Does masked hypertension impact left ventricular deformation?

Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023

Central Illustration : Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023 Proposal for including strain in the integrated diastolic function assessment algorithm, adapted from Nagueh et al.67 Am: mitral A-wave duration; Ap: reverse pulmonary A-wave duration; DD: diastolic dysfunction; LA: left atrium; LASr: LA strain reserve; LVGLS: left ventricular global longitudinal strain; TI: tricuspid insufficiency. Confirm concentric remodeling with LVGLS. In LVEF, mitral E wave deceleration time < 160 ms and pulmonary S-wave < D-wave are also parameters of increased filling pressure. This algorithm does not apply to patients with atrial fibrillation (AF), mitral annulus calcification, > mild mitral valve disease, left bundle branch block, paced rhythm, prosthetic valves, or severe primary pulmonary hypertension.

Unmasking left ventricular systolic dysfunction in masked hypertension: looking at myocardial strain. A review and meta-analysis

BACKGROUND AND AIM

A growing body of evidence supports the view that masked hypertension (MH) (i.e. normal office and elevated out-of-office BP) is a blood pressure (BP) phenotype associated with increased risk of subclinical organ damage, cardiovascular disease and death as compared to true normotension. Whether left ventricular (LV) systolic function is impaired in individuals with MH is still a poorly defined topic. Therefore, we aimed to provide a new piece of information on LV systolic dysfunction in the untreated MH setting, focusing on speckle tracking echocardiography (STE) studies investigating LV global longitudinal strain (GLS), a more sensitive index of systolic function than conventional LV ejection fraction (LVEF).

METHODS

A computerized search was performed using Pub-Med, OVID, EMBASE and Cochrane library databases from inception until June 30, 2022. Full articles reporting data on LV GLS in MH, as assessed by ambulatory BP monitoring (ABPM), and normotensive controls were considered suitable for the purposes of review and meta-analysis.

RESULTS

A total of 329 untreated individuals with MH and 376 normotensive controls were included in six studies. While pooled average LVEF was not different between groups [64.5 ± 1.5 and 64.5 ± 1.3%, respectively, standard means difference (SMD): -0.002 ± 0.08, confidence interval (CI): 0.15/-0.15, P = 0.98), LV GLS was worse in MH patients than in normotensive counterparts (-18.5 ± 0.70 vs. -20.0 ± 0.34%, SMD: 0.68 ± 0.28, CI: 0.12/1.24, P < 0.01).

CONCLUSIONS

Our findings suggest that early changes in LV systolic function not detectable by conventional echocardiography in the MH setting can be unmasked by STE and that its implementation of STE in current practice may improve the detection of subclinical organ damage of adverse prognostic significance.

Phenotyping the hypertensive heart

Arterial hypertension remains the most frequent cardiovascular (CV) risk factor, and is responsible for a huge global burden of disease. Echocardiography is the first-line imaging method for the evaluation of cardiac damage in hypertensive patients and novel techniques, such as 2D and D speckle tracking and myocardial work, provide insight in subclinical left ventricular (LV) impairment that would not be possible to detect with conventional echocardiography. The structural, functional, and mechanical cardiac remodelling that are detected with imaging are intermediate stages in the genesis of CV events, and initiation or intensification of antihypertensive therapy in response to these findings may prevent or delay progressive remodelling and CV events. However, LV remodelling—especially LV hypertrophy—is not specific to hypertensive heart disease (HHD) and there are circumstances when other causes of hypertrophy such as athlete heart, aortic stenosis, or different cardiomyopathies need exclusion. Tissue characterization obtained by LV strain, cardiac magnetic resonance, or computed tomography might significantly help in the distinction of different LV phenotypes, as well as being sensitive to subclinical disease. Selective use of multimodality imaging may therefore improve the detection of HHD and guide treatment to avoid disease progression. The current review summarizes the advanced imaging tests that provide morphological and functional data about the hypertensive cardiac injury.

Advanced imaging tools for evaluating cardiac morphological and functional impairment in hypertensive disease

Arterial hypertension represents a systemic burden, and it is responsible of various morphological, functional and tissue modifications affecting the heart and the cardiovascular system. Advanced imaging techniques, such as speckle tracking and three-dimensional echocardiography, cardiac magnetic resonance, computed tomography and PET-computed tomography, are able to identify cardiovascular injury at different stages of arterial hypertension, from subclinical alterations and overt organ damage to possible complications related to pressure overload, thus giving a precious contribution for guiding timely and appropriate management and therapy, in order to improve diagnostic accuracy and prevent disease progression. The present review focuses on the peculiarity of different advanced imaging tools to provide information about different and multiple morphological and functional aspects involved in hypertensive cardiovascular injury. This evaluation emphasizes the usefulness of the emerging multiimaging approach for a comprehensive overview of arterial hypertension induced cardiovascular damage.

[Associated factors and sub-clinical myocardial dysfunction in obese patients with masked hypertension]

INTRODUCTION

Obesity is a worldwide health problem. Masked hypertension is a relatively recent reported entity with a diagnostic problem. The aim of this study was to determine the clinical and paraclinical characteristics and to identify the predictive factors of masked hypertension in obese patients.

METHODS

It is a prospective study including obese patients with normal arterial pressure at office. All of these patients were given ambulatory blood pressure measurement (ABPM) to screen for masked hypertension, laboratory tests and a complete echocardiography study.

RESULTS

A total of 50 patients were included. The mean age was 46.52±10.4 years. The mean systolic blood pressure (BP) at office was 120.8±8.8mmHg and the mean diastolic BP was 75±7.3mmHg. The prevalence of masked hypertension in obese adults was 36% with a predominantly non-dipper profile (38%). The study of echocardiographic parameters found dilated left atrium (LA) in 16 patients (32%). The left ventricle (LV) was hypertrophied in 32 patients (64%). The overall LV global longitudinal strain (GLS) was on average -18.85±0.9% and the LA GLS was on average 37.35±4.5%. In our study, metabolic syndrome, low HDL cholesterol, elevated fasting blood glucose, hyperuricemia, LA dilatation, LV hypertrophy, diastolic LV dysfunction and altered myocardial deformities were factors associated with masked hypertension in obese adults.

CONCLUSION

It is important to screen for hypertension by ambulatory measurement in at-risk obese patients who present associated cardiovascular risk factors to reduce morbidity and mortality. Echocardiography and speckle tracking analysis could be helpful in detection sub-clinical myocardial deterioration in obese patients with masked hypertension.

Relationship Between Masked Hypertension Measured by Ambulatory Blood Pressure Monitoring and Left Ventricular Global Longitudinal Strain: A Retrospective Study

Purpose

Masked hypertension (MHT), as an independent clinical entity, the cardiac dysfunction caused by it can be early detected through left ventricular global longitudinal strain (GLS), yet the quantitative relation between MHT and GLS is still unclear. Therefore, we tried to conduct a community-based retrospective study to define this relationship.

Patients and Methods

A total of 308 enrolled participants from Dongguan, China, were divided into non-hypertension (NHT) and MHT groups. Baseline characteristics were recorded, and echocardiography and 24-hour ambulatory blood pressure monitoring were performed. Linear regression analysis and receiver-operating characteristic (ROC) curve analysis were used to assess the associations between MHT and GLS in univariate and multivariate models, and the dose–response curve was plotted to demonstrate their relationship.

Results

The mean age of the NHT and MHT groups was 57 and 60 years, respectively. Signs of left ventricular diastolic function, E/A was reduced and E/e’ was increased in the MHT group while those of the NHT group were nearly normal. The MHT group also showed a significantly lower (“worse”) GLS than NHT (−15.2% vs −19.9%, P < 0.001) while left ventricular ejection fraction (LVEF) did not differ between the groups. Worse GLS was independently and significantly associated with MHT both in univariate (odds ratio [OR]: 1.97, P < 0.001) and stepwise multivariate regression analysis (OR: 1.99, P < 0.001). Comparison of ROC curve results showed that area under curve of GLS was larger than that of E/e’ both in unadjusted (0.8673 vs 0.6831) and adjusted model (0.9178 vs 0.8284). Further analysis showed adjusted nonlinear correlation between MHT and GLS.

Conclusion

Based on the relationship between MHT and GLS, in clinical practice, GLS measurement could facilitate diagnosis for suspected MHT patients and could define the extent of left ventricular dysfunction for diagnosed MHT patients.

The Impact of Uncontrolled Hypertension on the Longitudinal Systolic Function of the Left Ventricle

BACKGROUND

The assessment of the longitudinal component of left ventricular (LV) function is of major clinical importance for the early detection of LV contractile impairment. The aim of this study was to determine the impact of uncontrolled hypertension, on LV longitudinal systolic performance.

METHODS

The study population included 400 hypertensive patients: 271 patients with uncontrolled blood pressure (BP) and 112 without controlled BP, all patients underwent a complete ultrasound evaluation with calculation of the LV mass, evaluation of diastolic function as well as longitudinal systolic function.

RESULTS

Conventional echo demonstrated that uncontrolled patients had increased LV mass (P 0.007), LA (left auricular) dimension (P 0.004), left ventricular wall thickness and impairment of diastolic function (E/E'6 ± 2.1 vs 7.4 ±3.0 P=0.001) while no affection of systolic function could be detected. By deformation imaging, there was a reduction in longitudinal strain (apical 4 view -16.2 ±2.9 vs -18.2± 2.6 P 0.02, apical 3 view -17.3 ± 3.3 vs. -18.9 ± 4.1 P 0.01). Similarly systolic strain rate (SRsys) and early diastolic SR (SRe) reduced significantly in longitudinal direction.

CONCLUSION

Although EF was not different between uncontrolled patients and controls, LV longitudinal strain and strain rate by 2D speckle tracking were lower in the uncontrolled group.

Factors associated with global longitudinal strain decline in hypertensive patients with normal left ventricular ejection fraction

Background

Early detection of risk factors for left ventricular (LV) dysfunction may be useful in patients with high blood pressure (HBP).

Methods

Patient from an outpatient HBP clinic underwent a two-dimensional Doppler-coupled echocardiography with determination of LV global longitudinal strain (GLS) by speckle-tracking.

Results

Among 200 patients (mean age 61.7 ± 9.7 years), 155 were overweight, 93 had diabetes, 83 had dyslipidemia, and 109 had uncontrolled HBP. LV hypertrophy (LVH) was found in 136 patients (68%), including concentric (n = 106) and eccentric (n = 30) LVH. Diastolic dysfunction patterns were observed in 178 patients (89%), and increased filling pressures were observed in 37 patients (18.5%). GLS ranged from –25% to –11.6% (mean –16.9 ± 3.2%). Low GLS values (&gt;–17%) were found in 91 patients (45.5%), 68 with and 23 without LVH. In univariate analysis, a reduced GLS was associated with HBP lasting for &gt;10 years (odds ratio (OR) = 3.51, 95% confidence interval (CI) 1.73–7.09; p = 0.002), uncontrolled HBP (OR = 3.55, 95% CI 1.96–6.43; p &lt; 0.0001), overweight (OR = 2.01, 95% CI 0.93–4.31; p = 0.0028), diabetes (OR = 2.21, 95% CI 1.25–3.90; p = 0.006), dyslipidemia (OR = 2.16, 95% CI 1.22–3.84; p = 0.008), renal failure (OR = 4.27, 95% CI 1.80–10.10; p = 0.001), an increased Cornell index (OR = 3.70, 95% CI 1.98–6.90; p &lt; 0.0001), concentric LVH (OR = 9.26, 95% CI 2.62–32.73; p = 0.001), remodeling (OR = 8.51, 95% CI 2.18–33.23; p = 0.002), and filling pressures (OR = 7.1, 95% CI 2.9–17.3; p &lt; 0.0001). In multivariable analysis, duration of HBP (p = 0.038), uncontrolled BP (p = 0.006), diabetes (p = 0.023), LVH (p = 0.001), and increased filling pressures (p = 0.003) remained associated with GLS decline.

Conclusion

Early impairment of LV function, detected by a reduced GLS, is associated with long-lasting, uncontrolled HBP, overweight, related metabolic changes, and is more pronounced in patients with LVH.

When Office Blood Pressure Is Not Enough: The Case of Masked Hypertension

An increasing attention has been devoted in the last two decades to masked hypertension (MH), a condition characterized by the fact that classification of a normal blood pressure (BP) status by office measurements is not confirmed by home and/or ambulatory BP monitoring (ABPM). MH definition (i.e., normal office BP, but high out-of-office BP) should be restricted to untreated subjects (true MH) whereas masked uncontrolled hypertension (MUCH) reserved to treated patients previously classified as hypertensives, presenting normal office BP and high ABPM or home values. Both MH and MUCH are associated with metabolic alterations, comorbidities, and hypertension-mediated organ damage (HMOD). Furthermore, the risk of cardiovascular events related to these conditions has been shown to be close or greater than that of sustained hypertension. This review discusses available evidence about MH and MUCH by focusing on its prevalence, clinical correlates, association with HMOD, prognostic significance, and their therapeutic implications.

Does Masked Hypertension Cause Early Left Ventricular Impairment in Youth?

Objectives: Masked hypertension (MH) is not uncommon in the youth and may increase risks of long-term cardiovascular impairment. However, little is known about the subclinical heart damage in this group of patients. Currently, 3-layer speckle tracking imaging based on two-dimensional echocardiography is feasible to detect the early signs of myocardial damage. We therefore aimed to investigate whether subtle changes of cardiac function occurred in the young MH patients by using advanced quantification with layer-specific speckle tracking. Methods: A total of 40 adolescents with MH (age 18 ± 3 years, 73% males) and 40 age-, gender-, race-, and height-matched normotensive volunteers were enrolled in our study. MH was defined as one or more of the ambulatory blood pressure (BP) parameters (24-h, daytime and night-time average BPs) higher than ≥ 95th percentile for gender and height according to the local reference. Both comprehensive two-dimensional echocardiography with layer-specific strain analysis and 24-h ambulatory BP monitoring were performed. Longitudinal strain and circumferential strain in endocardial, mid-myocardial, and epicardial layers were determined accordingly with the dedicated software (EchoPAC software version 201, GE Healthcare, Horten, Norway). Results: Compared with normotensive controls, youths with MH had higher ambulatory pulse rate and left ventricular mass index, and were more obese. Interestingly, similar ventricular volumes and ejection fraction were observed in the study groups, but further analysis with layer-specific strains revealed that endocardial and mid-myocardial longitudinal and circumferential mechanical function were decreased in the young MH subjects when compared to normotensive individuals (all p < 0.05). However, there were no difference regarding radial strain and apical rotation derived from traditional speckle tracking analysis. Conclusion: Subclinical change of LV mechanic function assessed by layer-specific speckle tracking is present in youth with MH despite considered as normal with conventional ways.Thus, MH in youth should be monitored closely instead of labeling as an entirely benign entity.