Left ventricular filling patterns in patients with systemic hypertension and left ventricular hypertrophy (the LIFE study). Losartan Intervention For Endpoint

In-treatment reduced left atrial diameter during antihypertensive treatment is associated with reduced new-onset atrial fibrillation in hypertensive patients with left ventricular hypertrophy: The LIFE Study

OBJECTIVE

It is unclear whether improvement of left atrial (LA) and ventricular (LV) structure results in reduction in new-onset atrial fibrillation (AF). The aim of the present study was to examine whether changes in-treatment LA diameter were related to changes in risk of new-onset AF.

METHODS

We followed 939 hypertensive patients with electrocardiographic LV hypertrophy randomized to atenolol or losartan-based regimens in the LIFE Study for a mean of 4.8 years with echocardiograms at enrolment and annually during treatment.

RESULTS

New-onset AF occurred in 46 patients (10.2/1000 patient-years of follow-up). At baseline, patients with new-onset AF were older, had higher systolic blood pressure and heart rate as well as higher prevalence of LA dilatation, but had similar prevalences of LV hypertrophy and mitral or aortic valve disease. In univariate Cox analysis baseline LA diameter (HR=4.67 per cm increase [95% CI 2.86-7.65], p<0.001) and LV mass index (HR=1.11 per 10 g/m(2) increase [95% CI 1.02-1.22], p<0.05) both predicted new-onset AF. In multivariate analysis, increased baseline LA diameter increased the risk of new-onset AF (HR=5.16 per cm [95% CI 2.85-9.35], p<0.001) whereas reduction of in-treatment LA diameter reduced the risk (HR=0.21 per cm lower LA diameter during treatment [95% CI 0.14-0.32], p<0.001) with adjustment for in-treatment LV mass in-treatment systolic blood pressure, age and Framingham risk score.

CONCLUSION

LA diameter at baseline and during antihypertensive treatment were equally strong predictors of new-onset AF independent of the level of arterial pressure, LV mass and other covariates. Prevention of AF during antihypertensive treatment may be improved by antihypertensive therapy that reduces LA size in addition to controlling blood pressure.

Fifteen years of losartan: what have we learned about losartan that can benefit chronic kidney disease patients?

Losartan, the first AT1 receptor blocker (ARB), was FDA approved 15 years ago. During those years, researchers and clinicians have developed a growing base of knowledge on the benefits of losartan, particularly for hypertension and renal disease. These benefits include decreasing proteinuria, slowing the progression of diabetic nephropathy, controlling hypertension, and decreasing stroke risk in patients with left ventricular hypertrophy. Although many of the benefits of losartan represent a class effect for ARBs, losartan has pharmacokinetic and pharmacodynamic characteristics and effects that are unique and are not a class effect. For example, a shorter duration of action is seen with this first ARB compared with other more recently approved ARBs. Losartan also has a uricosuric effect not seen in other ARBs and attenuates platelet aggregation, which is not seen or is seen to a lesser extent with the other ARBs. This review presents the physiological effects of losartan on the kidney and discusses relevant clinical outcomes.

Central aortic pressure is independently associated with diastolic function

BACKGROUND

Studies investigating the association between central aortic pressures and diastolic function have been limited.

METHODS

Consecutive ambulatory patients (n = 281, mean age 49 +/- 13 years, 49% male) with normal left ventricular (LV) systolic function were included. The LV filling pressure (E/Em) was estimated by Doppler-derived ratio of mitral inflow velocity (E) to septal (Em) by tissue Doppler, LV relaxation by Em, and central aortic pressures by radial tonometry. Central aortic systolic (cSBP), diastolic (cDBP), mean (cMAP) and pulse pressure (cPP) were entered individually into stepwise linear regression models to determine their association with E/Em or Em.

RESULTS

In univariate analysis, cPP correlated most strongly with E/Em (Spearman's rho = 0.45, P < .001), whereas cSBP correlated most strongly with Em (Spearman's rho = -0.51, P < .001). Multivariate analysis demonstrated that the pulsatile component of afterload, cPP, contributed most to E/Em (partial r(2) = 23%); meanwhile, the nonpulsatile components (cDBP and cMAP) were significant but small contributors (partial r(2) of 6% and 5%, respectively) of LV relaxation (Em).

CONCLUSION

The nonpulsatile components of aortic afterload (cMAP and cDBP) exhibited a weak but significant association with LV relaxation, whereas the pulsatile component of afterload, cPP, exhibited strong association with LV filling pressure.

Severe symptoms in mid and apical hypertrophic cardiomyopathy

BACKGROUND

We analyzed the clinical and quantitative echocardiographic characteristics of patients with sub-basal hypertrophic cardiomyopathy (HCM) to define the characteristics of patients (pts) with severe symptoms.

METHODS

Of 444 pts in a referral-based HCM program, 22 (5%) had midventricular or apical HCM. Quality of life (QoL) questionnaire was administered as an independent confirmer of symptomatic state.

RESULTS

Ten pts were NYHA III and IV, and 12 pts were NYHA I and II; QoL scores (41 +/- 26 vs. 10 +/- 13, P = 0.001) confirmed a priori division of two groups based on NYHA classification. Pts with more severe symptoms were more likely female (70% vs. 25%, P = 0.001) with atrial fibrillation (40% vs. 0%, P = 0.02). They more frequently had midventricular HCM 60% versus 8% (P = 0.01) (mid-LV thickness 17 +/- 6 vs. 12 +/- 2 mm, P = 0.03) and had much smaller LV diastolic volumes 68 +/- 12 versus 102 +/- 22 ml (39 +/- 4 vs. 53 +/- 12 ml/m(2), P = 0.001). Septal E/E' was higher in the severely symptomatic pts (15 +/- 5 vs. 7 +/- 3, P = 0.001) indicating higher estimated LV filling pressure. Midobstruction with apical akinetic chamber was noted in 4/10 pts who developed refractory symptoms. Cardiac mortality was higher in the severely symptomatic patients, 4/10 who had midventricular HCM as compared to 0/12 in the mildly symptomatic apical HCM group (P = 0.03).

CONCLUSIONS

In subbasal HCM, pts with severe symptoms have midventricular hypertrophy, with encroachment of the LV cavity and consequent very small LV volumes that may be complicated by mid-LV obstruction. Pts with mid-LV hypertrophy are more symptomatic than those with apical HCM, are often refractory to therapy, and have higher mortality.

Blood pressure development and hypertensive retinopathy: 20-year follow-up of middle-aged normotensive and hypertensive men

Screening for hypertensive organ damage is important in assessing cardiovascular risk in hypertensive individuals. In a 20-year follow-up of normotensive and hypertensive men, signs of end-organ damage were examined, focusing on hypertensive retinopathy. In all, 56 of the original 79 men were reexamined for hypertensive organ damage, including by digital fundus photography. The diameters of the central retinal artery equivalent (CRAE) and vein were estimated and the artery-to-vein diameter ratio calculated. Components of metabolic syndrome were assessed. Fifty percent of the normotensive men developed hypertension during follow-up. Significant differences appeared in CRAE between the different blood pressure groups (P=0.025) while no differences were observed for other markers of hypertensive organ damage. There were significant relationships between CRAE and blood pressure at baseline (r=-0.466, P=0.001) and at follow-up (r=-0.508, P<0.001). A linear decrease in CRAE was observed with increasing number of components of the metabolic syndrome (beta=-3.947, R(2)=0.105, P=0.023). Retinal vascular diameters were closely linked to blood pressures and risk factors of the metabolic syndrome. The diversity in the development of hypertensive organ damage, with changes in retinal microvasculature preceding other signs of damage, should encourage more liberal use of fundus photography in assessing cardiovascular risk in hypertensive individuals.

Mitral E wave deceleration time to peak E velocity ratio and cardiovascular outcome in hypertensive patients during antihypertensive treatment (from the LIFE echo-substudy)

The early mitral flow deceleration time (DTE) is a prognostically validated marker of left ventricular diastolic dysfunction. It has been reported that the DTE is influenced by the loading conditions, which can vary during antihypertensive treatment. We hypothesized that normalization of the DTE for mitral peak E-velocity (mitral deceleration index [MDI]) might better predict incident cardiovascular (CV) events in hypertensive patients during treatment compared to DTE alone or other traditional indexes of diastolic function, such as the mitral E/A ratio. We evaluated 770 hypertensive patients with electrocardiogram findings of left ventricular hypertrophy (age 66 +/- 7 years; 42% women) enrolled in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) echocardiographic substudy. Echocardiographic examinations were performed annually for 5 years during intensive antihypertensive treatment. We examined the utility of the MDI at baseline and as a time-varying predictor of incident CV events. Of the 770 patients, 70 (9%) had CV events. The baseline MDI was positively associated with age and relative wall thickness and negatively associated with gender and heart rate (all p <0.01). Unadjusted Cox regression analysis showed a positive association between the baseline MDI and CV events (hazard ratio 1.21, 95% confidence interval 1.07 to 1.37, p = 0.002). In the time-varied Cox models, a greater in-treatment MDI was associated with a greater rate of CV events (hazard ratio 1.43, 95% confidence interval 1.05 to 1.93, p = 0.022), independently of the covariates. No significant association was found for in-treatment DTE or any of the prognostically validated indexes of diastolic function. In conclusion, in our population of patients with treated hypertension with electrocardiographic findings of left ventricular hypertrophy, the MDI independently predicted future CV events. Normalization of DTE for E velocity might be preferred to other traditional diastolic function indexes in evaluating diastolic function during antihypertensive treatment.

Dual ACE-inhibition and AT1 receptor antagonism improves ventricular lusitropy without affecting cardiac fibrosis in the congenic mRen2.Lewis rat

BACKGROUND

Hypertension and left ventricular (LV) hypertrophy often precede diastolic dysfunction and are risk factors for diastolic heart failure. Although pharmacologic inhibition of the renin-angiotensin system (RAS) improves diastolic function and functional capacity in hypertensive patients with LV hypertrophy, the effects of combination therapy with an angiotensin converting enzyme inhibitor (ACEi) and an angiotensin receptor blocker (ARB) are unclear.

METHOD

We assessed the effects of the combined 10-week administration of lisinopril (10 mg/kg/ day, p.o.) and losartan (10 mg/kg/day, p.o.) (LIS/LOS) on diastolic function and LV structure in seven young (5 weeks), prehypertensive congenic mRen2.Lewis male rat, a model of tissue renin overexpression and angiotensin II (Ang II)-dependent hypertension compared to vehicle (VEH) treated (n = 7), age-matched rats.

RESULTS

Systolic blood pressures were 64% lower with the combination therapy (p < 0.001), but there were no differences in heart rate or systolic function between groups. RAS inhibition increased myocardial relaxation, defined by tissue Doppler mitral annular descent (e') by 2.2 fold (p < 0.001). The preserved lusitropy in the LIS/LOS-treated rats was accompanied by a reduction in phospholamban-to-SERCA2 ratio (p < 0.001). Despite lower relative wall thicknesses (VEH: 1.56+/-0.17 versus LIS/LOS: 0.78+/-0.05) and filling pressures, defined by the transmitral Doppler-to-mitral annular descent ratio (E/e', VEH: 28.7+/-1.9 versus LIS/LOS: 17.96+/-1.5), no differences in cardiac collagen were observed.

CONCLUSION

We conclude that the lusitropic benefit of early dual RAS blockade may be due to improved vascular hemodynamics and/or cardiac calcium handling rather than effects on extracellular matrix reduction.

Implications of persistent prehypertension for ageing-related changes in left ventricular geometry and function: the MONICA/KORA Augsburg study

BACKGROUND

It is unclear whether persistent prehypertension causes structural or functional alterations of the heart.

METHODS

We examined echocardiographic data of 1005 adults from a population-based survey at baseline in 1994/1995 and at follow-up in 2004/2005. We compared individuals who had either persistently normal (<120 mmHg systolic and <80 mmHg diastolic, n = 142) or prehypertensive blood pressure (120-139 mmHg or 80-89 mmHg, n = 119) at both examinations using multivariate regression modeling.

RESULTS

Over 10 years, left ventricular end-diastolic diameters were stable and did not differ between the two groups. However, the prehypertensive blood pressure group displayed more pronounced ageing-related increases of left ventricular wall thickness (+4.7 versus +11.9%, P < 0.001) and left ventricular mass (+8.6 versus +15.7%, P = 0.006). Prehypertension was associated with a raised incidence of left ventricular concentric remodeling (adjusted odds ratio 10.7, 95% confidence interval 2.82-40.4) and left ventricular hypertrophy (adjusted odds ratio 5.33, 1.58-17.9). The ratio of early and late diastolic peak transmitral flow velocities (E/A) decreased by 7.7% in the normal blood pressure versus 15.7% in the prehypertensive blood pressure group (P = 0.003) and at follow-up the ratio of early diastolic peak transmitral flow and early diastolic peak myocardial relaxation velocities (E/EM) was higher (9.1 versus 8.5, P = 0.031) and left atrial size was larger (36.5 versus 35.3 mm, P = 0.024) in the prehypertensive blood pressure group. Finally, the adjusted odds ratio for incident diastolic dysfunction was 2.52 (1.01-6.31) for the prehypertensive blood pressure group.

CONCLUSIONS

Persistent prehypertension accelerates the development of hypertrophy and diastolic dysfunction of the heart.

The effect of nondipping blood pressure patterns on cardiac structural changes and left ventricular diastolic functions in normotensives

BACKGROUND

Cardiac structural changes have been reported to be more prominent in nondipper normotensives than the dipper ones. But the influence of nondipping status on cardiac diastolic functions of normotensives has not been studied yet. In this study, we investigated the effect of nondipping status on both cardiac structural changes and left ventricular (LV) diastolic functions in normotensives.

METHODS

We performed ambulatory blood pressure (BP) monitoring (ABPM) and echocardiography in 62 normotensive subjects with the following criteria: (1) office BP < 140/90 mmHg; (2) average 24-hour ambulatory BP < 130/80 mmHg.

RESULTS

In the evaluation by tissue Doppler imaging (TDI), the early diastolic myocardial peak velocity (Em) and Em/late diastolic myocardial peak velocity (Am) ratio (Em/Am ratio) were lower in nondippers than those in dippers (P = 0.009 and P < 0.001, respectively). Isovolumic relaxation time (IRT) and myocardial performance index (MPI) were higher in nondippers than those in dippers (P = 0.036 and P = 0.026, respectively). Nondipping status, independent of other factors, was observed to cause both a decrease in the Em and Em/Am ratio and an increase in IRT. However, its effect on IRT was not statistically significant (coefficient =-0.27, P = 0.027; coefficient =-0.37, P = 0.002; coefficient = 0.20, P = 0.082, respectively).

CONCLUSIONS

Nondipping of nocturnal BP seems to be a determinant of cardiac remodeling and LV diastolic dysfunction (LVDD) and may result in a cardiovascular (CV) risk independent of the increase in LV mass (LVM) in normotensives.

Left atrioventricular remodeling in the assessment of the left ventricle diastolic function in patients with heart failure: a review of the currently studied echocardiographic variables

Multiparametric echocardiographic imaging of the failing heart is now increasingly used and useful in decision making in heart failure. The reasons for this, relies on the need of different strategies of handling these patients, as differentiation of systolic or diastolic dysfunction, as well as on the gamma of approaches available, such as percutaneous and surgical revascularization, devices implantations, and valvular regurgitations and stenosis corrections. Congestive heart failure in patients with normal left ventricular diameters or preserved left ventricular ejection fraction had been pointed out recently as present in a proportion so high as 40 to 50 percent of cases of heart failure, mainly due to the epidemics in well developed countries, as is the problem of not well controlled metabolic states (such as obesity and diabetes), but also due to the real word in developing countries, as is the case of hypertension epidemics and its lack of adequate control. As a matter of public utility, the guidelines in the diagnosis and treatment of such patients will have to be cheap, available, easily reproducible, and ideally will furnish answers for the clinician questions not in a binary "black or white" manner, but with graduations, so if possible it has to be quantitative. The present paper aim to focus on the current clinical applications of tissue Doppler and of left atrial function and remodeling, and its pathophysiologic relationship with the left ventricle, as will be cleared in the documented review of echocardiography that follows, considering that the need of universal data on the syndrome of the failing heart does not mean, unfortunately, that all patients and clinicians in developing countries have at their own health facilities the same imaging tools, since they are, as a general rule, expensive.

Independent association of coronary flow reserve with left ventricular relaxation and filling pressure in arterial hypertension

BACKGROUND

It has been recognized that "cross-talk" occurs between coronary flow and left ventricular (LV) function. This study tested the hypothesis that impairment of coronary flow reserve (CFR) in arterial hypertension is associated with LV systolic and diastolic dysfunction, independent of abnormalities in LV geometry.

METHODS

We studied 59 newly diagnosed, never-treated hypertensive patients, using transthoracic Doppler echocardiography including pulsed Tissue Doppler of mitral annulus and CFR on left anterior descending artery (low-dose dipyridamole). The study population was divided into two groups on the basis of age-normalized relative wall thickness (RWTn): 36 patients with normal LV geometry (RWTn < or = 0.41) and 23 patients with LV concentric geometry (RWTn > 0.41).

RESULTS

Patients with LV concentric geometry (RWTn > 0.41) had significantly lower values of midwall shortening (but not of endocardial shortening), longer isovolumic relaxation time (IVRT), lower Tissue Doppler-derived early diastolic velocity (Em), higher ratio of transmitral E velocity to Em, and lower CFR as compared to patients with normal LV geometry (RWTn < or = 0.41). In the whole population, a lower CFR was significantly associated with lower values of midwall shortening and Em, longer IVRT, and higher E/Em ratio. After controlling for heart rate, mean blood pressure, and RWTn, only the relation of CFR with IVRT, Em, and E/Em ratio remained significant.

CONCLUSIONS

Reduced midwall mechanics is associated with lower CFR, a relationship that depends on LV concentric geometry. A reduced CFR is associated with both impaired relaxation and increased filling pressure, a relation that is independent of LV geometry and pressure load.

The effects of losartan on signal-averaged P wave in patients with atrial fibrillation

BACKGROUND

Losartan has recently been reported to suppress atrial structural remodeling. However, few reports exist on signal-averaged electrocardiography (ECG) for preventing atrial electrical remodeling. We examined the effect of losartan on atrial electricity by using signal-averaged ECG of P waves.

METHODS

The subjects comprised 40 patients with essential hypertension complicated with symptomatic paroxysmal atrial fibrillation. The patients received pilsicainide for the complication; they were defibrillated and divided into two subgroups for antihypertensive therapy: calcium antagonist-administrated (CB) and losartan-administrated (LOS) groups. We recorded the signal-averaged electrocardiography of P waves and calculated (1) filtered P wave duration (PD), (2) the voltage integral for the entire P wave (integral-p), and (3) the root mean square voltages of the terminal 40, 30, and 20 ms (RMS-40, RMS-30, and RMS-20). Procollagen C propeptide type I (PIP) and A- and B-type natriuretic peptide (ANP and BNP, respectively) levels in the groups were measured before and after antihypertensive agent administration.

RESULTS

RMS-20 increased significantly and PD decreased significantly in the LOS group 24 weeks after antihypertensive drug administration; however, they remained unchanged in the CB group. Integral-p decreased significantly in both groups, and the decrease rate was significantly higher in the LOS group. Serum BNP levels decreased significantly only in the LOS group.

CONCLUSIONS

Losartan inhibits atrial remodeling by inhibiting left atrial fibrosis as indicated by the procollagen C propeptide type I, ANP, and BNP levels. Signal-averaged ECG demonstrated that losartan suppresses atrial fibrillation recurrence by improving atrial conduction disturbance.

The Mitral Annular Middiastolic Velocity Curve: Functional Correlates and Clinical Significance in Patients with Left Ventricular Hypertrophy

BACKGROUND

Little is known regarding the tissue Doppler characteristics and clinical significance of mitral annular motion during diastasis (L' wave).

METHODS

In consecutive patients with left ventricular hypertrophy and normal ejection fraction, standard Doppler and Doppler tissue imaging were performed. Patients were followed up for heart failure (HF) hospitalization.

RESULTS

Of 177 patients, 53 (30%) had an L', detected most frequently at the lateral mitral annulus, whereas 35 (20%) had middiastolic transmitral flow (L wave), which almost invariably coexisted with the L'. The L' predicted increased left ventricular filling pressure with 74% sensitivity and 82% specificity, and increased risk of future HF (hazard ratio 3.9 [P = .030]), even after adjusting for baseline clinical differences (hazard ratio 6.5 [P = .024]). When associated with an L wave, HF risk increased further.

CONCLUSIONS

Middiastolic annular motion, detectable in almost a third of patients with left ventricular hypertrophy, may be an early marker of diastolic dysfunction and a prognostic marker for HF.

Hypertensive heart disease: effects of lifestyle modifications and antihypertensive drug treatment

Target-organ protection in hypertensive patients has become increasingly important. This review will focus on hypertensive heart disease that is mainly characterized by myocardial hypertrophy and increased interstitial fibrosis. Cardiac remodeling develops as an adaptive response but actually represents a powerful independent risk factor for cardiovascular morbidity and mortality. The review will begin with a brief discussion on the complex pathophysiology of hypertensive cardiac remodeling and its clinical consequences. The effects of nonpharmacologic and pharmacologic antihypertensive treatments on the development and progression of hypertensive heart disease are presented. Finally, the impact of the regression of myocardial hypertrophy and fibrosis on cardiac function and cardiovascular risk are discussed.

Effect of angiotensin receptor blockade and antihypertensive drugs on diastolic function in patients with hypertension and diastolic dysfunction: a randomised trial

BACKGROUND

Diastolic dysfunction might represent an important pathophysiological intermediate between hypertension and heart failure. Our aim was to determine whether inhibitors of the renin-angiotensin-aldosterone system, which can reduce ventricular hypertrophy and myocardial fibrosis, can improve diastolic function to a greater extent than can other antihypertensive agents.

METHODS

Patients with hypertension and evidence of diastolic dysfunction were randomly assigned to receive either the angiotensin receptor blocker valsartan (titrated to 320 mg once daily) or matched placebo. Patients in both groups also received concomitant antihypertensive agents that did not inhibit the renin-angiotensin system to reach targets of under 135 mm Hg systolic blood pressure and under 80 mm Hg diastolic blood pressure. The primary endpoint was change in diastolic relaxation velocity between baseline and 38 weeks as determined by tissue doppler imaging. Analyses were done by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00170924.

FINDINGS

186 patients were randomly assigned to receive valsartan; 198 were randomly assigned to receive placebo. 43 patients were lost to follow-up or discontinued the assigned intervention. Over 38 weeks, there was a 12.8 (SD 17.2)/7.1 (9.9) mm Hg reduction in blood pressure in the valsartan group and a 9.7 (17.0)/5.5 (10.2) mm Hg reduction in the placebo group. The difference in blood pressure reduction between the two groups was not significant. Diastolic relaxation velocity increased by 0.60 (SD 1.4) cm/s from baseline in the valsartan group (p<0.0001) and 0.44 (1.4) cm/s from baseline in the placebo group (p<0.0001) by week 38. However, there was no significant difference in the change in diastolic relaxation velocity between the groups (p=0.29).

INTERPRETATION

Lowering blood pressure improves diastolic function irrespective of the type of antihypertensive agent used.

Arterial Plasma Vasopressin and Aldosterone Predict Left Ventricular Mass in Men Who Develop Hypertension Over 20 Years

Left ventricular (LV) hypertrophy is related to blood pressure level and neurohormonal factors. The authors previously demonstrated that arterial norepinephrine levels predict LV mass in middle-aged men who developed hypertension through 20 years. The aim of this 20-year prospective study was to investigate arterial vasopressin, aldosterone, and renin as long-term predictors of LV mass. Normotensives (n=17), subjects who developed hypertension (n=17), and sustained hypertensives (n=22) were compared at baseline (42 years) and at follow-up (62 years). There were no significant differences in baseline vasopressin, aldosterone, or renin levels. The group with sustained hypertension had more LV hypertrophy (P=.025) at follow-up. Among new hypertensives, multiple regression analysis demonstrated that baseline arterial vasopressin (beta-0.53; P=.041) and aldosterone (beta-0.56;P=.032) independently explained LV mass index (R(2)=0.85; P=.035). In conclusion, baseline arterial vasopressin and aldosterone, but not renin, appear to predict LV mass in middle-aged men who developed hypertension over a 20-year period.

Left Ventricular Diastolic Dysfunction in Chronic Aortic Dissection

BACKGROUND

In chronic aortic dissection, compression of the true lumen by the expanded false lumen may be a cause of left ventricular afterload elevation, which may result in diastolic dysfunction. We compared the left ventricular diastolic function by echocardiography between those patients who had double-barrel descending aortic dissection and those who did not.

METHODS

Twelve patients (mean age, 61 +/- 12 years) with chronic type B aortic dissection were enrolled in this study. Patients in group I had double-barrel aortic dissection that had expanded the patent false lumen and narrowed the true lumen (n = 7, 58.3%), and patients in group II had a wider-caliber true lumen with a thrombosed false lumen (n = 5, 41.7%). We evaluated the left ventricular diastolic function with the transmitral flow pattern (E and A waves) with the pulsed Doppler method and flow propagation velocity (FPV) with color M-mode Doppler images, and classified its severity into grade I (abnormal relaxation), grade II (pseudonormalization) and grade III (restriction).

RESULTS

All patients in group II had grade I diastolic dysfunction, with an E/A of less than 1.0. By contrast, 4 of the 7 patients in group I had grade II diastolic dysfunction, with an FPV/E of less than 0.6 and a pseudonormalized (> 1.0) E/A ratio (p = 0.081). Consequently, the E/A ratio was higher in group I than in group II (1.16 +/- 0.39 versus 0.68 +/- 0.18; p < 0.05).

CONCLUSIONS

It is suggested that left ventricular diastolic function is severely reduced in the patients having aortic dissection with a double-barrel and narrowed true lumen.

Left Atrial Size and Risk of Major Cardiovascular Events During Antihypertensive Treatment

The influence of left atrial size on cardiovascular events during antihypertensive treatment has not been reported previously from a long-term, prospective, randomized hypertension treatment trial. We recorded left atrial diameter by annual echocardiography and cardiovascular events in 881 hypertensive patients (41% women) with electrocardiographic left ventricular hypertrophy aged 55 to 80 (mean: 66) years during a mean of 4.8 years of randomized losartan- or atenolol-based treatment in the Losartan Intervention for Endpoint Reduction in Hypertension Study. During follow-up, a total of 88 primary end points (combined cardiovascular death, myocardial infarction, or stroke) occurred. In Cox regression, baseline left atrial diameter/height predicted incidence of cardiovascular events (hazard ratio: 1.98 per cm/m [95% CI: 1.02 to 3.83 per cm/m]; P =0.042) adjusted for significant effects of Framingham risk score and history of atrial fibrillation. Greater left atrial diameter reduction during follow-up was associated with greater reduction in left ventricular hypertrophy, absence of new-onset atrial fibrillation or mitral regurgitation during follow-up, and losartan-based treatment (B=−0.13±0.03 cm/m; P <0.001) in multiple linear regression, adjusting for baseline left atrial diameter/height. However, in time-varying Cox regression analysis, left atrial diameter reduction was not independent of left ventricular hypertrophy regression in predicting cardiovascular events during follow-up. In conclusion, left atrial diameter/height predicts risk of cardiovascular events independent of other clinical risk factors in hypertensive patients with left ventricular hypertrophy and may be useful in pretreatment clinical assessment of cardiovascular risk in these patients.

Arterial plasma noradrenaline predicts left ventricular mass independently of blood pressure and body build in men who develop hypertension over 20 years

BACKGROUND

Increased sympathetic activity may be an underlying mechanism in cardiovascular disease. It has been hypothesized that the degree of left ventricular (LV) hypertrophy is partly related to the blood pressure level, and partly to neurohormonal factors. The aim of this study was to investigate predictors of LV mass, including arterial plasma noradrenaline as an index of sympathetic activity, with particular emphasis on subjects who developed hypertension over a period of 20 years.

METHODS

In a 20-year prospective study of middle-aged men, sustained hypertensives (n = 22), new hypertensives (crossovers) (n = 17) and sustained normotensives (controls) (n = 17) were examined both at baseline and after 20 years of follow-up (at ages 42.1 +/- 0.5 and 62.3 +/- 0.6 years, respectively). Relationships between arterial plasma catecholamines, blood pressure and body mass index at baseline to left ventricular parameters by echocardiography at follow-up were investigated.

RESULTS

Groups were homogeneous regarding age, gender, race and body build. The group of sustained hypertensives had significantly more LV hypertrophy (P = 0.025) and diastolic dysfunction (P = 0.010). Among the crossovers, LV mass index was positively correlated to arterial plasma noradrenaline (r = 0.50, P = 0.043) and body mass index (BMI) (r = 0.51, P = 0.039) and showed a positive trend with systolic blood pressure (SBP) at baseline. Arterial plasma noradrenaline (beta = 0.47) was found to predict LV mass index after 20 years independently of BMI (beta = 0.45) and SBP (beta = 0.22) at baseline (R adjusted = 0.345, P = 0.037). Such a relationship was not found in the controls or in the sustained hypertensives, of which 16 were treated with antihypertensive drugs.

CONCLUSIONS

Arterial plasma noradrenaline at baseline, as an index of sympathetic activity, predicts LV mass at follow-up independently of systolic blood pressure and body build in middle-aged men who developed hypertension over a period of 20 years.

Acute administration of a single dose of valsartan improves left ventricular functions: a pilot study to assess the role of tissue velocity echocardiography in patients with systemic arterial hypertension in the TVE-valsartan study I

BACKGROUND

The advent of colour-coded tissue velocity echocardiography (TVE) has now made it possible to quantify left ventricular (LV) functions in patients with systemic arterial hypertension (HTN). Hypothesis In this project, we have studied the cardiac effects of a single dose of orally administered valsartan in patients with known HTN.

METHODS

Fifty-five patients with HTN with a mean age of 56 +/- 10 years were given an early morning dose of 80 mg valsartan withholding regular antihypertensive medications on the day of investigation. TVE images, acquired on VIVID systems were digitized for postprocessing of longitudinal and radial peak systolic velocities, strain rate, and systolic and diastolic time intervals before (pre) and 5 h after (post) administration of the drug.

RESULTS

Blood pressure (mmHg) pre and post, respectively, were 147 +/- 15 versus 137 +/- 14 systolic and 90 +/- 7 versus 86 +/- 7 diastolic (all P<0.01). LV longitudinal systolic velocities (cm s(-1)) were significantly higher post in LV septum (5.7 +/- 1.1 versus 6.4 +/- 1.6; P<0.001) with similar results obtained in other LV walls. Radial strain rate (1 s(-1)) was significantly higher post compared with pre valsartan (2.1 +/- 0.6 versus 2.3 +/- 0.9; P<0.01). Regional diastolic filling and ejection times (ms) were significantly shorter post (390 +/- 122 versus 370 +/- 120 and 275 +/- 32 versus 163 +/- 36 respectively; all P<0.05).

CONCLUSIONS

Within 5 h after oral administration of valsartan, improvement in regional myocardial systolic functions could be registered. Although the changes could well be secondary to afterload reduction, additional effects of the drug, evidenced by improved strain rate that is relatively load-independent, may have contributed in this improvement.

The prognostic value of the mitral diastolic filling velocity ratio for all-cause mortality and cardiovascular morbidity in African Americans: the Atherosclerotic Risks in Communities (ARIC) study

BACKGROUND

Although recent data suggest that the mitral diastolic early-to-late (E/A) ratio may be prognostic in selected population-based cohorts, its predictive value for morbidity and mortality in African Americans has not yet been well studied.

METHODS

The study population consisted of African American participants from the Jackson cohort of the Atherosclerotic Risks in Community Study. Three subgroups of E/A ratios were defined: E/A <0.7, E/A 0.7-1.5, and E/A >1.5, using the middle group as reference. Cox proportional hazard models were used to assess the association between the E/A ratio and both all-cause mortality and incident cardiovascular disease (CVD). The mean follow-up period was 6.8 +/- 1.3 years.

RESULTS

Of the 2211 participants in the study population (mean age 62 years, 65.1% women), 8.2% had an E/A ratio <0.7, 84.7% had an E/A 0.7-1.5, and 7.1% had an E/A >1.5. An E/A >1.5 was independently associated with all-cause mortality (hazard ratio [HR] 2.18, 95% confidence interval [CI] 1.20-4.03) in the multivariable model. An E/A <0.7 was associated with higher all-cause mortality (HR 1.79, 95% CI 1.17-2.73) and incident CVD (HR 1.91, 95% CI 1.29-2.83) compared with a normal E/A in the age and sex adjusted model but was not independently predictive in the multivariable model (P > .05).

CONCLUSIONS

In a population-based cohort of middle-aged African Americans, an E/A >1.5 independently predicts all-cause mortality. An E/A >1.5 and an E/A <0.7 were both associated with incident CVD when adjusted for age and sex alone but were not independently predictive in the multivariable analysis.

Electrocardiographic strain pattern and left ventricular diastolic function in hypertensive patients with left ventricular hypertrophy: the LIFE study

BACKGROUND

Whether the typical electrocardiographic (ECG) strain pattern (Strain, in leads V5 and/or V6), which is associated with left ventricular hypertrophy (LVH) and LV systolic dysfunction, is independently associated with LV diastolic dysfunction is unknown.

METHODS

The Losartan Intervention For Endpoint reduction in hypertension (LIFE) study enrolled hypertensive patients with ECG-LVH, of whom 10% underwent Doppler echocardiography. LV diastolic function measures included peak mitral E and A wave velocities and their ratio (E/A); E wave deceleration time (EDT); atrial filling fraction (AFF); and isovolumic relaxation time (IVRT). Normal filling pattern was defined by E/A < 1 with EDT >or= 150 and <or= 250 ms and IVRT <or= 100 and >or=60 ms; abnormal relaxation by E/A < 1 with EDT > 250 ms or IVRT > 100 ms; pseudonormal filling pattern by E/A >or= 1 associated with IVRT > 100 ms or EDT > 250 ms; restrictive pattern by E/A >or= 1 with IVRT < 100 ms and EDT < 250 ms. A combined index of LV systolic-diastolic function was also computed (isovolumic time/ejection time, modified myocardial performance index). Of LIFE echo substudy participants with all needed ECG and Doppler data (n = 791), 110 (14%) had Strain.

RESULTS

Strain was associated with male gender, African-American race, diabetes, history of coronary heart disease (CHD), higher systolic blood pressure (BP), LV mass and relative wall thickness, and higher prevalences of echo-LV hypertrophy and wall motion abnormalities, and with slower heart rate (all P < 0.05). Age, diastolic BP and LV ejection fraction were similar in patients with or without Strain. Diastolic parameters, and prevalences of different LV filling patterns, did not differ significantly between patients with versus those without Strain (all P > 0.1), but modified myocardial performance index was higher with Strain (P < 0.05). Findings were consistent in multivariate analyses. The association of Strain with higher modified myocardial performance index was no longer statistically significant after accounting for LV systolic function and wall motion abnormalities.

CONCLUSIONS

In hypertensive patients with ECG-LVH, the ECG Strain pattern did not identify independently those with more severe LV diastolic abnormalities.

Rationale and design: the VALsartan In Diastolic Dysfunction (VALIDD) Trial: evolving the management of diastolic dysfunction in hypertension

BACKGROUND

Although 50% of hypertensive patients in the community are estimated to have diastolic dysfunction, there is no specific guideline for diastolic dysfunction therapy at present despite the condition's clear association with increased cardiovascular risk. Although the efficacy of angiotensin II receptor blockers (ARBs) in hypertension and left ventricular hypertrophy regression has been established, the effect of angiotensin II receptor blockade on intrinsic parameters of diastolic function has not been evaluated in large-scale studies.

METHODS

The VALIDD Trial is an investigator-initiated randomized, controlled, double-blind clinical trial on approximately 350 patients designed to explore whether antihypertensive therapy with the ARB valsartan, in addition to standard therapy, would improve intrinsic diastolic properties of the myocardium in patients with hypertension and evidence of diastolic dysfunction. The result of such therapy will be compared with placebo after 38 weeks of treatment. The primary efficacy variable is change in early diastolic lateral mitral annular relaxation velocity measured by tissue Doppler imaging on week 38.

CONCLUSIONS

We expect the VALIDD Trial to provide novel insights into the specific effects of ARBs on diastolic dysfunction, as assessed by tissue Doppler imaging, in hypertensive patients. The trial may provide clinically useful data on whether such therapy can directly improve diastolic function in patients with hypertension.

Longitudinal Mitral Annulus Velocities Are Reduced in Hypertensive Subjects With or Without Left Ventricle Hypertrophy

Normotensive and hypertensive subjects with and without left ventricular (LV) hypertrophy (LV mass index [LVMI] >51 g/m 2.7 ) were examined by conventional echocardiography and tissue Doppler imaging of mitral annulus motion. The subgroups included nonobese normotensive subjects (n=16; age 51±9 years; 11 female; systolic blood pressure [SBP] 109±11 mm Hg, body mass index [BMI] 24±2.7 kg/m 2 ; LVMI 32±5.5 g/m 2.7 ), nonobese hypertensive subjects without LV hypertrophy (n=16; age 54±12 years; 12 female; SBP 166±15 mm Hg; BMI 25±2.7 kg/m 2 ; LVMI 42±5.5 g/m 2.7 ), and hypertensive subjects with LV hypertrophy (n=22; age 56±10 years; 10 female; SBP 181±19 mm Hg; BMI 26±2.3 kg/m 2 ; LVMI 69±16 g/m 2.7 ). Ejection fraction was comparable among the subgroups, but midwall fractional shortening was reduced in hypertensive subjects with LV hypertrophy (≈26%). Isovolumic relaxation time was increased in subjects with LV hypertrophy, whereas mitral wave A velocity was increased in hypertensive subjects with and without LV hypertrophy. Tissue Doppler imaging mitral annulus systolic (S M ) and diastolic (E M ) velocities were reduced in subjects with and without LV hypertrophy compared with normotensive subjects. There was a positive correlation between S M and E M ( r =0.68; P <0.0001) and negative correlations between these 2 variables and LVMI (S M , r =−0.41; P =0.002; E M , r =−0.56; P <0.0001). Thus, reductions in mitral annulus systolic and diastolic velocities parallel increases in LV mass in hypertensive subjects, beginning at LV mass within the clinically defined normal values.

Matrix metalloproteinases/tissue inhibitors of metalloproteinases: relationship between changes in proteolytic determinants of matrix composition and structural, functional, and clinical manifestations of hypertensive heart disease

BACKGROUND

Chronic hypertension may cause left ventricular (LV) remodeling, alterations in cardiac function, and the development of chronic heart failure (CHF). Changes in the composition of the extracellular matrix (ECM) known to occur in hypertension are believed to be causally related to these structural, functional, and clinical outcomes. However, whether the determinants of ECM composition, such as the balance between ECM proteases (matrix metalloproteinases [MMPs]) and their tissue inhibitors [TIMPs]), are altered in hypertensive heart disease is unknown.

METHODS AND RESULTS

Plasma MMP-2, -9, and -13 values, TIMP-1 and -2 values, and Doppler echocardiography images were obtained for 103 subjects divided into 4 groups: (1) reference subjects (CTL) with no evidence of cardiovascular disease, (2) hypertensive (HTN) subjects with controlled blood pressure and no LV hypertrophy, (3) hypertensive subjects with controlled blood pressure and with LV hypertrophy (HTN+LVH) but no CHF, and (4) hypertensive subjects with controlled blood pressure, LVH, and CHF (HTN+LVH+CHF). Compared with CTL, patients with HTN had no significant changes in any MMP or TIMP. Patients with HTN+LVH had decreased MMP-2 and MMP-13 values and increased MMP-9 values. Only patients with HTN+LVH+CHF had increased TIMP-1 values. A TIMP-1 level >1200 ng/mL was predictive of CHF.

CONCLUSIONS

Patients with hypertension but normal LV structure and function had normal MMP/TIMP profiles. Changes in MMP profiles that favor decreased ECM degradation were associated with LVH and diastolic dysfunction. An increased TIMP-1 level predicted the presence of CHF. Although these findings should be confirmed in a larger prospective study, these data do suggest that changes in the MMP/TIMP balance may play an important role in the structural, functional, and clinical manifestations of hypertensive heart disease.

Effect of cilnidipine on left ventricular function in hypertensive patients as assessed by tissue Doppler Tei index

Tissue Doppler Tei index is pointed to be more effective in the evaluation of global cardiac function than systolic and diastolic measurements alone in various heart diseases. This study was designed to assess the effect of cilnidipine on left ventricular function in hypertensive patients by using this index. A group of 40 hypertensives (mean age 55+/-8 years, range: 35-65) and 16 controls (mean age 52+/-9 years, range: 36-65) were included. Hypertensives were classified into non-left ventricular hypertrophy (NLVH) group (25 patients) and left ventricular hypertrophy (LVH) group (15 patients), and treated with cilnidipine for 2 months. Before and after treatment, the participants were examined by echocardiography. Tissue Doppler Tei index was calculated as diastolic time interval measured from end of late diastole to origin of early diastole (a') minus systolic Sm duration (b') divided by b', that is Tei index = (a'-b')/b'. Thirty-seven hypertensive patients finished the treatment. Tei index was significantly higher in NLVH and LVH groups than in control group, and in LVH group than in NLVH group (0.44+/-0.07 vs 0.28+/-0.06, P < 0.001; 0.51+/-0.13 vs 0.28+/-0.06, P < 0.001; 0.51+/-0.13 vs 0.44+/-0.07, P < 0.05). After treatment, Tei index was significantly decreased (0.40+/-0.11 vs 0.46+/-0.10, P < 0.0001); systolic blood pressure and diastolic blood pressure were also decreased significantly. In conclusion, Tei index is impaired in hypertensives before development of ventricular hypertrophy and impairment is more prominent in hypertrophy. Cilnidipine can improve left ventricular function. Tissue Doppler Tei index is gaining importance in evaluating LV function after drug intervention in hypertensive patients.

Effect of Losartan and Amlodipine on Left Ventricular Diastolic Function in Patients With Mild-to-Moderate Hypertension (J-ELAN) Rationale and Design

BACKGROUND

Hypertension is a major underlying disease that may cause left ventricular (LV) diastolic dysfunction, even without LV systolic dysfunction, and antihypertensive drugs could affect LV diastolic function.

METHODS AND RESULTS

The Effect of Losartan and Amlodipine on Left Ventricular Diastolic Function in Patients With Mild-to-Moderate Hypertension (J-ELAN) study is a multicenter, prospective, randomized trial designed to assess the effects of losartan and amlodipine on LV diastolic function in hypertensive patients with LV diastolic dysfunction in the absence of systolic dysfunction. A total of 300 patients (150 patients in each group) will be enrolled. In addition to Doppler echocardiographic indices of LV diastolic function, changes in LV structure and atherosclerosis of the carotid arteries will be serially assessed. The maximum follow-up period is 18 months.

CONCLUSIONS

This study will provide the characteristic differences in the effects of amlodipine and losartan on LV diastolic dysfunction in hypertensive patients.

Impairment of cardiac function in hypertensive patients with Type 2 diabetes: a LIFE study

AIMS

Type 2 diabetic patients with hypertension have an increased left ventricular (LV) mass and impaired cardiac function compared to hypertensive patients without diabetes. However, it is unknown if the impaired cardiac function can be explained solely by LV hypertrophy, or is independently related to diabetes. The aim of the present study was to compare LV function between diabetic and non-diabetic hypertensive patients with electrocardiographic LV hypertrophy.

METHODS

In 937 patients participating in the LIFE echocardiographic substudy, all echocardiograms were centrally evaluated by a core reading centre measuring LV mass, systolic and diastolic LV function. Known diabetes was present in 105 patients.

RESULTS

Left ventricular mass was similar in diabetic and non-diabetic patients. Endocardial systolic LV function, estimated by LV ejection fraction, was reduced and indices of midwall systolic LV function were impaired in the diabetic patients. Diastolic LV filling pattern was impaired and arterial stiffness, measured by pulse pressure/stroke index, was increased in diabetic patients.

CONCLUSIONS

Systolic and diastolic LV function in hypertensive patients with electrocardiographic LV hypertrophy and diabetes are impaired independent of LV mass, most likely reflecting the adverse effects of diabetes per se.

The mitral L wave: A marker of pseudonormal filling and predictor of heart failure in patients with left ventricular hypertrophy

OBJECTIVES

We sought to examine the relationship of the mitral L wave with echocardiographic indexes of diastolic function and heart failure (HF) events in patients with left ventricular (LV) hypertrophy (LVH).

BACKGROUND

The L wave, representing middiastolic transmitral flow, is of unknown clinical and prognostic significance in patients with LVH. Methods Consecutive echocardiograms performed during a 6-month period were screened for patients with LVH, normal LV ejection fraction, in sinus rhythm, and no significant valvular disease. Clinical and echocardiographic characteristics were analyzed, and patients were followed up for incident HF.

RESULTS

Of 177 patients, the L wave was present in 35 (20%) (group I) and absent in 142 (group II). Patients in group I had higher early (E) to late (A) transmitral flow velocity (E/A) ratio (1.2 vs 0.8), shorter mitral E wave deceleration time (201 vs 225 milliseconds), lower pulmonary venous systolic/diastolic velocity ratio (1.1 vs 1.6), shorter LV isovolumic relaxation time (83 vs 94 milliseconds), larger left atrial volume (36 vs 23 mL/m 2 ), and higher E to early mitral annular velocity (E/E') ratio (septal E/E', 12.2 vs 9.1; lateral annular E/E', 10.9 vs 7.8) compared with group II (all P < .05). The difference between pulmonary venous atrial reversal and mitral A wave durations was > or = 30 milliseconds in more patients of group I (70% vs 6%, P < .001). During a mean follow-up of 12.0 months, 11 patients were hospitalized for HF. The L wave was associated with a hazard ratio of 4.7 ( P = .011) for incident HF, and remained a significant predictor (hazard ratio 4.2, P = .026) after adjustment for cardiovascular risk factors.

CONCLUSIONS

In patients with LVH, the mitral L wave appears to be a marker of pseudonormal LV filling and predictor of future HF events.

Left ventricular structure and function in sedentary and physically active subjects with left ventricular hypertrophy (the LIFE Study)

Patients with left ventricular hypertrophy had higher heart rates, left ventricular mass, and left atrial size independent of gender, blood pressure, or body mass index than physically active patients.

Exercise blood pressure, cardiac structure, and diastolic function in young normotensive patients with polycystic kidney disease: a prehypertensive state

BACKGROUND

Increased left ventricular mass (LVM) and left ventricular hypertrophy have been found in early stages of autosomal dominant polycystic kidney disease (ADPKD). The mechanisms that lead to an increase in LVM in this population are unknown. The aim of this study is to evaluate blood pressure (BP) response to exercise and very early alterations in cardiac structure and diastolic function in young normotensive patients with ADPKD.

METHODS

Color Doppler echocardiography and exercise treadmill testing according to the Bruce protocol were performed in 18 young normotensive patients with ADPKD and 18 healthy subjects.

RESULTS

LVM index was greater and isovolumic relaxation time (IVRT) was longer in patients with ADPKD than controls (93.3 +/- 21.4 versus 77.5 +/- 18.6 g/m2; P = 0.02; 100 +/- 20.2 versus 80 +/- 9.7 milliseconds; P = 0.001, respectively). Exercise capacity in metabolic equivalents was similar in both groups. Systolic BP response during exercise and recovery were similar in both groups. Diastolic BP decreased during exercise, but the magnitude of decrease was lower in patients with ADPKD than controls (P = 0.01). During recovery, patients with ADPKD showed a greater sustained diastolic BP than controls (P = 0.02). Patients with ADPKD with an exaggerated systolic BP response had a greater LVM index than those with a normal response (112.1 +/- 10.4 versus 84 +/- 19.2 g/m2; P = 0.001). Multivariate regression analysis showed that exercise systolic BP and diastolic BP were independent predictors of LVM index and IVRT, respectively.

CONCLUSION

Young normotensive patients with ADPKD showed increased LVM index and prolonged IVRT, which are related to exercise BP response. Exaggerated diastolic BP response during exercise suggests an impaired capacity for exercise-induced vasodilatation and may indicate a greater risk for the development of future hypertension.

Left ventricular concentric geometry is associated with impaired relaxation in hypertension: the HyperGEN study

AIMS

We tested the hypothesis that abnormal left ventricular (LV) relaxation is associated with concentric LV geometry.

METHODS AND RESULTS

Doppler LV filling properties were studied in 1384 hypertensive participants without cardiovascular disease, from the HyperGEN population (731 women, 784 obese, 236 diabetic) and compared in four LV geometry groups; normal, concentric remodelling (3.5%), eccentric (23%), and concentric LV hypertrophy (4%), based on echocardiographic LV mass index (in g/m(2.7)). Abnormal LV relaxation was identified by European Society of Cardiology criteria in 275 subjects (20%). After accounting for significant confounders, E/A ratio and isovolumic relaxation time were not related to the presence of LV hypertrophy, but indicated abnormal relaxation when LV geometry was concentric (both P<0.0001). Deceleration time of E velocity was prolonged with LV hypertrophy (P<0.03), but the behaviour in relation to concentric LV geometry differed in the presence (prolonged) or absence (reduced) of LV hypertrophy (P=0.05), a difference independently related to the magnitude of both transmitral gradients and stroke volume (all P<0.05). Logistic regression showed that, compared with normal LV geometry, the odds of abnormal LV relaxation was 2.3-fold greater when LV geometry was concentric and that LV hypertrophy conferred a borderline higher risk than normal LV mass.

CONCLUSIONS

In hypertensive individuals without prevalent cardiovascular disease from a multi-ethnic population-based sample, delayed LV relaxation is independently associated with concentric LV geometry.

No association of interleukin-6 gene polymorphism (−174 G/C) with myocardial infarction or traditional cardiovascular risk factors

BACKGROUND

Recently, a polymorphism at position -174 (G>C) of the interleukin-6 (IL-6) promoter was found to be associated with an increased prevalence of myocardial infarction (MI). The aim of the present study was to further investigate the association of the IL-6 -174 G/C allele status with specific end organ damage, i.e. myocardial infarction in large population-based samples.

METHODS

Individuals from two Bavarian samples of MI patients (total n=1322) and the population-based Augsburg MONICA survey (1023 unselected controls) were studied by questionnaire, physical examination, echocardiographical assessment and biochemical analyses. The -174 G/C polymorphism was genotyped using a newly established PCR-RFLP. IL-6 levels were measured in a subset of 574 MI patients.

RESULTS

In the population-based sample, the IL-6 genotype was neither associated with traditional cardiovascular risk factors (systolic and diastolic blood pressure, total cholesterol, HDL and LDL cholesterol, body mass index, diabetes mellitus) nor with cardiac structural or functional parameters (left ventricular mass index, ejection fraction, diastolic inflow pattern). Moreover, the genotype distribution of the -174 G/C polymorphism was not different in MI patients (GG: 34.1%; GC: 47.4%; CC: 18.5%) and population-based controls (GG: 32.4%; GC: 48.8%; CC: 18.9%) (p=0.67). IL-6 levels were neither related to the -174 G/C polymorphism (p=0.29) nor to ACE-inhibitor treatment (2.16 with vs. 2.09 pg/ml without ACE-inhibitor, p=0.27). However, patients receiving statins displayed significantly lower IL-6 levels (1.83 vs. 2.32 pg/ml in the group without statins, p<0.0001).

CONCLUSIONS

This extensive investigation failed to obtain evidence that the IL-6 -174 G/C promoter polymorphism affects traditional cardiovascular risk factors or the prevalence of myocardial infarction in a Caucasian sample.

Relation of impaired left ventricular filling to systolic midwall mechanics in hypertensive patients with normal left ventricular systolic chamber function: the Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) study

BACKGROUND

Patients with hypertensive left ventricular (LV) hypertrophy commonly have diastolic dysfunction with preserved LV ejection fraction. LV systolic midwall shortening (MWS) may be impaired in hypertensive patients with normal LV ejection fraction. However, it is unclear whether impaired LV filling is related to depressed systolic midwall mechanics.

METHODS

Echocardiographic measures of LV diastolic filling and systolic performance were compared in 632 unmedicated patients with stage II or III hypertension and LV hypertrophy determined by electrocardiogram, with LV ejection fraction >55% and <2+ mitral regurgitation.

RESULTS

Stress-corrected LV MWS, an index of myocardial contractility, was lower in patients with abnormal as opposed to normal LV filling patterns (98% +/- 12% vs 102% +/- 10%, P <.001) and in patients with prolonged as opposed to normal isovolumic relaxation time (IVRT) (98% +/- 13% vs 101% +/- 12%, P =.014). Stress-corrected MWS was <85% of predicted levels in more patients with abnormal LV filling patterns (11.8% vs 6.3%) or with long IVRT (> or =105 msec) (34% vs 21%, both P <.05). In regression analyses, lower stress-corrected MWS and higher LV mass were independent correlates of longer IVRT, while lower stress-corrected MWS was the only independent correlate of prolonged mitral valve deceleration time (P =.017). Higher LV mass had strong, statistically independent relationships to longer IVRT (by 0.3 g/msec) and decreased stress-corrected MWS (by 0.5 g/%; both P <.0001), independent of body size and age.

CONCLUSION

In patients with moderate hypertension and target organ damage who have normal LV ejection fraction, impaired early diastolic LV relaxation (abnormal E/A ratio, prolonged IVRT and deceleration time) is associated with impaired LV systolic midwall mechanics independent of higher LV mass.

Impact of age on left ventricular hypertrophy regression during antihypertensive treatment with losartan or atenolol (the LIFE study)

To assess the influence of age on changes in left ventricular (LV) mass and geometry during antihypertensive treatment, we related age to clinical and echocardiographic findings before and after 4 years of antihypertensive treatment in a subset of 560 hypertensive patients without known concurrent disease in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study, which randomized patients to blinded losartan- or atenolol-based treatment. Patients >/=65 years (older group) included more women and patients with isolated systolic hypertension or albuminuria (all P<0.05). Compared to patients <65 years, older patients had higher pulse pressure, LV mass, and prevalence of concentric hypertrophy at baseline (78 vs 69 mmHg, 234 vs 224 g, and 28 vs 16%, respectively, all P<0.01), while the mean blood pressure did not differ. Over 4 years, reductions in LV mass and the mean blood pressure were similar in both groups, but older patients more often had residual hypertrophy (31 vs 15%, P<0.001) with a preponderance of eccentric geometry. In multivariate analysis of 4-year change in LV mass controlling for baseline mass, larger hypertrophy reduction was associated with losartan treatment, while age, gender, body mass index, and 4-year change in pulse pressure and albuminuria did not enter (Multiple R (2)=0.40, P<0.001). Thus, in up-to-80-year-old hypertensive patients with left ventricular hypertrophy, age did not significantly attenuate hypertrophy reduction during antihypertensive treatment, although residual hypertrophy was more prevalent in older patients as a consequence of higher initial LV mass.

Association of left bundle branch block with left ventricular structure and function in hypertensive patients with left ventricular hypertrophy: the LIFE study

Electrocardiographic (ECG) left bundle branch block (LBBB) is associated with left ventricular hypertrophy (LVH), but its relation to left ventricular (LV) geometry and function in hypertensive patients with ECG LVH is unknown. Echocardiograms were performed in 933 patients (548 women, mean age 66+/-7 years) with essential hypertension and LVH by baseline ECG in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study. LBBB, defined by Minnesota code 7.1, was present in 47 patients and absent in 886 patients. Patients with and without LBBB were similar in age, gender, body mass index, blood pressure, prevalence of diabetes, and history of myocardial infarction. Despite similarly elevated mean LV mass (126+/-25 vs 124+/-26 g/m(2)) and relative wall thickness (0.41+/-0.07 vs 0.41+/-0.07, P=NS), patients with LBBB had lower LV fractional shortening (30+/-6 vs 34+/-6%), ejection fraction (56+/-10 vs 61+/-8%), midwall shortening (14+/-2 vs 16+/-2%), stress-corrected midwall shortening (90+/-13 vs 97+/-13%) (all P<0.001), and lower LV stroke index (38+/-7 vs 42+/-9 ml/m(2)) (P<0.05). Patients with LBBB also had reduced LV inferior wall and lower mitral E/A ratio (0.75+/-0.18 vs 0.87+/-0.38) (all P<0.05). The above univariate results were confirmed by multivariate analyses adjusted for gender, age, blood pressures, height, weight, body mass index, heart rate, and LV mass index. Among hypertensive patients at high risk because of ECG LVH, the presence of LBBB identifies individuals with worse global and regional LV systolic function and impaired LV relaxation without more severe LVH by echocardiography.

Left Ventricular Concentric Geometry During Treatment Adversely Affects Cardiovascular Prognosis in Hypertensive Patients

Left ventricular (LV) mass and geometry predict risk for cardiovascular events in hypertension. Regression of LV hypertrophy (LVH) may imply an important prognostic significance. The relation between changes in LV geometry during antihypertensive treatment and subsequent prognosis has not yet been determined. A total of 436 prospectively identified uncomplicated hypertensive subjects with a baseline and follow-up echocardiogram (last examination 72+/-38 months apart) were followed for an additional 42+/-16 months. Their family doctor gave antihypertensive treatment. After the last follow-up echocardiogram, a first cardiovascular event occurred in 71 patients. Persistence of LVH from baseline to follow-up was confirmed as an independent predictor of cardiovascular events. Cardiovascular morbidity and mortality were significantly greater in patients with concentric (relative wall thickness > or =0.44) than in those with eccentric geometry (relative wall thickness <0.44) in patients presenting with LVH (P=0.002) and in those without LVH (P=0.002) at the follow-up echocardiogram. The incidence of cardiovascular events progressively increased from the first to the third tertile of LV mass index at follow-up (partition values 91 and 117 g/m2), but for a similar value of LV mass index it was significantly greater in those with concentric geometry (OR: 4.07; 95% CI: 1.49 to 11.14; P=0.004 in the second tertile; OR: 3.45; 95% CI: 1.62 to 7.32; P=0.001 in the third tertile; P<0.0001 in concentric versus eccentric geometry). Persistence or development of concentric geometry during follow-up may have additional prognostic significance in hypertensive patients with and without LVH.