Prognostic value of left ventricular mass in uncomplicated acute myocardial infarction and one-vessel coronary artery disease

Rationale and Design of the Cardiac Magnetic Resonance Imaging Substudy of the ONTARGET Trial Programme

Angiotensin-converting enzyme (ACE) inhibitors have been shown to improve cardiovascular disease outcomes in high-risk patients, but evidence for the cardioprotective effects of angiotensin II receptor blockers (ARBs) is less extensive. The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) and the parallel Telmisartan Randomized AssessmeNt Study in aCE iNtolerant subjects with cardiovascular Disease (TRANSCEND) - which together form The ONTARGET Trial Programme – are long-term, large-scale, double-blind, multinational outcome studies with the primary objectives of determining if the combination of the ARB telmisartan 80 mg and the ACE inhibitor ramipril 10 mg is more effective than ramipril 10 mg alone, and if telmisartan is at least as effective as ramipril (in the case of ONTARGET), and if telmisartan is superior to placebo (in the case of TRANSCEND), in providing cardiovascular protection for high-risk patients. A pre-defined substudy is being conducted within The ONTARGET

Trial Programme to compare the effects of these agents, alone and in combination, on cardiac structure and function. The substudy overcomes criticisms of many previous studies, which have been performed in small numbers of patients using suboptimal methodology, by evaluating changes in left ventricular structure and function using sophisticated technology provided by magnetic resonance imaging (MRI). Some 300 randomized patients within ONTARGET, recruited from selected centres in Australia, Canada, Germany, Hong Kong, New Zealand and Thailand, will have MRI undertaken at baseline and at 2-year follow-up. As this method of assessing left ventricular dysfunction is somewhat time-consuming, expensive and complex, and in the light of current interest in the role of B-type natriuretic peptide (BNP) as a simple, inexpensive diagnostic and prognostic tool, the substudy will also examine whether changes in BNP during follow-up correlated with changes in left ventricular dysfunction.

Left Ventricular Wall Stress-Mass-Heart Rate Product and Cardiovascular Events in Treated Hypertensive Patients: LIFE Study

In the Losartan Intervention for End Point Reduction in Hypertension (LIFE) study, 4.8 years' losartan- versus atenolol-based antihypertensive treatment reduced left ventricular hypertrophy and cardiovascular end points, including cardiovascular death and stroke. However, there was no difference in myocardial infarction (MI), possibly related to greater reduction in myocardial oxygen demand by atenolol-based treatment. Myocardial oxygen demand was assessed indirectly by the left ventricular mass×wall stress×heart rate (triple product) in 905 LIFE participants. The triple product was included as time-varying covariate in Cox models assessing predictors of the LIFE primary composite end point (cardiovascular death, MI, or stroke), its individual components, and all-cause mortality. At baseline, the triple product in both treatment groups was, compared with normal adults, elevated in 70% of patients. During randomized treatment, the triple product was reduced more by atenolol, with prevalences of elevated triple product of 39% versus 51% on losartan (both P≤0.001). In Cox regression analyses adjusting for age, smoking, diabetes mellitus, and prior stroke, MI, and heart failure, 1 SD lower triple product was associated with 23% (95% confidence interval 13%-32%) fewer composite end points, 31% (18%-41%) less cardiovascular mortality, 30% (15%-41%) lower MI, and 22% (11%-33%) lower all-cause mortality (all P≤0.001), without association with stroke (P=0.34). Although losartan-based therapy reduced ventricular mass more, greater heart rate reduction with atenolol resulted in larger reduction of the triple product. Lower triple product during antihypertensive treatment was strongly, independently associated with lower rates of the LIFE primary composite end point, cardiovascular death, and MI, but not stroke.

Prognostic value of left ventricular global function index in patients after ST-segment elevation myocardial infarction

AIMS

The left ventricular global function index (LVGFI) is a novel indicator of left ventricular performance. Its prognostic value in patients after ST-segment elevation myocardial infarction (STEMI) is unknown. We sought to evaluate the prognostic significance of LVGFI measured by cardiovascular magnetic resonance (CMR) imaging after STEMI.

METHODS AND RESULTS

Two hundred eligible STEMI patients (56 ± 11 years, 16% female) revascularized by primary percutaneous coronary intervention were followed-up for 3.1 [2-4.1] years for major adverse cardiac events (MACE). MACE was defined as a composite of death, non-fatal myocardial re-infarction, and new congestive heart failure. All patients underwent CMR imaging within 2 [2-4] days after STEMI. Late enhancement and cine images were acquired to assess myocardial injury as well as myocardial function, including LVGFI. Patients suffering a MACE event (n = 20, 10%) had a significantly lower LVGFI (P = 0.001). In Kaplan-Meier analysis, a decreased LVGFI was associated with a reduced MACE-free survival (P < 0.001). Multivariate Cox regression analysis revealed a decreased LVGFI as a predictor for MACE [hazard ratio = 4.79, 95% confidence interval (CI) 1.46-15.67, P = 0.010] after adjusting for microvascular obstruction, left ventricular mass, and multivessel disease. In receiver operating characteristic analysis, LVGFI was a strong predictor for MACE (area under the curve = 0.73, CI 0.61-0.85). However, c-statistics revealed that LVGFI does not provide incremental prognostic information over left ventricular ejection fraction (LVEF) (P = 0.38).

CONCLUSION

LVGFI assessed by CMR is a strong predictor of MACE within 3 years after first STEMI. A superior predictive value as compared with LVEF was not found in this study.

Effects of bariatric surgery on cardiac structure and function: a systematic review and meta-analysis

BACKGROUND

Morbid obesity, a condition increasingly treated with bariatric procedures, is strongly associated with left ventricular (LV) hypertrophy and impaired LV function. We analyzed the literature to provide comprehensive information on cardiac structural and functional changes, as assessed by imaging techniques, after bariatric surgery.

METHODS

The studies were identified by the following search terms: "bariatric surgery," "obesity," "left ventricle," "left ventricular hypertrophy," "cardiac hypertrophy," "ventricular dysfunction," "left ventricular hypertrophy regression," "echocardiography," "magnetic resonance imaging," and "cardiac imaging techniques."

RESULTS

In a pooled population of 1,022 obese subjects with preserved systolic function included in 23 studies, bariatric procedures induced (i) a decrease in LV mass (standardized mean difference (SMD) = -0.46; P < 0.001) and relative wall thickness (SMD = -0.20; P < 0.001); (ii) an improvement of LV diastolic function, as reflected by the increase in mitral flow E/A ratio (SMD = +0.39; P < 0.001); (iii) a decrease in left atrium diameter (SMD = -0.26; P < 0.001); or (iv) no changes in LV ejection fraction (SMD = +0.03; P = 0.46).

CONCLUSIONS

The present meta-analysis, the largest to date focusing on cardiac structural and functional changes in morbidly obese subjects after bariatric surgery, documents that this therapeutic approach exerts important cardioprotective effects in terms of regression of LV hypertrophy, improvement of LV geometry and diastolic function, and reduction of left atrial size.

Association of left ventricular mass with all-cause mortality, myocardial infarction and stroke

BACKGROUND

Our aim was to assess the association of left ventricular mass with mortality and nonfatal cardiovascular events.

METHODOLOGY/PRINCIPAL FINDINGS

Left ventricular mass was measured by echocardiography in 40138 adult patients (mean age 61.1 ± 16.4 years, 52.5% male). The primary endpoint was all-cause mortality. Secondary endpoints included nonfatal myocardial infarction and nonfatal stroke. During a mean follow-up period of 5.6 ± 3.9 years, 9181 patients died, 901 patients had a nonfatal myocardial infarction, and 2139 patients had a nonfatal stroke. Cumulative 10-year mortality was 26.8%, 31.9%, 37.4% and 46.4% in patients with normal, mildly, moderately and severely increased left ventricular mass, respectively (p<0.001). Ten-year rates of nonfatal myocardial infarction and stroke ranged from 3.2% and 6.7% in patients with normal left ventricular mass to 5.3% and 12.7% in those with severe increase in left ventricular mass, respectively. After multivariate adjustment, left ventricular mass remained an independent predictor of all-cause mortality (hazard ratio [HR] per 100 g increase 1.21, 95% confidence interval [CI] 1.14-1-27, p<0.001 in women, and HR 1.09, 95% CI 1.04-1-13, p<0.001 in men), myocardial infarction (HR 1.60, 95% CI 1.31-1.94, p<0.001 in women and HR 1.15, 95% CI 1.02-1.29, p=0.019 in men) and stroke (HR 1.26, 95% CI 1.13-1.40, p<0.001 in women and HR 1.19, 95% CI 1.09-1.30, p<0.001 in men).

CONCLUSIONS/SIGNIFICANCE

Left ventricular mass has a graded and independent association with all-cause mortality, myocardial infarction and stroke.

Hypertension and acute myocardial infarction: an overview

History of hypertension is a frequent finding in patients with acute myocardial infarction (AMI) and its recurring association with female sex, diabetes, older age, less frequent smoking and more frequent vascular comorbidities composes a risk profile quite distinctive from the normotensive ischemic counterpart.Antecedent hypertension associates with higher rates of death and morbid events both during the early and long-term course of AMI, particularly if complicated by left ventricular dysfunction and/or congestive heart failure. Renin-angiotensin-aldosterone system blockade, through either angiotensin-converting enzyme inhibition, angiotensin II receptor blockade or aldosterone antagonism, exerts particular benefits in that high-risk hypertensive subgroup.In contrast to the negative implications carried by antecedent hypertension, higher systolic pressure at the onset of chest pain associates with lower mortality within 1 year from coronary occlusion, whereas increased blood pressure recorded after hemodynamic stabilization from the acute ischemic event bears inconsistent relationships with recurring coronary events in the long-term follow-up.Whether antihypertensive treatment in post-AMI hypertensive patients prevents ischemic relapses is uncertain. As a matter of fact, excessive diastolic pressure drops may jeopardize coronary perfusion and predispose to new acute coronary events, although the precise cause-effect mechanisms underlying this phenomenon need further evaluation.

Correlation between coronary artery disease severity, left ventricular mass index and carotid intima media thickness, assessed by radio-frequency

Background

Intima-media thickness of the common carotid artery (CCA-IMT) is a validated marker of systemic atherosclerosis process. The aim of this study was to evaluate the association between coronary artery disease (CAD), left ventricular hypertrophy (LVH) and CCA-IMT, assessed by Radio Frequency-Quality Intima Media Thickness (^RFQIMT) method, the next generation of IMT real-time measurement, based on the direct analysis of the radiofrequency signal and endowed with high accuracy and reproducibility in early detection of arterial wall thickness.

Methods

115 patients (76 men, mean age: 65.1 ± 12 years) referred to our department and shown significant (≥ 70% luminal obstruction) stenosis at least in one major epicardial coronary artery were studied. Coronary angiograms were divided for severity and extent of the disease: 79 patients (69%) had one, 24 patients (21%) two, 12 patients (10%) three major epicardial coronary arteries with ≥ 70% stenosis. All patients underwent echocardiography and carotid ultrasound examination, assessed by RF.

Results

Dividing ^RFQIMT data in tertiles, dyslipidaemia (31 patients with IMT ≥ 1.20 mm vs 16 with IMT = 0.91-1.19 vs 25 with IMT ≤ 0.9, p = 0.004), LVMI (153.5 ± 20.6 g/m² in IMT ≥ 1.20 mm vs 131.2 ± 8.4 g/m² in IMT = 0.91-1.19 mm vs 114.3 ± 11.1 g/m² in IMT ≤ 0.9 mm, P < 0.001) and number of high stenosed coronary arteries (IMT ≥ 1.20 mm population more often showed three vessel diseases than IMT ≤ 0.90 mm one, P < 0.001) seemed to be significantly related to CCA-IMT increases. Furthermore, LVMI is positively related to IMT (r = 0.91; P < 0.001). In a multivariate regression model (R² = 0.88), ^RFQIMT remained significantly associated with the dyslipidemia (regression coefficient ± standard error [SE]: 0.057 ± 0.023; p = 0.017), LVMI (regression coefficient ± SE: 0.01 ± 0.001; P < 0.0001) and number of damaged coronaries (regression coefficient ± SE: 0.0174 ± 0.028; P < 0.0001).

Conclusions

^RFQIMT is a sophisticated method for carotid ultrasound evaluation. Its evaluation in patients with at least one important major epicardial coronary vessel stenosis would help the accuracy in the general assessment of the number of coronary lesions in these patients.

Prognostic impact of left ventricular mass severity according to the classification proposed by the American Society of Echocardiography/European Association of Echocardiography

BACKGROUND

The American Society of Echocardiography (ASE) and European Association of Echocardiography (EAE) recommend the use of quantitative estimation of left ventricular (LV) mass and defined partition values for mild, moderate, and severe hypertrophy. However, the prognostic implications associated with this categorization are unknown.

METHODS

In this observational cohort study of unselected adults undergoing echocardiography for any indication, LV hypertrophy was assessed using the ASE/EAE-recommended formula and measurement convention from LV linear dimensions indexed to body surface area. Mortality and incident hospitalizations for cardiovascular disease were the outcomes of this study.

RESULTS

Of 2,545 subjects (mean age, 61.9 ± 15.8 years; 56.3% women), 52.9% had normal LV mass, and 15.4% had mild, 12.1% moderate, and 19.6% severe LV hypertrophy. During a mean follow-up period of 2.5 ± 1.2 years, 121 deaths and 292 incident hospitalizations for cardiovascular disease occurred. In multivariate models including age, gender, LV ejection fraction, wall motion score index, significant valvular disease, and atrial fibrillation, the adjusted hazard ratios for death were 1.81 (95% confidence interval [CI], 1.03-3.20; P = .041) for mild, 2.31 (95% CI, 1.33-4.01; P = .003) for moderate, and 2.30 (95% CI, 1.39-3.79, P = .001) for severe LV hypertrophy. The adjusted hazard ratios for incident cardiovascular hospitalizations were 1.24 (95% CI, 0.84-1.82; P = .277) for mild, 2.02 (95% CI, 1.42-2.88; P = .0001) for moderate, and 2.38 (95% CI, 1.75-3.22, P < .0001) for severe LV hypertrophy. After adjustment for known risk predictors, there was a 1.3-fold risk for death and cardiovascular disease events per category of LV mass (P = .001).

CONCLUSIONS

In a cohort study of unselected adult outpatients, the categorization of LV mass according to the ASE/EAE recommendations offered prognostic information independently of age, gender, and other known predictors.

Aortic elastic properties in nonalcoholic fatty liver disease

BACKGROUND

Recent studies have shown that patients with nonalcoholic fatty liver disease (NAFLD) have an increased risk of developing cardiovascular disease. Aortic stiffness, an early marker of arteriosclerosis, is associated with cardiovascular mortality. In this study, the aortic elastic properties of nondiabetic, normotensive NAFLD patients were evaluated.

METHODS

Thirty-five patients with NAFLD and 30 age-matched and sex-matched healthy controls were enrolled. Aortic distensibility, aortic strain, aortic stiffness index (ASI), left ventricular mass index (LVMI), homeostasis model assessment of insulin resistance (HOMA-IR) and fasting lipid parameters were assessed in both the groups.

RESULTS

ASI was higher in NAFLD patients (7.1+/-2.0) than in the control group (3.8+/-1.0) (P<0.01). Aortic distensibility and aortic strain were also significantly decreased in NAFLD patients as compared with the control group (2.9+/-0.7 cm/dyn vs. 6.3+/-2.4 cm/dyn, P<0.0001 and 7.1+/-1.7 vs. 14.5+/-4.0, P<0.0001, respectively). Although ASI was significantly correlated with age, HOMA-IR, waist circumference, body mass index and LVMI, a stepwise multiple linear regression analysis showed that HOMA-IR and LVMI were the only variables associated with ASI index [(standardized beta coefficient= 0.41, P=0.004, overall R=0.17) and (standardized beta coefficient=0.31, P=0.02, overall R=0.10), respectively].

CONCLUSION

Our data suggest that aortic elasticity is significantly impaired and is also associated with insulin resistance and LVMI in NAFLD patients, which may contribute to the relationship between NAFLD and the increased risk of cardiovascular disease among these patients.

A distinct AMP-activated protein kinase phosphorylation site characterizes cardiac hypertrophy induced by L-thyroxine and angiotensin II

1. The purpose of the present study was to evaluate differences in the AMP-activated protein kinase (AMPK) phosphorylation sites in cardiac hypertrophy induced by L-thyroxine and angiotensin (Ang) II. 2. Cardiac hypertrophy was induced in wild-type and AMPKalpha2-knockout mice by treatment with 1 mg/kg, i.p., thyroxine or 1.44 mg/kg per day AngII for 14 days. The phenotype of the hypertrophy was evaluated using echocardiographic measurements and histological analyses. The phosphorylation of AMPK at alpha-Ser(485/491) and alpha-Thr(172) was determined by western blot analysis. 3. In wild-type mice, the phosphorylation of AMPKalpha-Ser(485/491) was significantly elevated in the AngII-treated group, but not in the thyroxine-treated group, compared with the vehicle control group. In contrast, the phosphorylation of AMPKalpha-Thr(172) was significantly increased by thyroxine, but not AngII, treatment compared with the vehicle control group. Furthermore, knockout of the AMPKalpha2 subunit abolished phosphorylation at the alpha-Ser(485/491) site and significantly suppressed phosphorylation at the alpha-Thr(172) site, resulting in alleviation of thyroxine- but not AngII-induced hypertrophy. 4. In conclusion, L-thyroxine and AngII induce the phosphorylation of distinct sites of AMPK in cardiac hypertrophy. Phosphorylation of AMPK alpha-Thr(172) may contribute to thyroxine-induced cardiac hypertrophy.

Prevalence and risk factors of myocardial remodeling in hemodialysis patients

BACKGROUND

Left ventricular hypertrophy (LVH) is an independent risk factor for morbidity/mortality in patients with end stage renal disease (ESRD). Our study aimed to identify prevalence as well as independent risk factors that contribute to the development of LV geometric remodeling in our HD patients.

METHODS

The left ventricles of 116 HD patients were classified echocardiographically into four different geometric patterns on the basis of LV mass and relative wall thickness. Furthermore, we measured inferior vena cava (IVC) diameter and its collapsibility index (CI) by echocardiography. Finally, we modeled a stepwise multiple regression analysis to determine the predictors of LV geometry.

RESULTS

Our study provides evidence that HD patients had a prevalence of abnormal LV geometry in 92% and LVH in 81%. We found all four geometric models of LV. Most dominant were eccentric LVH. Concentric LVH was observed in 37, normal geometry (NG) in 9, and concentric remodeling (CR) in 13 of HD patients. Mean arterial blood pressure was significantly higher in the cLVH group (95 +/- 10 mmHg) than in the NG and CR groups (81.6 +/- 12.3 and 80 +/- 11.8, respectively, p < 0.001). The cLVH and eCLVH groups had significantly lower mean hemoglobin (10.3 +/- 1.4 g/dL and 10.6 +/- 1g/dL, respectively) compared with the NG group (11.9 +/- 1.4 g/dL), p < 0.001. Furthermore, interdialytic weight gain (kg) was significantly higher in eCLVH group (3.13 +/- 0.8) than in NG group (2.3 +/- 1.1), p < 0.001. Mean IVC index of the eLVH group (10.83 +/- 2.07 mm/m(2)) was significantly higher than corresponding indexes of NG (10.83 +/- 2.07 mm/m(2)), CR (8.31 +/- 1.32 mm/m(2)) and cLVH (8.12 +/- 2.06 mm/m(2)) groups (p < 0.001 for each comparisons).

CONCLUSION

Mean arterial pressure, hemoglobin, IVC index, and interdialytic weight gain were found to be independent predictors of LV geometry (R(2) = 0.147; p < 0.001) in HD patients.

Feasibility of automatic assessment of four-chamber cardiac function with MDCT: Initial clinical application and validation

BACKGROUND

The ability to perform a simultaneous analysis of ventricular and atrial volumes may provide clinically useful information for diagnosis and prognosis. We aimed to evaluate the feasibility and clinical value of a novel algorithm that performs fully automatic evaluation of the four cardiac chambers and myocardium from gated CT datasets.

METHODS

50 patients were studied-Group 1: 30 consecutive unselected patients, Group 2A: 10 patients after myocardial infarction and Group 2B: 10 normal controls. Fully automatic, segmentation of the heart was performed with a model-based segmentation algorithm requiring no user input other than loading the datasets. Qualitative and quantitative evaluation of segmentation quality was performed. Left ventricular (LV) and right ventricular (RV) stroke volumes (SV) were compared.

RESULTS

Overall, segmentation succeeded in all patients although 11/500 (2.2%) cardiac chambers achieved poor segmentation grading. Correlation coefficients between automatic and manually derived volumes were excellent (r>0.98) for all chambers. Bland-Altman analysis showed minimal bias (-1.0ml, 0.4ml, -1.8ml) for the LV and RV, and right atria, respectively, with mild overestimation of LV myocardial volume (5.2ml). Significant, yet consistent, overestimation of left atrial volume (23.6ml) due to inclusion of proximal pulmonary veins was observed. LV and RV ejection fraction (r=0.91 and 0.98) and SV (r=0.98 and 0.99) also correlated closely with minimal bias (<2%). Most significantly, LV SV (91.0+/-21.6ml) correlated highly with RV SV (81.7+/-18.2ml, r=0.86). Outliers could usually be explained by valvular regurgitation.

CONCLUSIONS

Fully automatic segmentation of all cardiac chambers can be achieved with high accuracy over multiple cardiac phases, enabling reliable comprehensive evaluation of four-chamber cardiac function.

Usefulness of electrocardiographic and echocardiographic left ventricular hypertrophy to predict adverse events in patients with a first non-ST-elevation acute myocardial infarction

Left ventricular hypertrophy (LVH) portends a worse outcome after non-ST-elevation acute myocardial infarction (NSTEMI). However, its definition has varied and the incremental prognostic information provided by echocardiography has been unclear. Different electrocardiographic and echocardiographic criteria for LVH were compared for their ability to predict in-hospital complications in 451 consecutive patients with a first NSTEMI, 337 of whom had a reliable echocardiogram. Five to 8% had LVH using Sokolow-Lyon or Cornell (voltage or product) criteria on admission; 15%, using either electrocardiographic criteria; and 24%, using echocardiography. LVH predicted the occurrence of adverse events (death, reinfarction, or severe angina or heart failure), with the strongest association found for the Cornell product (50.0% vs 24.9% of patients meeting or not meeting this criterion had complications, respectively; p = 0.002). This association persisted after adjusting for baseline clinical predictors (odds ratio 2.52, 95% confidence interval 1.19 to 5.35), and considering echocardiographic LVH did not improve the prediction. LVH was more closely related to heart failure occurrence than to recurrent ischemic events. A progressive increase in the rate of complications was observed across quartiles of the components of all LVH criteria (17.1%, 23.7%, 31.7%, and 36.2% for Cornell product, respectively; p <0.001). In conclusion, LVH, especially an abnormal Cornell product, increased the risk of heart failure, but was weakly related to recurrent ischemia in patients with NSTEMI. Echocardiographic LVH did not appear to add prognostic information to the electrocardiogram. However, considering LVH criteria in a more quantitative manner may augment their ability to predict adverse events in this population.

Electrocardiographic (ECG) criteria for determining left ventricular mass in young healthy men; data from the LARGE Heart study

BACKGROUND

Doubts remain over the use of the ECG in identifying those with increased left ventricular (LV) mass. This is especially so in young individuals, despite their high prevalence of ECG criteria for LV hypertrophy. We performed a study using cardiovascular magnetic resonance (CMR), which provides an in vivo non-invasive gold standard method of measuring LV mass, allowing accurate assessment of electrocardiography as a tool for defining LV hypertrophy in the young.

METHODS AND RESULTS

Standard 12-lead ECGs were obtained from 101 Caucasian male army recruits aged (mean +/- SEM) 19.7 +/- 0.2 years. LV mass was measured using CMR. LV mass indexed to body surface area demonstrated no significant correlation with the Cornell Amplitude criteria or Cornell Product for LV hypertrophy. Moderate correlations were seen with the Sokolow-Lyon Amplitude (0.28) and Sokolow-Lyon Product (0.284). Defining LV hypertrophy as a body surface area indexed left ventricular mass of 93 g/m(2), calculated sensitivities [and specificities] were as follows; 38.7% [74.3%] for the Sokolow-Lyon criteria, 43.4% [61.4%] for the Sokolow-Lyon Product, 19.4% [91.4%] for Cornell Amplitude, and 22.6% [85.7%] for Cornell Product. These values are substantially less than those reported for older age groups.

CONCLUSION

ECG criteria for LV hypertrophy may have little value in determining LV mass or the presence of LV hypertrophy in young fit males.

Measurement of left ventricular mass by contrast ventriculography

BACKGROUND

Elevated left ventricular mass (LVM) has been shown to be an important predictor of adverse cardiac events. Calculation of LVM using contrast ventriculography, as described by Rackley, involves measuring left ventricular wall thickness in a single plane, with assumptions made about ventricular geometry.

HYPOTHESIS

We hypothesized that a modification of the Rackley method, involving multiple measurements of left ventricular (LV) wall thickness in 2 orthogonal planes, may add value in the determination of LVM in patients with LV remodeling and dysfunction.

METHODS

The LVM was determined in 24 patients with LV dysfunction who had undergone both cardiac magnetic resonance imaging (CMRI) and contrast left ventriculography. Right anterior oblique (RAO) and left anterior oblique (LAO) still frames in diastole were used to measure LV length, chamber area, and wall thickness. From these variables, LV volume, myocardial volume, and LVM were calculated. The LVM calculations using an average wall thickness from the LAO and RAO projections were compared with LVM measured by CMRI.

RESULTS

Eighty eight percent of patients had hypertension, 100% had coronary artery disease, and mean left ventricular ejection fraction by contrast left ventriculography was 41 +/- 14%. Averaging left ventricular wall thickness from RAO and LAO projections using biplane ventriculography for LVM calculation yielded a strong correlation (r = 0.77, p < 0.01) with LVM calculated from CMR.

CONCLUSIONS

In patients with left ventricular dysfunction, biplane left ventricular wall thickness measurements for contrast ventriculography LVM calculations render a strong correlation with LVM calculated by CMRI.

Antecedent left ventricular mass and infarct size in ST-elevation myocardial infarction

BACKGROUND

Increased left ventricular mass index (LVMI) is associated with a greater incidence of acute myocardial infarction (AMI), but there are no data regarding its impact on infarct size.

OBJECTIVES

The objective of this study was to determine whether LVMI impacts on infarct size.

METHODS

We analyzed consecutive patients with a first ST-elevation AMI and successful reperfusion of the culprit artery who underwent an echocardiographic assessment of LVMI and regional wall motion score index (RWMSI) <72 hours post AMI.

RESULTS

Of the 165 patients (76.4% men) with a mean age of 61.0 +/- 13.9 years, 53.9% had anterior wall involvement and 59.3% had increased LVMI. There were no significant differences in baseline characteristics between patients with and without increased LVMI, except for a greater prevalence of hypertension among patients with increased LVMI (44.0% vs 22.4%, P < .001). The distributions of anterior wall AMI location and culprit artery involvement were similar between the groups. Patients with increased LVMI were more likely to present with single-vessel coronary artery disease (P = .04) and heart failure upon presentation (P = .03). There was no significant difference between patients with and without increased LVMI in peak creatine kinase (2106.8 +/- 1642.7 vs 2551.2 +/- 2357.4 U/L, P = .16) or RWMSI (1.62 +/- 0.44 vs 1.61 +/- 0.38, P = .91). In addition, no correlation was observed between LVMI as a continuous variable and RWMSI (r = 0.11, P = .18) or peak creatine kinase values (r = 0.02, P = .81).

CONCLUSIONS

Among patients with a first ST-elevation AMI and successful reperfusion, antecedent increased LVMI was fairly common and did not impact on infarct size.

Proximal to Middle Left Coronary Artery Flow Velocity Ratio, As Assessed Using Color Doppler Echocardiography, Predicts Coronary Artery Atherosclerosis in Mice

Background— We aimed to establish a completely noninvasive technique to assess coronary artery atherosclerosis in living mice using proximal to middle left coronary artery (LCA) velocity ratio as assessed with color Doppler echocardiography (CDE).

Methods and Results— Three groups of apolipoprotein E/low-density lipoprotein receptor double-knockout (apoE/LDLr dko) mice 10, 40, and 80 weeks of age and 3 additional age-matched groups of C57BL/6 mice were examined under anesthesia. Coronary flow velocity in proximal (V prox ) and middle part (V mid ) of LCA was measured using CDE. A 40-MHz ultrasound biomicroscope (UBM) was used to visualize lumen and outer vessel diameter in the proximal LCA. Flow velocity in the proximal LCA increased significantly with age and remained constant in the middle part in the apoE/LDLr dko mice, whereas velocities at both the sites remained unchanged in C57 mice. CDE-assessed flow velocity ratio (V prox /V mid ) increased significantly with age in apoE/LDLr dko mice ( P =0.0055) and correlated significantly to percentage wall thickness, as assessed by UBM ( P =0.0044; r =0.65) and histology ( P =0.0002; r =0.78). Wall thickness increased with age in the apoE/LDLr dko mice as measured with UBM ( P =0.0093; r =0.49), which was also confirmed with histology ( P <0.0001; r =0.73).

Conclusions— CDE and UBM are useful noninvasive tools to quantify mouse coronary artery atherosclerosis in vivo.

Losartan for the treatment of hypertension and left ventricular hypertrophy: the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study

Losartan is an orally active, selective, nonpeptide, angiotensin-II Type I-receptor antagonist, and was the first drug marketed in this class. It has been approved for the treatment of hypertension, and may be used alone or in combination with other antihypertensive agents. Based on the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study, losartan has been approved for the reduction of cardiovascular events in patients with hypertension and left ventricular hypertrophy, but there is evidence that this benefit does not apply to black patients. Based on the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) study, losartan is also indicated for the treatment of diabetic nephropathy with an elevated serum creatinine and proteinuria, in patients with Type 2 diabetes. The focus of this review is the LIFE study.

Carotid Intima-Media Thickness Is Correlated with Impairment of Coronary Flow Reserve in Hypertensive Patients without Coronary Artery Disease

Hypertensive individuals occasionally experience angina-like chest pain despite having angiographically normal coronary arteries, and the etiology of this phenomenon has been suggested to be associated with depressed coronary flow reserve (CFR). Carotid intima-media thickness (IMT) assessed by ultrasound is correlated with not only cerebrovascular disease but also coronary artery disease and left ventricular hypertrophy (LVH). The aim of our study was to investigate the association between CFR and carotid IMT in patients with essential hypertension. We performed transthoracic Doppler recording of diastolic coronary flow velocity in the left anterior descending coronary artery at baseline and after maximal vasodilation by adenosine triphosphate infusion in 24 normotensive subjects and 125 hypertensive patients. CFR was defined as the ratio of hyperemic to basal averaged peak coronary flow velocity. Common cardiovascular risk factors, left ventricular mass index (LVMI), relative wall thickness (RWT), and carotid IMT were evaluated. The CFR of hypertensive patients (2.55 +/- 0.52) was significantly decreased compared with that of normotensive subjects (3.15 +/- 0.45). CFR showed a significant correlation with age, systolic blood pressure, RWT, and carotid IMT. Stepwise regression analysis revealed that, among carotid IMT, LVMI and RWT, only carotid IMT was a strong and independent parameter for predicting CFR in hypertensive patients. In conclusion, B-mode ultrasound scanning of the carotid artery seemed to be of clinical value in the screening of patients with LVH and impaired microcoronary circulation. These associations may explain the links between cardiac and cerebrovascular involvements in patients with hypertension.

Range and prevalence of cardiac abnormalities in patients hospitalized in a medical ICU

BACKGROUND

Patients hospitalized in medical ICUs (MICUs) with acute noncardiac illnesses have an undefined prevalence of underlying cardiovascular abnormalities. Because of the acuteness of illness, the need for frequent concurrent mechanical ventilation, and the nature of the underlying diseases, routine cardiac examination may be suboptimal for identifying concurrent cardiac abnormalities.

PURPOSE

The purpose of this study was to utilize transthoracic echocardiography and Doppler echocardiography interrogation to identify the range and prevalence of occult cardiac abnormalities that may be present in patients admitted to an MICU.

METHODS

Over a 12-month period, 500 consecutive patients who had been admitted to the MICU of a large university tertiary care center underwent complete two-dimensional echocardiography and Doppler scanning within 18 h of admission. The final study population comprised 467 patients. No study subject had been admitted to the MICU for a primary cardiac diagnosis. Cardiovascular abnormalities were prospectively defined, and all echocardiograms were interpreted independently by blinded observers. Both MICU and overall mortality rates as well as length of stay were compared to the presence or absence of cardiac abnormalities.

RESULTS

One or more cardiac abnormalities was noted in 169 patients (36%). The average (+/-SD) age of patients in the study was 52 +/- 17 years (age range, 17 to 100 years), and the average age was 57 +/- 18 years (age range, 18 to 93 years) in patients with underlying cardiac abnormalities. A single cardiac abnormality was noted in 103 patients (22%), two cardiac abnormalities were noted in 34 patients (7.2%), and three or more cardiac abnormalities were noted in 32 patients (6.8%). Based on subsequent requests for cardiac diagnostic studies, 67 patients (14.3%) were clinically suspected of having significant cardiovascular abnormalities, 39 of whom (58%) had one or more cardiac abnormalities on seen on echocardiography. Cardiac abnormalities were unsuspected in 130 of 169 patients (77%) and were only noted at the time they underwent surveillance echocardiography. Although there was no correlation between the presence of cardiac abnormalities and mortality, both MICU and hospital length of stay were increased in patients with cardiac abnormalities.

CONCLUSION

A significant proportion of patients admitted to an MICU with noncardiac illness have underlying cardiac abnormalities, which can be detected with surveillance echocardiography at the time of admission. Cardiac abnormalities were associated with an increased length of stay but not with increased mortality.

Intima-media thickness of the common carotid arteries is related to coronary atherosclerosis and left ventricular hypertrophy in older adults

Increased intima-media thickness (IMT) of the common carotid arteries is related to generalized atherosclerosis and increased risk of future myocardial infarction and cerebrovascular disease. An association between IMT and the presence of coronary artery disease (CAD) has been documented, but controversial data have been found about the relation between increased IMT and the extent of CAD. An association between carotid atherosclerosis and cardiac remodeling has also been reported. It is still unclear whether increased IMT of the common carotid arteries might be associated with prevalent cardiovascular disease in older adults. This study included 70 patients, 37 with CAD and 33 matched for age and gender without CAD. All patients underwent a baseline clinical examination, B-mode ultrasound of the carotid arteries, and echocardiography. The authors evaluated the possible association between increased IMT with the presence and extent of CAD and the presence of left ventricular hypertrophy (LVH). The patients with CAD had significantly increased IMT compared to patients without CAD. IMT was found to increase with the number of coronary vessels affected, after adjustment for age, gender, hypertension, hypercholesterolemia, diabetes mellitus, and smoking habits. The test for trend was highly significant (p<0.001). Patients with LVH had significantly increased IMT as compared with patients without LVH. IMT of the common carotid arteries was increased in the presence of CAD and increased with the number of coronary vessels diseased. Second, the authors found that IMT of the common carotid arteries was significantly increased in patients with LVH. Increased IMT, as an indicator of subclinical cardiovascular disease, may help to identify patients who would benefit from aggressive therapeutic measures.

Echocardiographic comparison of left ventricular structure and function in hypertensive patients with primary aldosteronism and essential hypertension

BACKGROUND

In experimental renovascular hypertension, aldosterone has been implicated in myocardial remodeling and fibrosis, but it is uncertain whether excess aldosterone effects left ventricular structure and function in hypertensive patients.

METHODS

Hypertensive patients from the Cardiovascular Center of the New York Presbyterian Hospital-Weill Cornell Medical Center in New York and the Russian Cardiovascular Research Institute, Moscow, Russia, were studied. The sample included 35 patients with primary aldosteronism and 35 controls with essential hypertension matched for age, gender, and blood pressure (BP). Left ventricular (LV) mass, endocardial and midwall fractional shortening, and circumferential end-systolic stress were calculated. The observed/predicted midwall shortening ratio was used as an index of LV performance corrected for afterload.

RESULTS

Primary aldosteronism and essential hypertension patients had comparable LV dimensions, wall thickness, mass, mass/body surface area, and mass/height. Endocardial and midwall fractional shortening, and afterload-corrected midwall shortening were similar in primary aldosteronism and essential hypertension groups from both clinics. Moreover, logistic regression analysis using BP, body mass index, height, gender, and center as covariates failed to identify statistical differences in LV geometry or systolic function between primary aldosteronism and essential hypertension patients.

CONCLUSIONS

Patients with primary aldosteronism, a state characterized by chronic aldosterone excess, had similar LV geometry and systolic function compared to essential hypertension patients matched for age, gender, and BP. This argues against important independent associations between aldosterone and these aspects of LV response to human hypertension.

Left ventricular hypertrophy in hypertension as a predictor of coronary events: relation to geometry

The present review examines epidemiological evidence for a relation of left ventricular hypertrophy with coronary heart disease, and mechanisms that may represent pathophysiological links between left ventricular hypertrophy and coronary events. Left ventricular hypertrophy has been demonstrated to be a powerful predictor of coronary heart disease, and when geometry is concentric the relation is even stronger. In addition to its association with risk factors for atherosclerosis and mechanisms that precipitate acute heart attacks, left ventricular hypertrophy also directly predisposes to and aggravates clinical presentation of coronary heart disease through a number of biological mechanisms. These include the following: increase in oxygen requirement related to left ventricular geometry; coronary hypertension, with endothelial dysfunction and reduced coronary reserve; diastolic dysfunction; and structural remodelling of myocardium and vascular bed. Some of these alterations are also worsened by underlying coronary heart disease, and can potentially be maintained by loop mechanisms. A recognizable stage of abnormal coronary haemodynamics in the context of left ventricular hypertrophy is probably that at which coronary reserve is impaired in the absence of any other sign of heart disease; in many circumstances, this may occur early in the disease process.

Left ventricular mass and cardiovascular morbidity in essential hypertension: the MAVI study

OBJECTIVES

This study investigated the prognostic value of left ventricular (LV) mass at echocardiography in uncomplicated subjects with essential hypertension.

BACKGROUND

Only a few single-center studies support the prognostic value of LV mass in uncomplicated hypertension.

METHODS

The MAssa Ventricolare sinistra nell'Ipertensione study was a multicenter (45 centers) prospective study. The prespecified aim was to explore the prognostic value of LV mass in hypertension. Admission criteria included essential hypertension, no previous cardiovascular events, and age > or =50. There was central reading of echocardiographic tracings. Treatment was tailored to the single subject.

RESULTS

Overall, 1,033 subjects (396 men) were followed for 0 to 4 years (median, 3 years). Mean age at entry was 60 years, and systolic/diastolic blood pressure was 154/92 mm Hg. The rate of cardiovascular events (x100 patient-years) was 1.3 in the group with normal LV mass and 3.2 in the group (28.5% of total sample) with LV mass > or =125 g/body surface area (p = 0.005). After adjustment for age (p < 0.01), diabetes (p < 0.01), cigarette smoking (p < 0.01) and serum creatinine (p = 0.03), LV hypertrophy was associated with an increased risk of events (RR [relative risk] 2.08; 95% CI [confidence interval]: 1.22 to 3.57). For each 39 g/m(2) (1 SD) increase in LV mass there was an independent 40% rise in the risk of major cardiovascular events (95% CI: 14 to 72; p = 0.0013).

CONCLUSIONS

Our findings show a strong, continuous and independent relationship of LV mass to subsequent cardiovascular morbidity. This is the first study to extend such demonstration to a large nationwide multicenter sample of uncomplicated subjects with essential hypertension.

Effects of once-daily angiotensin-converting enzyme inhibition and calcium channel blockade-based antihypertensive treatment regimens on left ventricular hypertrophy and diastolic filling in hypertension: the prospective randomized enalapril study evaluating regression of ventricular enlargement (preserve) trial

BACKGROUND

The Prospective Randomized Enalapril Study Evaluating Regression of Ventricular Enlargement (PRESERVE) study was designed to test whether enalapril achieves greater left ventricular (LV) mass reduction than does a nifedipine gastrointestinal treatment system by a prognostically meaningful degree on a population basis (10 g/m(2)).

METHODS AND RESULTS

An ethnically diverse population of 303 men and women with essential hypertension and increased LV mass at screening echocardiography were enrolled at clinical centers on 4 continents and studied by echocardiography at baseline and after 6- and 12-month randomized therapy. Clinical examination and blinded echocardiogram readings 48 weeks after study entry in an intention-to-treat analysis of 113 enalapril-treated and 122 nifedipine-treated patients revealed similar reductions in systolic/diastolic pressure (-22/12 versus -21/13 mm Hg) and LV mass index (-15 versus -17g/m(2), both P>0.20). No significant between-treatment difference was detected in population subsets defined by monotherapy treatment, sex, age, race, or severity of baseline hypertrophy. Similarly, there was no between-treatment difference in change in velocities of early diastolic or atrial phase transmitral blood flow. More enalapril-treated than nifedipine-treated patients required supplemental treatment with hydrochlorothiazide (59% versus 34%, P<0.001) but not atenolol (27% versus 22%, NS).

CONCLUSIONS

Once-daily antihypertensive treatment with enalapril or long-acting nifedipine, plus adjunctive hydrochlorothiazide and atenolol when needed to control blood pressure, both had moderately beneficial and statistically indistinguishable effects on regression of LV hypertrophy.

Effect of regression of left ventricular hypertrophy from systemic hypertension on systolic function assessed by midwall shortening (HOT echocardiographic study)

Depressed midwall shortening has been shown to be an independent predictor of cardiovascular morbid events in hypertensive patients with left ventricular (LV) hypertrophy despite normal endocardial fractional shortening. The effects of LV mass changes in hypertensive patients on midwall shortening are unclear. To determine the impact of LV hypertrophy regression on LV systolic function assessed at the endocardium and the midwall level, 508 patients (58% men, 57% Caucasians, mean age 60 +/- 7 years) participating in the Hypertension Optimal Treatment study were prospectively studied by serial echocardiography at baseline, year 1, year 2, and at the end of the study. The Hypertension Optimal Treatment study was designed to challenge the existence of the J-curve phenomenon in hypertension. This study enrolled men and women between 50 and 80 years of age with mild to moderate hypertension. Patients were treated with a regimen based on felodipine with the addition of other antihypertensive drug classes as needed to reduce the diastolic blood pressure to a predefined target of < or =80, < or =85, or < or =90 mm Hg. From baseline to year 1, year 2, and end of the study, body mass index was unchanged (30.4, 30.1, 30.2, and 30.5 kg/m(2)); however, diastolic blood pressure was significantly reduced (99, 83, 80, and 80 mm Hg, p <0.0001), as was systolic blood pressure (161, 139, 137, and 134 mm Hg, p <0.0001) and LV mass index (117, 119, 107, and 106 g/m(2), p <0.0001). Over the same period of observation the endocardial fractional shortening did not change significantly (40%, 42%, 43%, and 44%); however, shortening at the midwall level showed improvement (20%, 21%, 22%, and 30%, p <0.001). In conclusion, midwall shortening is a more sensitive index of systolic function in subjects with pressure-overload hypertrophy, and it identifies high-risk patients who may benefit from a more aggressive antihypertensive program. The disparity between midwall and endocardial shortening suggests reduced myofibril function in patients with hypertension-induced hypertrophy.

Cerivastatin, a hydroxymethylglutaryl coenzyme a reductase inhibitor, improves endothelial function in elderly diabetic patients within 3 days

BACKGROUND

The short-term effects of hydroxymethylglutaryl coenzyme A reductase inhibitors (statins) on endothelial function at doses that do not affect plasma lipid levels are not known.

METHODS AND RESULTS

We investigated the short-term effects of cerivastatin, a hydroxymethylglutaryl coenzyme A reductase inhibitor, on endothelial function and endothelium-related products in elderly diabetic patients. Twenty-seven elderly diabetic patients (aged 69.3+/-3.4 years), with or without mild hypercholesterolemia, were enrolled in this study, which tested cerivastatin treatment (0.15 mg/d) for 3 days. Endothelium-dependent flow-mediated dilatation, endothelium-independent dilatation by nitroglycerin in the brachial artery, nitric oxide-related products (nitrite/nitrate and cGMP), endothelium-related products (von Willebrand Factor, soluble vascular cell adhesion molecule-1, and soluble intercellular adhesion molecule-1), and a marker of oxidant stress (8-isoprostane) were assessed. Levels of plasma lipids were not changed before and after treatment with cerivastatin. Flow-mediated dilatation was significantly increased by cerivastatin treatment, as were plasma nitrite/nitrate levels (from 16.9+/-3.4 to 22.0+/-3.7 micromol/L, P<0.05) and cGMP values. The percent of nitroglycerin-induced dilatation was not changed. Plasma concentrations of 8-isoprostane decreased, and levels of soluble vascular cell adhesion molecule also tended to decrease with cerivastatin.

CONCLUSIONS

Improvement of endothelial function was in line with antiatherosclerotic effects. Cerivastatin improved impaired endothelial function in the short-term without affecting lipid profiles in elderly diabetic patients. This effect may be partly due to upregulation of endothelial nitric oxide synthase.

Reference values for echocardiographic measurements in urban and rural populations of differing ethnicity: the Strong Heart Study

Discrepancies in reported reference values for left ventricular (LV) dimensions and mass may be due to imaging errors with early echocardiographic methods or effects of subject characteristics and inclusion criteria. To determine whether contemporary echocardiographic methods provide stable normal limits for left ventricular measurements in different populations, M-mode/2-dimensional echocardiography was applied in 176 American Indian participants in the Strong Heart Study and 237 New York City residents who were clinically normal. No consistent difference in any measure of LV size or function existed between populations. Upper normal limits (98th percentile) for LV mass were 96 g/m(2) in women and 116 g/m(2) in men and 3.27 cm/m for LV chamber diameter normalized for height. Thus contemporary M-mode/2D echocardiography provides reference ranges for LV measurements that approximate necropsy measurements and have acceptable stability in apparently normal white, African-American/Caribbean, and American Indian populations.

Evaluation of various electrocardiographic criteria for left ventricular hypertrophy in patients with stable angina pectoris: influence of using modified limb electrodes

BACKGROUND

Left ventricular hypertrophy (LVH) in coronary heart disease is associated with poor prognosis. Electrocardiography (ECG) criteria for LVH, when using ECG with modified limb electrode positions, has not been validated in patients with angina pectoris.

METHODS

Echocardiography and resting ECGs with modified limb electrode positions, i.e. with the limb leads placed on the abdomen instead of the extremities, were registered from 468 patients (295 men) with stable angina pectoris. To evaluate the influence of using modified limb electrode positions, ECGs with standard and modified limb electrode positions were compared in a control group consisting of 50 other patients.

RESULTS

The ECG criteria for LVH according to the Perugia score, the Minnesota code and Romhilt & Estes reached the highest sensitivity values, 27-31% in men and 24-38% in women, while the sensitivities of different Cornell criteria were as low as 6-10% in men and 19-29% in women. In the control group, the R- and S-wave amplitudes of the precordial leads were only slightly changed, as expected, whereas those of the limb leads changed considerably. Based on these results, we corrected aVL in the main study, which increased the sensitivity of the Cornell voltage criteria from 15 to 30%, while the specificity was maintained at 95%.

CONCLUSIONS

ECGs registered with modified limb electrode positions can be used to detect LVH with traditional ECG criteria, but changes in the limb leads are considerable and influence the sensitivities.

Randomized, placebo-controlled trial of the angiotensin-converting enzyme inhibitor, ramipril, in patients with coronary or other occlusive arterial disease. PART-2 Collaborative Research Group. Prevention of Atherosclerosis with Ramipril

OBJECTIVES

The primary objective of this study was to investigate the effects of the angiotensin-converting enzyme (ACE) inhibitor, ramipril, on carotid atherosclerosis in patients with coronary, cerebrovascular or peripheral vascular disease.

BACKGROUND

Angiotensin-converting enzyme inhibitors have been shown to reduce the risk of coronary events in various patient groups and to prevent the development of atherosclerosis in animal models. It has been hypothesized that the clinical benefits of ACE inhibitors may, therefore, be mediated by effects on atherosclerosis.

METHODS

Six hundred seventeen patients were randomized in equal proportions to ramipril (5-10 mg daily) or placebo. At baseline, two years and four years, carotid atherosclerosis was assessed by B-mode ultrasound, and left ventricular mass was assessed by M-mode echocardiography.

RESULTS

Blood pressure (BP) was reduced by a mean of 6 mm Hg systolic and 4 mm Hg diastolic in the ramipril group compared with the placebo group (p<0.001). There was no difference between groups in the changes in common carotid artery wall thickness (p = 0.58) or in carotid plaque (p = 0.93). Left ventricular mass index decreased by 3.8 g/m2 (4%) in the ramipril group compared with the placebo group (2p = 0.04).

CONCLUSIONS

The results provide no support for the hypothesis that reduced atherosclerosis is responsible for the beneficial effects of ACE inhibitors on major coronary events. It is more likely that the benefits are due to lower BP, reduced left ventricular mass or other factors such as reversal of endothelial dysfunction.

Left ventricular wall stresses and wall stress-mass-heart rate products in hypertensive patients with electrocardiographic left ventricular hypertrophy: the LIFE study. Losartan Intervention For Endpoint reduction in hypertension

OBJECTIVE

Left ventricular (LV) hypertrophy on echocardiogram (ECG) strongly predicts coronary heart disease events, but the mechanisms linking increased LV mass to ischemic vascular events is uncertain.

DESIGN

Variables related to myocardial oxygen demand were compared among normotensive adults and patients with mild and more severe hypertension, and among groups of moderately hypertensive patients with target organ damage in relation to gender, LV geometry and LV systolic function.

SETTING

The Losartan Intervention For Endpoint reduction in hypertension (LIFE) trial, in which hypertensive patients with ECG LV hypertrophy (Cornell voltage-duration product, > 2440 mm x ms and/or SV1 + RV(5-6) > 38 mm) were randomized to > or = 4 years double-blinded treatment with losartan or atenolol.

PATIENTS/PARTICIPANTS

A total of 964 LIFE participants enrolled in an echocardiographic substudy, and groups of 282 employed hypertensive and 366 apparently normal adults.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

ECG LV parameters contributing to myocardial oxygen demand (wall stresses, LV mass, heart rate and wall stress-mass-heart rate products).

RESULTS

In both women and men, stepwise increases from reference subjects to employed hypertensives to LIFE patients were observed for LV wall stresses, mass and stress-mass-heart rate products. LIFE men patients had slightly higher wall stresses and significantly higher triple products than women. Wall stresses were increased in patients with normal LV geometry, eccentric or concentric hypertrophy; triple products were about three and two times normal with eccentric and concentric hypertrophy, with smaller increases in other geometric groups. Patients with decreased LV fractional shortening had two times normal end-systolic stresses and three or four times normal triple products; smaller increases in stresses and triple products occurred with decreased LV midwall function.

CONCLUSIONS

Hypertensive patients with ECG LV hypertrophy have increased LV wall stresses and stress-mass-heart rate products, suggesting a contribution of high myocardial oxygen demand to increased risk in such patients. Particularly high stresses and triple products were associated with echocardiographic LV hypertrophy, and subnormal LV chamber and midwall function.

Prognostic value of left ventricular hypertrophy and geometry in patients with a first, uncomplicated myocardial infarction

BACKGROUND

The prognostic impact of left ventricular (LV) geometry on cardiovascular risk for patients with a first, uncomplicated acute myocardial infarction (AMI), and echocardiographic ejection fraction > or =50% has not been well described.

METHODS AND RESULTS

Accordingly, 111 AMI consecutive patients (mean age 59.3+/-10 years) performed echocardiographic examination at predischarge. LV mass was calculated by means of Devereux's formula and subsequently indexed by body surface area. Fifty-three patients had LV hypertrophy and 58 patients had normal LV mass. The two groups were homogeneous for demographic, clinical and angiographic variables as well as for the incidence of residual ischemia on predischarge stress testing. During follow-up period there were 24 cardiac events (cardiac death, unstable angina and non-fatal reinfarction) in the 53 patients with LV hypertrophy and only four events in the remaining 58 patients without LV hypertrophy (RR=2.45; CI=1.76-3.41; P<0.0001). The patients with concentric LV hypertrophy showed a higher incidence of events (64%) than patients with eccentric LV hypertrophy (32%, P<0. 05) and patients with normal geometry and mass (6%, P<0.0001). Multivariate Cox regression model identified concentric geometry as the most powerful predictor of combined end-points (chi(2)=32.7, P<0. 0001).

CONCLUSIONS

An increased LV mass and concentric geometry resulted important independent markers of an adverse outcome in patients with a first, uncomplicated myocardial infarction and good LV function.

Continuous relation between left ventricular mass and cardiovascular risk in essential hypertension

The detection of left ventricular (LV) hypertrophy on echocardiography is a powerful risk indicator in essential hypertension. However, the prognostic impact of LV mass values within the "normal" range and the shape of the relation between LV mass and prognosis remain unclear. Thus, 1925 white subjects with uncomplicated essential hypertension underwent off-therapy 24-hour blood pressure monitoring and M-mode echocardiography. During 4. 0+/-2 years of follow-up, there were 181 major cardiovascular events (2.4/100 patient-years) and 49 deaths from all causes. In the 5 gender-specific quintiles of LV mass distribution (partition values: 92, 105, 120, and 138 g/m(2) in men and 79, 91, 102, and 116 g/m(2) in women), cardiovascular event rates were 0.8, 1.7, 2.2, 2.9, and 4. 3 per 100 patient-years. After adjustment for several risk factors, including 24-hour ambulatory blood pressure, the relative risk (RR) of developing a cardiovascular event increased progressively from the first quintile (RR 1) to the second (RR 1.6, 95% CI 0.8 to 3.1), third (RR 1.9, 95% CI 1.01 to 4.0), fourth (RR 3.0, 95% CI 1.5 to 5. 8), and fifth (RR 3.5, 95% CI 1.8 to 6.8) quintile. For all-cause death, the RR in the fifth quintile compared with the first quintile was 4.3 (95% CI 1.2 to 13.4). In conclusion, the powerful relation between LV mass and risk of cardiovascular disease in subjects with uncomplicated essential hypertension is continuous over a wide range of LV mass values, even below the current "upper normal" limits. The relation remains significant after control for traditional risk factors, including ambulatory blood pressure.

Left ventricular hypertrophy as a surrogate end-point in hypertension

OBJECTIVES

To examine the adequacy of available evidence that left ventricular hypertrophy (LVH) and its regression influence the rate of cardiovascular events in hypertension.

DESIGN AND METHODS

Statistical, epidemiologic and treatment trial literature concerning ECG and echocardiographic LVH was reviewed to address the above question.

RESULTS

Results of 7 electrocardiographic and 10 echocardiographic studies (total n about 20,000 subjects) show consistently higher risks of morbid events in individuals with than without LVH (odds ratios 1.4 to 5.4). Available data (5 studies, 1,544 subjects) suggest that morbid events occur in higher proportions of individuals in whom LVH progresses (13 to 59%) than regresses (7 to 12%).

CONCLUSIONS

Strict criteria to establish LVH as a fully adequate surrogate end-point for morbid events in hypertension are being increasingly satisfied by mounting evidence, but the independence of the relation of LVH change to prognosis from blood pressure or other factors has not yet been fully established.