Ventricular and myocardial function following treatment of hypertension

Prognostic value of depressed midwall systolic function in cardiac light-chain amyloidosis

BACKGROUND

Cardiac amyloidosis represents an archetypal form of restrictive heart disease, characterized by profound diastolic dysfunction. As ejection fraction is preserved until the late stage of the disease, the majority of patients do fulfill the definition of diastolic heart failure, that is, heart failure with preserved ejection fraction (HFpEF). In another clinical model of HFpEF, that is, pressure-overload hypertrophy, depressed midwall fractional shortening (mFS) has been shown to be a powerful prognostic factor.

OBJECTIVE AND METHODS

To assess the potential prognostic role of mFS in cardiac light-chain amyloidosis with preserved ejection fraction, we enrolled 221 consecutive untreated patients, in whom a first diagnosis of cardiac light-chain amyloidosis was concluded between 2008 and 2010. HFpEF was present in 181 patients. Patients in whom cardiac involvement was excluded served as controls (n = 121). Prognosis was assessed after a median follow-up of 561 days.

RESULTS

When compared with light-chain amyloidosis patients without myocardial involvement, cardiac light-chain amyloidosis was characterized by increased wall thickness (P <0.001), reduced end-diastolic left ventricular volumes (P <0.001), and diastolic dysfunction (P <0.001). In patients with preserved ejection fraction, mFS was markedly depressed [10.6% (8.7-13.5) vs. 17.8% (15.9-19.5) P <0.001]. At multivariable analysis, mFS, troponin I, and NT-pro-brain natriuretic peptide were the only significant prognostic determinants (P <0.001), whereas other indices of diastolic (E/E' ratio, transmitral and pulmonary vein flow velocities) and systolic function (tissue Doppler systolic indices, ejection fraction), or the presence/absence of congestive heart failure did not enter the model.

CONCLUSION

In cardiac light-chain amyloidosis with normal ejection fraction, depressed circumferential mFS, a marker of myocardial contractile dysfunction, is a powerful predictor of survival.

Ketamine reduce left ventricular systolic and diastolic function in patients with ischaemic heart disease

OBJECTIVE

Ketamine may be followed by a general increase in haemodynamics and oxygen consumption, which may be of concern in patients with ischaemic heart disease. The purpose of this study was to evaluate the effect of ketamine on left ventricular (LV) systolic and diastolic function by different modalities of echocardiography and tissue Doppler imaging in patients with ischaemic heart disease.

METHODS AND RESULTS

Prospective observational study of 11 patients acting as own control based on echocardiographic imaging before and after bolus ketamine 0.5 mg/kg. Simpson's 2 D-volumetric method was used to quantify left ventricular volume and ejection fraction. General global LV deformation was assessed by Speckle tracking ultrasound, systolic LV longitudinal displacement was assessed by Tissue Tracking score index and the diastolic function was evaluated from changes in early-(E') and atrial (A') peak velocities during diastole. Average heart rate (34%) and blood pressure (35%) increased significantly after ketamine (P<0.0001). Mean tissue tracking score index decreased from 11.2 ± 2.3 to 8.3 ± 2.6 (P=0.005) and Global Speckle tracking 2D strain from 17.7 ± 2.7 to 13.7 ± 3.6 (P=0.0014) indicating a decrease in LV global systolic function. The E'/A' ratio decreased from 1.11 ± 0.43 to 0.81 ± 0.46 (P=0.044) indicating impaired relaxation.

CONCLUSION

Different modalities of echocardiography in combination with tissue Doppler indicate both diminished systolic and diastolic function after ketamine administration in patients with ischaemic heart disease.

Doppler-derived myocardial performance index in patients with impaired left ventricular relaxation and preserved systolic function

BACKGROUND

The Doppler-derived myocardial performance index (MPI) has been used in the evaluation of left ventricular (LV) function in several diseases. In patients with isolated diastolic dysfunction, the diagnostic utility of this index remains unclear. The aim of this study was to determine the diagnostic utility of MPI in patients with systemic hypertension, impaired LV relaxation, and normal ejection fraction.

METHODS

Thirty hypertensive patients with impaired LV relaxation were compared to 30 control subjects. MPI and its components, isovolumetric relaxation time (IRT), isovolumetric contraction time (ICT), and the ejection time (ET), were measured from LV outflow and mitral inflow Doppler velocity profiles.

RESULTS

MPI was higher in patients than in control subjects (0.45 +/- 0.13 vs 0.37 +/- 0.07 P < 0.0029). The increase in MPI was due to the prolongation of IRT without significant change of ICT and ET. MPI cutoff value of > or =0.40 identified impaired LV relaxation with a sensitivity of 63% and specificity of 70% while an IRT >94 ms had a sensitivity of 67% and specificity of 80%. Multivariate analysis identified relative wall thickness, mitral early filling wave velocity (E), and systolic myocardial velocity (Sm) as independent predictors of MPI in patients with hypertension.

CONCLUSIONS

MPI was increase in patients with hypertension, diastolic dysfunction, and normal ejection fraction but was not superior to IRT to detect impaired LV relaxation.

High thoracic epidural analgesia improves left ventricular function in patients with ischemic heart

BACKGROUND

In patients with ischemic heart disease, high thoracic epidural analgesia (HTEA) has been proposed to improve myocardial function. Tissue Doppler Imaging (TDI) is a tool for quantitative determination of myocardial systolic and diastolic velocities and a derivative of TDI is tissue tracking (TT), which allows quantitative assessment of myocardial systolic longitudinal displacement during systole. The purpose of this study was to evaluate the effect of thoracic epidural analgesia on left ventricular (LV) systolic and diastolic function by means of two-dimensional (2D) echocardiography and TDI in patients with ischemic heart disease.

METHODS

The effect of a high epidural block (at least Th1-Th5) on myocardial function in patients (N=15) with ischemic heart disease was evaluated. Simpson's 2D volumetric method was used to quantify LV volume and ejection fraction. Systolic longitudinal displacement was assessed by the TT score index and the diastolic function was evaluated from changes in early (E'') and atrial (A'') peak velocities during diastole.

RESULTS

After HTEA, 2D measures of left ventricle function improved significantly together with the mean TT score index [from 5.87 +/- 1.53 to 6.86 +/- 1.38 (P<0.0003)], reflecting an increase in LV global systolic function and longitudinal systolic displacement. The E''/A'' ratio increased from 0.75 +/- 0.27 to 1.09 +/- 0.32 (P=0.0026), indicating improved relaxation.

CONCLUSION

A 2D-echocardiography in combination with TDI indicates both improved systolic and diastolic function after HTEA in patients with ischemic heart disease.

Regional diastolic dysfunction in individuals with left ventricular hypertrophy measured by tagged magnetic resonance imaging--the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

Impairment of global diastolic function is considered to be the mechanism of congestive heart failure in individuals with preserved systolic left ventricular (LV) function. Left ventricular hypertrophy (LVH) is known to be a risk factor for congestive heart failure with preserved systolic function, and this process may begin as a regional process. We investigated whether regional LV diastolic function measured by magnetic resonance tagging is altered in asymptomatic participants of the MESA with LVH and preserved systolic LV function.

METHODS

Regional systolic and diastolic strain rates were calculated from strain data in 218 participants of the MESA study. Circumferential strain was calculated from the midwall layer of the septum, anterior, lateral, and inferior walls at mid-LV level. Global LV function measures were studied by magnetic resonance imaging in 4291 MESA participants. Left ventricular hypertrophy for men and women was defined from the MESA population using previously established Framingham criteria.

RESULTS

Global systolic function was slightly less in the LVH (ejection fraction = 0.66 +/- 0.10) versus the non-LVH group (ejection fraction = 0.69 +/- 0.07, P < .001). Stepwise regression analyses showed a direct relationship between regional diastolic dysfunction and increasing LV mass. Regional systolic strain and strain rate measures from participants with LVH were not significantly different from those without LVH. However, regional diastolic strain rate was significantly reduced in participants with LVH (1.5 +/- 1.1 s(-1)) compared with the non-LVH group (2.2 +/- 1.1 s(-1), P < .001) regardless of age or sex.

CONCLUSIONS

Left ventricular hypertrophy is associated with regional diastolic dysfunction in individuals without evidence of clinical cardiovascular disease and preserved systolic function. Magnetic resonance imaging tagging provides detailed quantification of regional diastolic function noninvasively.

Midwall mechanics in physiologic and hypertensive concentric hypertrophy

OBJECTIVE

We sought to analyze and compare midwall fractional shortening (mFS), and its relations with circumferential end-systolic stress (cESS) and relative wall thickness (RWT), among subjects with physiologic concentric left ventricular (LV) hypertrophy, patients with hypertension and concentric LV hypertrophy, and control subjects.

METHODS

A total of 51 normotensive athletes and 56 young patients with hypertension and echocardiographic evidence of concentric LV hypertrophy were enrolled. In addition, 49 age- and sex-matched control subjects were recruited. LV cavity size and wall thicknesses, LV mass, RWT, cESS, and mFS were determined by echocardiography.

RESULTS

The 3 groups were similar in age, sex, height, weight, body surface area, LV diameters, and conventional indices of systolic function. LV thicknesses, RWT, LV mass, and LV mass index were similarly increased in the athletes and in the hypertensive group when compared with the control subjects. A similar depression in mFS was observed in both the athletes (22.4 +/- 2.6%) and hypertensive group (22.5 +/- 3.6%) in comparison with the control group (24.5 +/- 2.5%, P =.0003). The depression in mFS was still significant after taking into account the effect of cESS, but was no more evident after indexation of mFS by RWT or LV mass. At regression analysis, the relation between mFS and cESS showed a steeper negative slope in the patients with hypertension than in the other 2 groups.

CONCLUSIONS

MFS is similarly depressed in physiologic and hypertensive concentric LV hypertrophy. The depression is abolished by adjustment for RWT or LV mass, suggesting that geometric factors are the major determinants of midwall performance in both types of concentric LV hypertrophy. However, an impaired response to different values of cESS seems to exist only in hypertensive concentric LV hypertrophy, because increasing levels of cESS may be associated with more evident mFS depression in patients with hypertension than in the athletes and control subjects.

Change in systolic left ventricular performance after 3 years of antihypertensive treatment: the Losartan Intervention for Endpoint (LIFE) Study

BACKGROUND

We have shown that hypertensive patients with left ventricular (LV) hypertrophy have decreased LV midwall mechanics, but the effect of antihypertensive therapy remains unclear.

METHODS AND RESULTS

Echocardiograms were recorded at baseline in 679 hypertensive patients and ECG LV hypertrophy and repeated yearly during 3 years of blinded treatment to achieve target blood pressures (BPs) of 140/90 mm Hg. On average, BP was reduced from 174+/-21 to 147+/-19 over 95+/-11 to 82+/-10 mm Hg and LV mass from 234+/-56 to 194+/-50 g. Endocardial fractional shortening (FS) decreased slightly, whereas midwall FS increased from 15.4+/-2.0% to 16.8+/-2.1% and stress-corrected midwall FS increased from 97+/-13 to 105+/-12% (all P<0.001). Change in midwall FS was related inversely to change in LV mass (LVM), relative wall thickness (RWT), and diastolic BP and directly to change in Doppler stroke volume (SV, all P<0.001). Multivariate analysis showed that change in MWS was independently inversely related to changes in LVM (beta=-0.211), RWT (beta=-0.334, all P<0.001), and diastolic BP (beta=-0.088, P<0.05) and directly related to SV (beta=0.192, P<0.001) with control for blinded therapy. Change in stress-corrected midwall shortening was inversely independently associated with changes in LVM (beta=-0.153) and RWT (beta=-0.562) and directly with changes in SV (beta=0.145) and systolic BP (beta=0.s221, all P<0.001) with control for blinded therapy.

CONCLUSIONS

Antihypertensive therapy reduced LVM and increased LV midwall shortening and contractility with a small decrease in LV chamber function and significant increase in SV. Change in systolic LV performance was independently associated inversely with change in LVM, RWT, and BP and directly with change in SV.