional and nontraditional cardiovascular disease risk factors are highly prevalent in children with chronic kidney disease (CKD). We examined the longitudinal association of adiposity with cardiac damage among children with CKD and explored whether this association was modified by sex.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

Children with mild-to-moderate CKD enrolled in the Chronic Kidney Disease in Children (CKiD) Study at 49 pediatric nephrology centers across North America.

EXPOSURE

Age- and sex-specific body mass index (BMI) z score.

OUTCOME

Age- and sex-specific left ventricular mass index (LVMI) z score and left ventricular hypertrophy (LVH).

ANALYTICAL APPROACH

Longitudinal analyses using mixed-effects models to estimate sex-specific associations of BMI z scores with LVMI z score and with LVH, accounting for repeated measurements over time.

RESULTS

Among 725 children with 2,829 person-years of follow-up, median age was 11.0 years and median estimated glomerular filtration rate was 52.6mL/min/1.73m2. Nearly one-third of both boys and girls were overweight or obese, median LVMI z score was 0.18 (IQR: -0.67, 1.08), and 11% had LVH. Greater BMI z scores were independently associated with greater LVMI z scores and greater odds of LVH. For each 1-unit higher BMI z score, LVMI z score was 0.24 (95% CI, 0.17-0.31) higher in boys and 0.38 (95% CI, 0.29-0.47) higher in girls (Pinteraction = 0.01). For each 1-unit higher BMI z score, the odds of LVH was 1.5-fold (95% CI, 1.1-2.1) higher in boys and 3.1-fold (95% CI, 1.8-4.4) higher in girls (Pinteraction = 0.005).

LIMITATIONS

Not all children had repeated measurements. LVH is a surrogate and not a hard cardiac outcome. The observational design limits causal inference.

CONCLUSIONS

In children, adiposity is independently associated with the markers of cardiac damage, LVMI z score and LVH. This association is stronger among girls than boys. Pediatric overweight and obesity may therefore have a substantial impact on cardiovascular risk among children with CKD.

Discrepancies Between BMI and Classic Cardiovascular Risk Factors

BACKGROUND

Obesity is related to increased cardiovascular risk. It is unknown whether increasing levels of obesity also increase levels of cardiovascular risk factors and systemic inflammation. This study describes the relationship between classic cardiovascular risk factors and inflammatory markers with BMI in a group of obese and non-obese subjects.

MATERIALS AND METHODS

Obese subjects (BMI ≥ 30 kg/m²; n = 576; mean ± SD BMI 43.8 ± 7.58 kg/m²) scheduled for bariatric surgery were included. The reference population consisted of non-obese volunteers (BMI < 30 kg/m²; n = 377, BMI 25.0 ± 2.81 kg/m²). The relationship between BMI quintiles and the levels of cardiovascular risk factors was analyzed. Adipose tissue volumetry was performed in 42 obese subjects using abdominal CT scans.

RESULTS

The obese group included more women and subjects with type 2 diabetes mellitus, hypertension, and current smoking behavior. In obese subjects, HDL-C and triglycerides decreased with increasing BMI. Systolic and diastolic blood pressure, total cholesterol, LDL-C, and apoB were not related to BMI in the obese group, in contrast to the non-obese group. Inflammatory markers CRP, leukocyte count, and serum complement C3 increased with increasing BMI in the obese group, while these relations were less clear in the non-obese group. The subcutaneous adipose tissue surface was positively correlated to BMI, while no correlation was observed between BMI and visceral adipose tissue.

CONCLUSIONS

Markers of inflammation are strongest related to BMI in obese subjects, most likely due to increased adipose tissue mass, while cardiovascular risk factors do not seem to deteriorate above a certain BMI level. Limited expansion capacity of visceral adipose tissue may explain these findings.

Effect of fitness on cardiac structure and function in overweight and obesity (the FATCOR study)

BACKGROUND AND AIMS

Obesity is associated with reduced left ventricular (LV) systolic myocardial function. We aimed to explore by means of a cross-sectional study whether this effect is offset in the presence of good fitness.

METHODS AND RESULTS

We studied clinical and echocardiographic data from 469 overweight (body mass index [BMI] >27 kg/m²) and obese (BMI ≥30 kg/m²) women and men without known cardiovascular (CV) disease in the FAT associated CardiOvasculaR dysfunction (FATCOR) study. The participants were grouped according to obesity and sex- and age adjusted peak oxygen uptake, obtained by ergospirometry. LV systolic myocardial function was assessed by peak systolic global longitudinal strain (GLS) measured by speckle tracking echocardiography. The association of fitness with GLS was tested in logistic regression analyses and reported as odds ratio (OR) with 95% confidence interval (CI). In the total study population, participants were 47 years old, 60% were women, and mean BMI was 32.0 kg/m². GLS did not differ between fit and unfit subjects within the overweight and obese groups (both p > 0.05), but the overweight fit group had higher GLS (more negative value) compared to the obese unfit group (-20.1 ± 2.6 vs. -19.0 ± 3.0, p < 0.05). In obese subjects, fitness was associated with higher GLS (OR 0.88 [95% CI 0.79-0.99, p < 0.05) in multivariable logistic regression analysis, independent of significant associations with higher arterial stiffness and lower fat percentage (all p < 0.05). In the overweight group, fitness was not significantly associated with GLS.

CONCLUSION

In obesity, fitness was independently associated with higher GLS, while no association was found in overweight.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.govNCT02805478.

Weight loss facilitates reduction of left ventricular mass in obese hypertensive patients: The Campania Salute Network

BACKGROUND AND AIMS

Reduction of left ventricular mass index (LVMi) during antihypertensive treatment is less likely to occur in obese subjects. The aim of the study was to assess whether weight loss influences reduction of LVMi in treated, obese, hypertensive patients.

METHODS AND RESULTS

From the Campania Salute Network registry, we identified 1546 obese hypertensive patients (50 ± 9 years, 43% women) with more than 12 months follow-up. Echocardiographic reduction of LVMi was considered as achievement of normal values (<47 g/m^2.7 in women or <50 g/m^2.7 in men) or a reduction of ≥10% during follow-up. Weight loss was considered as ≥5% reduction in body weight, and occurred in 403 patients (26%) during a median follow-up of 50 months (IQrange:31-93). Median weight loss was 8.6% (IQrange:6.5-12). Patients with weight loss had higher baseline body mass index (p < 0.05), while there was no difference in age, sex, duration of hypertension, prevalence of diabetes, metabolic syndrome and average blood pressure during follow-up. During follow-up, 152 patients (9.8%) exhibited reduction of LVMi. Reduction of LVMi was more frequent (12.9% vs 9.1%, p < 0.030) in patients losing weight than in those who did not. In logistic regression analysis, weight loss was associated with reduction of left ventricular mass index (OR 1.51 [95%CI 1.02-2.23], p = 0.039), independent of significant associations with younger age, lower average systolic blood pressure during follow-up, longer follow-up time and higher LVMi at baseline.

CONCLUSION

In treated obese hypertensive patients, weight loss during follow-up promotes significant reduction of LVMi, independent of baseline characteristics and blood pressure control.

Left ventricular hypertrophy offsets the sex difference in cardiovascular risk (the Campania Salute Network)

BACKGROUND

In general, women have lower risk for cardiovascular disease. We tested whether this sex-specific protection persists also in the presence of hypertensive left ventricular hypertrophy (LVH).

METHODS

12,329 women and men with hypertension and free from prevalent cardiovascular disease enrolled in the prospective Campania Salute Network registry were followed over a median of 4.1years. Subjects were grouped according to the absence or the presence of LVH identified by echocardiography using validated sex-specific cut-off values of LV mass index (>47g/m^2.7 in women and >50g/m^2.7 in men). Main outcome was major cardiovascular events (MACE; combined acute coronary syndromes, stroke, hospitalization for heart failure and incident atrial fibrillation).

RESULTS

The cardiovascular risk profile accompanying LVH did not differ between sexes, but presence of obesity and diabetes carried higher probability for LVH in women, and LVH was more prevalent in women than men (43.4 vs. 32.1%, p<0.001). Among patients without LVH (n=7764), women had a 35% lower hazard rate (HR) for MACE (n=179) than men (95% confidence interval [CI] 0.44-0.96, p=0.031) in Cox regression analysis adjusting for cardiovascular risk factors and antihypertensive treatment during follow up. In contrast, among patients with LVH (n=4565), women had a similar HR for MACE as men (HR 0.94 [95% CI 0.69-1.30], p=0.720).

CONCLUSION

This study demonstrates that presence of LVH in hypertension offsets the female sex-protection in cardiovascular risk. Thus among hypertensive subjects with LVH, women and men have comparable cardiovascular risk.

Sex differences in subclinical cardiac disease in overweight and obesity (the FATCOR study)

BACKGROUND AND AIMS

Subclinical cardiac disease, like abnormal left ventricular (LV) geometry or left atrial (LA) dilatation, is common in obesity. Less is known about sex differences in the prevalence and type of subclinical cardiac disease in obesity.

METHODS AND RESULTS

Clinical and echocardiographic data from 581 women and men without established cardiovascular disease and body mass index (BMI) > 27.0 kg/m² participating in the FAT associated CardiOvasculaR dysfunction (FATCOR) study was analyzed. LA dilatation was recognized as LA volume indexed for height² ≥16.5 ml/m² in women and ≥18.5 ml/m² in men, and abnormal LV geometry as LV hypertrophy and/or increased relative wall thickness. On average, the participants were 48 years old, 60% women and mean BMI was 32.1 kg/m². Overall, the prevalence of subclinical cardiac disease was higher in women than men (77% vs. 62%, p < 0.001). Women had a higher prevalence of LA dilatation than men (74% vs. 56%, p < 0.001), while men had a higher prevalence of abnormal LV geometry (30% vs. 21%, p = 0.011). After adjusting for confounders in multivariable logistic regression analysis, female sex was associated with a 2-fold higher risk of subclinical cardiac disease, in particular LA dilatation (confidence interval [CI] 1.67-3.49, p < 0.001), while male sex was associated with a 2-fold higher risk of abnormal LV geometry (CI 1.30-3.01, p = 0.001).

CONCLUSION

The majority of overweight and obese participants in the FATCOR study had subclinical cardiac disease, which may contribute to the impaired prognosis observed in obesity. Women had a higher prevalence of subclinical cardiac disease than men.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.govNCT02805478.

Ankylosing Spondylitis Is Associated with Increased Prevalence of Left Ventricular Hypertrophy

OBJECTIVE

Ankylosing spondylitis (AS) is associated with increased risk for cardiovascular disease (CVD). Left ventricular (LV) hypertrophy is a strong precursor for clinical CVD. The aim of our study was to assess whether having AS was associated with increased prevalence of LV hypertrophy.

METHODS

Clinical and echocardiographic data from 139 AS patients and 126 age- and sex-matched controls was used. LV mass was calculated according to guidelines and indexed to height^2.7. LV hypertrophy was considered present if LV mass index was > 49.2 g/m^2.7 in men and > 46.7 g/m^2.7 in women.

RESULTS

Patients with AS were on average 49 ± 12 years old, and 60% were men. The prevalence of hypertension (HTN; 35% vs 41%) and diabetes (5% vs 2%) was similar among patients and controls, while patients with AS had higher serum C-reactive protein level (CRP; p < 0.001). The prevalence of LV hypertrophy was higher in patients with AS compared to controls (15% vs 6%, p = 0.01). In multivariable logistic regression analysis, having AS was associated with OR 6.3 (95% CI 2.1-19.3, p = 0.001) of having LV hypertrophy independent of the presence of HTN, diabetes, and obesity. In multivariable linear regression analyses, having AS was also associated with higher LV mass (β 0.15, p = 0.007) after adjusting for CVD risk factors including sex, body mass index, systolic blood pressure, diabetes, and serum CRP (multiple R² = 0.41, p < 0.001).

CONCLUSION

Having AS was associated with increased prevalence of LV hypertrophy independent of CVD risk factors. This finding strengthens the indication for thorough CVD risk assessment in patients with AS.

Differential effect of obesity on prevalence of cardiac and carotid target organ damage in hypertension (the Campania Salute Network)

BACKGROUND

Whether increasing body mass index (BMI) is independently associated with parallel increased prevalence of hypertensive vascular and cardiac target organ damage (TOD) needs further clarification.

METHODS

We analyzed 8815 hypertensive patients without prevalent cardiovascular disease, participating in the Campania Salute Network, grouped into BMI classes (normal 20-24.9kg/m², overweight 25-29.9kg/m² and obese ≥30kg/m²). Vascular and cardiac TOD was defined as ultrasound plaque (intima-media thickness>1.5mm) in >1 of the common or internal carotid arteries and echocardiographic left ventricular (LV) hypertrophy (LVH) (LV mass/height^2.7>47g/m^2.7 in women and >50g/m^2.7 in men), respectively.

RESULTS

A majority of patients were either overweight (49%) or obese (27%). In spite of more use of combination therapy, the obese group had higher blood pressure (BP) and prevalence of TOD. In multivariate logistic analyses, obesity was associated with a 6.9 times higher prevalence of LVH (95% confidence interval [CI] 5.84-8.17, p=0.0001), independent of significant associations with female sex, age, diabetes mellitus, office systolic BP, antihypertensive and antiplatelet treatment. In contrast, only a 17% increased prevalence of carotid plaques (OR=1.17; 95% CI 1.02-1.33, p=0.02) was found in obese patients independent of significant effect of male sex, older age and higher clinic systolic BP, an association that disappeared once effect of metabolic risk factors and related therapy was also considered.

CONCLUSIONS

In hypertensive patients participating in the Campania Salute Project, concomitant obesity was associated with a modestly increased prevalence of carotid plaques and a pronounced increase in prevalent LVH.

The Role of Obesity in the Development of Left Ventricular Hypertrophy Among Children and Adolescents

Both obesity and hypertension have increased substantially among children over the last several decades. At the same time, mounting evidence has pointed to the role of these and other cardiovascular disease risk factors on the development of end organ damage such as left ventricular hypertrophy in children. While traditionally thought to occur in response to an increased afterload as in systemic hypertension, evidence demonstrates that obesity is associated with left ventricular hypertrophy independent of blood pressure. Both hemodynamic and non-hemodynamic factors contribute to the pathogenesis of obesity-related left ventricular remodeling. However, more contemporary research suggests that adiposity and blood pressure have a greater effect on left ventricular geometry when present together than when present alone. Normalization of left ventricular mass in obese hypertensive individuals requires achievement of both normotension and weight loss. Additional strategies are needed to promote the cardiovascular health of children, with greater emphasis placed on obesity prevention.

Left-ventricular hypertrophy and obesity: a systematic review and meta-analysis of echocardiographic studies

AIM

Left-ventricular hypertrophy (LVH) is a frequent complication in obese individuals; an updated review and meta-analysis focusing on this issue is lacking. Thus, we analysed the literature in order to provide a comprehensive information on the left-ventricular structural changes, as assessed by echocardiography, associated to obesity.

DESIGN

A literature search using the keywords 'left ventricle', 'left-ventricular hypertrophy', 'cardiac hypertrophy', 'obesity', 'hypertension' and 'echocardiography' was performed in order to identify relevant papers. Full articles published in English language in the past 12 years reporting studies in adult obese individuals were considered.

RESULTS

A total of 22 studies including 5486 obese individuals were considered. Overall, in the pooled obese population, prevalence of LVH, defined by 12 criteria, was 56.0% (range 20.0-85.0%). Data provided by 15 studies (n = 4999 obese individuals), including 6623 non-obese controls, showed that the probability of having LVH was much higher in cases than in non-obese counterparts (odds ratio 4.19, 95% confidence interval 2.67-6.53, P < 0.01). A meta-regression analysis (n = 2214; 14 studies) showed a direct correlation between BMI and left-ventricular mass (P < 0.01). Among obese patients with LVH (n = 1930; 15 studies), eccentric hypertrophy was more frequent than the concentric phenotype (66 versus 34%; P < 0.01).

CONCLUSIONS

Our analysis shows that LVH is present in a consistent fraction of the obese population and that eccentric hypertrophy prevails over the concentric phenotype. As obesity-related LVH is a powerful risk factor for systolic/diastolic dysfunction, the prevention/treatment of obesity may have a strong, favourable impact on incident heart failure.

Impact of obesity and nonobesity on grading the severity of aortic valve stenosis

We tested the hypothesis that the disproportionate increase of body surface area in obesity may lead to the overestimation of aortic stenosis (AS) severity when the aortic valve area (AVA) is indexed (AVAI) for body surface area in 1,524 patients enrolled in the Simvastatin and Ezetimibe in AS study. Obesity was defined as a body mass index of ≥30 kg/m(2). Peak aortic jet velocity, mean aortic gradient, AVA, and energy loss (EL) did not differ, although AVAI and EL indexed (ELI) for body surface area were significantly smaller in the obese group (n = 321) compared with the nonobese (n = 1,203) group (both p <0.05). Severe AS by AVAI (<0.6 cm(2)/m(2)) but nonsevere by AVA (>1.0 cm(2); AVAI/AVA discordance) was found in 15% of the patients, whereas severe AS by ELI (<0.6 cm(2)/m(2)) but nonsevere by EL (>1.0 cm(2); ELI/EL discordance) was found in 9% of the patients. Obesity was associated with a 2.4-fold higher prevalence of AVAI/AVA discordance and a 1.6-fold higher prevalence of ELI/EL discordance. Discordant grading was also associated with male gender, larger body size, higher mean aortic gradient, and stroke volume (all p <0.05). During a median follow-up of 4.3 years, 419 patients were referred for aortic valve replacement and 177 patients died or were hospitalized because of heart failure. In the Cox regression analyses, AVAI/AVA discordance was associated with a 28% higher rate of aortic valve replacement (p <0.05) but did not predict the rate of combined death and hospitalization for heart failure. In conclusion, using AVAI and ELI for the grading of stenosis in patients with obesity may lead to overestimation of true AS severity.

Lack of reduction of left ventricular mass in treated hypertension: the strong heart study

Background

Hypertensive left ventricular mass (LVM) is expected to decrease during antihypertensive therapy, based on results of clinical trials.

Methods and Results

We assessed 4‐year change of echocardiographic LVM in 851 hypertensive free‐living participants of the Strong Heart Study (57% women, 81% treated). Variations of 5% or more of the initial systolic blood pressure (SBP) and LVM were categorized for analysis. At baseline, 23% of men and 36% of women exhibited LV hypertrophy (LVH, P<0.0001). At the follow‐up, 3% of men and 10% of women had regression of LVH (P<0.0001 between genders); 14% of men and 15% of women, free of baseline LVH, developed LVH. There was an increase in LVM over time, more in men than in women (P<0.001). Participants whose LVM did not decrease had similar baseline SBP and diastolic BP, but higher body mass index (BMI), waist/hip ratio, heart rate (all P<0.008), and urinary albumin/creatinine excretion (P<0.001) than those whose LVM decreased. After adjusting for field center, initial LVM index, target BP, and kinship degree, lack of decrease in LVM was predicted by higher baseline BMI and urinary albumin/creatinine excretion, independently of classes of antihypertensive medications, and significant effects of older age, male gender, and percentage increase in BP over time. Similar findings were obtained in the subpopulation (n=526) with normal BP at follow‐up.

Conclusions

In a free‐living population, higher BMI is associated with less reduction of hypertensive LVH; lack of reduction of LVM is independent of BP control and of types of antihypertensive treatment, but is associated with renal damage.

Prevalence and covariates of abnormal left ventricular geometry in never-treated hypertensive patients in Tanzania

AIM. To assess prevalence, type and covariates of abnormal left ventricular (LV) geometry in untreated native Tanzanian patients with hypertension in relation to normotensive controls. METHODS. Echocardiography was performed in 161 untreated hypertensive outpatients and 80 normotensive controls at a tertiary hospital in Tanzania. Hypertensive heart disease was defined as presence of increased LV mass or relative wall thickness (RWT). RESULTS. The prevalence of hypertensive heart disease increased with the severity of hypertension and was on average 62.1% among patients and 12.5% in controls. In multivariate analyses, higher LV mass index was associated with higher systolic blood pressure (β = 0.28), body mass index (β = 0.20), peak early transmitral to medial mitral annulus velocity ratio (β = 0.16), and with lower stress-corrected midwall shortening (scMWS) (β = - 0.44) and estimated glomerular filtration rate (β = - 0.16), all p < 0.05. Higher RWT was associated with higher systolic blood pressure (β = 0.16), longer E-wave deceleration time (β = 0.23) and lower scMWS (β = - 0.66), irrespective of LV mass (all p < 0.05). CONCLUSION. Subclinical hypertensive heart disease is highly prevalent in untreated native hypertensive Tanzanians and associated with both systolic and diastolic LV dysfunction. Management of hypertension in Africans should include high focus on subclinical hypertensive heart disease.