The effect of weight reduction on left ventricular mass. A randomized controlled trial in young, overweight hypertensive patients

Effects of Different Kinds of Physical Activity on Vascular Function

Regular exercise is one of the main non-pharmacological measures suggested by several guidelines to prevent and treat the development of hypertension and cardiovascular disease through its impact on the vascular system. Routine aerobic training exerts its beneficial effects by means of several mechanisms: decreasing the heart rate and arterial pressure as well as reducing the activation of the sympathetic system and inflammation process without ignoring the important role that it plays in the metabolic profile. Through all these actions, physical training counteracts the arterial stiffening and aging that underlie the development of future cardiovascular events. While the role of aerobic training is undoubted, the effects of resistance training or combined-training exercise on arterial distensibility are still questioned. Moreover, whether different levels of physical activity have a different impact on normotensive and hypertensive subjects is still debated.

Obesity, Preserved Ejection Fraction Heart Failure, and Left Ventricular Remodeling

Owing to the overwhelming obesity epidemic, preserved ejection fraction heart failure commonly ensues in patients with severe obesity and the obese phenotype of preserved ejection fraction heart failure is now commonplace in clinical practice. Severe obesity and preserved ejection fraction heart failure share congruent cardiovascular, immune, and renal derangements that make it difficult to ascertain whether the obese phenotype of preserved ejection fraction heart failure is the convergence of two highly prevalent conditions or severe obesity enables the development and progression of the syndrome of preserved ejection fraction heart failure. Nevertheless, the obese phenotype of preserved ejection fraction heart failure provides a unique opportunity to assess whether sustained and sizeable loss of excess body weight via metabolic bariatric surgery reverses the concentric left ventricular remodeling that patients with preserved ejection fraction heart failure commonly display.

Hypertension and cardiomyopathy associated with chronic kidney disease: epidemiology, pathogenesis and treatment considerations

Chronic kidney disease (CKD) is a complex condition with a prevalence of 10-15% worldwide. An inverse-graded relationship exists between cardiovascular events and mortality with kidney function which is independent of age, sex, and other risk factors. The proportion of deaths due to heart failure and sudden cardiac death increase with progression of chronic kidney disease with relatively fewer deaths from atheromatous, vasculo-occlusive processes. This phenomenon can largely be explained by the increased prevalence of CKD-associated cardiomyopathy with worsening kidney function. The key features of CKD-associated cardiomyopathy are increased left ventricular mass and left ventricular hypertrophy, diastolic and systolic left ventricular dysfunction, and profound cardiac fibrosis on histology. While these features have predominantly been described in patients with advanced kidney disease on dialysis treatment, patients with only mild to moderate renal impairment already exhibit structural and functional changes consistent with CKD-associated cardiomyopathy. In this review we discuss the key drivers of CKD-associated cardiomyopathy and the key role of hypertension in its pathogenesis. We also evaluate existing, as well as developing therapies in the treatment of CKD-associated cardiomyopathy.

Cardiometabolic-based chronic disease: adiposity and dysglycemia drivers of heart failure

Heart failure (HF) is a complex clinical syndrome, associated with high rates of mortality, hospitalization, and impairment of quality of life. Obesity and type 2 diabetes are major cardiometabolic drivers, represented as distinct stages of adiposity- and dysglycemia-based chronic disease (ABCD, DBCD), respectively, and leading to cardiometabolic-based chronic disease (CMBCD). This review focuses on one aspect of the CMBCD model: how ABCD and DBCD influence genesis and progression of HF phenotypes. Specifically, the relationships of ABCD and DBCD stages with structural and functional heart disease, HF risk, and outcomes in overt HF are detailed. Also, evidence-based lifestyle, pharmacological, and procedural interventions that promote or reverse cardiac remodeling and outcomes in individuals at risk or with HF are discussed. In summary, driver-based chronic disease models for individuals at risk or with HF can expose prevention targets for more comprehensive interventions to improve clinical outcomes. Future randomized trials that investigate structured lifestyle, pharmacological, and procedural therapies specifically tailored for the CMBCD model are needed to develop personalized care plans to decrease HF susceptibility and improve outcomes.

Serum uric acid and left ventricular hypertrophy in hypertensive patients in Ado-Ekiti

Introduction

systemic hypertension is a foremost risk factor for cardiovascular morbidity and mortality. Its actions are manifested on organs like the brain, heart and kidneys. High serum uric acid (SUA) escalates cardiovascular vulnerability in patients with systemic hypertension.

Methods

a cross-sectional study was performed in 271 (178 females, 93 males) patients with systemic hypertension. Two hundred and seventy one healthy age and sex matched non-hypertensive persons obliged as controls. Left ventricular hypertrophy (LVH) was estimated by echocardiography. Blood samples were collected for measuring uric acid levels.

Results

mean SUA was significantly higher among the hypertensive patients (371±125μmol/L) than in the controls (269 ± 101.4μmol/L; p < 0.001), and the prevalence of hyperuricemia was 46.9% among the hypertensives and 11.1% among the controls (P < 0.001). Independent predictors of SUA were class of systemic hypertension, left ventricular mass index (LVMI), body mass index (BMI) and age. However, class of hypertension was the best independent predictor of SUA levels in the multivariate regression model (β = 0.597). Linear regression revealed SUA levels ≥ 430μmols/l as a predictor of stage 2 hypertension (F = 26.620, p = < 0.001). Among the hypertensive patients, LVH was present in 39.3% of those with hyperuricemia and in 28.0% of those with normal SUA levels (p = 0.003).

Conclusion

results indicate serum uric acid is positively correlated with hypertension and a reliable indicator of LVH in study population.

Left ventricular hypertrophy and hypertension

Hypertension (HTN) is a major modifiable risk factor for cardiovascular disease (CVD) morbidity and mortality. The left ventricle (LV) is a primary target for HTN end-organ damage. In addition to being a marker of HTN, LV geometrical changes: concentric remodeling, concentric or eccentric LV hypertrophy (LVH) are major independent risk factors for not only CVD morbidity and mortality but also for all-cause mortality and neurological pathologies. Blood pressure control with lifestyle changes and antihypertensive agents has been demonstrated to prevent and regress LVH. Herein, we provide a comprehensive review of literature on the relationship between HTN and LV geometry abnormalities with a focus on diagnosis, prognosis, pathophysiological mechanisms, and treatment approaches.

Hypertension and Heart Failure

Hypertensive heart disease represents a spectrum of illnesses from uncontrolled hypertension to heart failure. The authors discuss the natural history and pathogenesis of heart failure owing to hypertensive heart disease, reviewing the important role of left ventricular hypertrophy as the inciting process leading to diastolic dysfunction and heart failure with preserved ejection fraction. They describe the various mechanisms by which a subset of patients ultimately develops systolic heart failure. They discuss management strategies for hypertensive heart disease at all stages of the disease process. Treatment in the initial stages before onset of heart failure may result in regression of disease.

Joint statement of the European Association for the Study of Obesity and the European Society of Hypertension: obesity and heart failure

Obese individuals are more likely to develop heart failure. Yet, once heart failure is established, the impact of overweight and obesity on prognosis and survival is unclear. The purpose of this joint scientific statement of the European Association for the Study of Obesity and the European Society of Hypertension is to provide an overview on the current scientific literature on obesity and heart failure in terms of prognosis, mechanisms, and clinical management implications. Moreover, the document identifies open questions that ought to be addressed. The need for more tailored weight management recommendations in heart failure will be emphasized and, in line with the emerging evidence, aims to distinguish between primary disease and secondary outcome prevention. In the primary prevention of heart failure, it appears prudent advising obese individuals to lose or achieve a healthy body weight, especially in those with risk factors such as hypertension or type 2 diabetes. However, there is no evidence from clinical trials to guide weight management in overweight or obese patients with established heart failure. Prospective clinical trials are strongly encouraged.

The association of sleep disordered breathing with left ventricular remodeling in CAD patients: a cross-sectional study

Background

There is still insufficient knowledge on the potential effect of mild to moderate sleep-disordered breathing (SDB) that is widely prevalent, often asymptomatic, and largely undiagnosed in patients with stable coronary artery disease (CAD). SDB affects 34% of men and 17% of women aged between 30 and 70. The objective of this study was to evaluate the association between SDB and left ventricular (LV) hypertrophy as well as structural remodeling in stable CAD patients.

Methods

The study was based on a cross-sectional design. Echocardiography and polysomnography was performed in 772 patients with CAD and with untreated sleep apnea. All study participants underwent testing by Epworth Sleepiness Scale questionnaire. Their mean age, NYHA and left ventricular ejection fraction were, respectively: 57 ± 9 years, 2.1 ± 0.5 and 51 ± 8%, and 76% were men. Sleep apnea (SA) was defined as an apnea-hypopnea-index (AHI) ≥5 events/h, and, non-SA, as an AHI <5.

Results

Sleep apnea was present in 39% of patients, and a large fraction of those patients had no complaints on excessive daytime sleepiness. The patients with SA were older, with higher body mass and higher prevalence of hypertension. LV hypertrophy (LVH), defined by allometrically corrected (LV mass/height^2.7) gender-independent criteria, was more common among the patients with SA than those without (86% vs. 74%, p < 0.001). The frequency of LVH by wall thickness criteria (interventricular septal thickness or posterior wall thickness ≥ 12 mm: 49% vs. 33%, p < 0.001) and concentric LVH (61% vs. 47%, p = 0.001) was higher in CAD patients with SA. The patients with SA had significantly higher values of both interventricular septal thickness and posterior wall thickness. Multiple logistic regression analysis showed that even mild sleep apnea was an independent predictor for LVH by wall thickness criteria and concentric LVH (OR = 1.5; 95% CI 1.04–2.2 and OR = 1.9; 1.3–2.9 respectively).

Conclusions

We concluded that unrecognized sleep apnea was highly prevalent among patients with stable CAD, and the majority of those patients did not report daytime sleepiness. Mild to moderate sleep apnea was associated with increased LV wall thickness, LV mass, and with higher prevalence of concentric LV hypertrophy independently of coexisting obesity, hypertension, diabetes mellitus or advancing age.

Left Ventricular Hypertrophy in Pediatric Hypertension: A Mini Review

Adults with arterial hypertension (HTN) have stroke, myocardial infarction, end-stage renal disease (ESRD), or die at higher rates than those without. In children, HTN leads to target organ damage, which includes kidney, brain, eye, blood vessels, and heart, which precedes "hard outcomes" observed in adults. Left ventricular hypertrophy (LVH) or an anatomic and pathologic increase in left ventricular mass (LVM) in response to the HTN is a pediatric surrogate marker for HTN-induced morbidity and mortality in adults. This mini review discusses current definitions, clinically relevant methods of LVM measurements and normalization methods, its epidemiology, management, and issue of reversibility in children with HTN. Pediatric definition of LVH and abnormal LVM is not uniformed. With multiple definitions, prevalence of pediatric HTN-induced LVH is difficult to ascertain. In addition while in adults cardiac magnetic resonance imaging is considered "the gold standard" for LVM and LVH determination, pediatric data are limited to "special populations": ESRD, transplant, and obese children. We summarize available data on pediatric LVH treatment and reversibility and offer future directions in addressing LVH in children with HTN.

Current Perspectives on Left Ventricular Geometry in Systemic Hypertension

Hypertension (HTN) is a global health problem and a leading risk factor for cardiovascular disease (CVD) morbidity and mortality. The hemodynamic overload from HTN causes left ventricular (LV) remodeling, which usually manifests as distinct alterations in LV geometry, such as concentric remodeling or concentric and eccentric LV hypertrophy (LVH). In addition to being a common target organ response to HTN, LV geometric abnormalities are well-known independent risk factors for CVD. Because of their prognostic implications and quantifiable nature, changes in LV geometric parameters have commonly been included as an outcome in anti-HTN drug trials. The purpose of this paper is to review the relationship between HTN and LV geometric changes with a focus on (1) diagnostic approach, (2) epidemiology, (3) pathophysiology, (4) prognostic effect and (5) LV response to anti-HTN therapy and its impact on CVD risk reduction.

Visceral adiposity and left ventricular remodeling: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIMS

Visceral fat (VF) is a source of pro-inflammatory adipokines implicated in cardiac remodeling. We sought to determine the impact of visceral fat and subcutaneous fat (SQ) depots on left ventricular (LV) structure, function, and geometry in the Multi-Ethnic Study of Atherosclerosis (MESA).

METHODS AND RESULTS

We performed a post-hoc analysis on 1151 participants from MESA with cardiac magnetic resonance quantification of LV mass and LV mass-to-volume ratio (LVMV, an index of concentricity) and computed tomographic-derived SQ and VF area. Multivariable regression models to estimate association between height-indexed SQ and VF area (per cm(2)/m) with height-indexed LV mass (per height(2.7)) and LVMV were constructed, adjusted for clinical, biochemical, and demographic covariates. We found that both VF and SQ area were associated with height-indexed LV mass (ρ = 0.36 and 0.12, P < 0.0001, respectively), while only VF area was associated with LVMV (ρ = 0.28, P < 0.0001). Individuals with above-median VF had lower LV ejection fraction, greater indexed LV volumes and mass, and higher LVMV (all P < 0.001). In multivariable models adjusted for weight, VF (but not SQ) area was associated with LV concentricity and LV mass index, across both sexes.

CONCLUSION

Visceral adiposity is independently associated with LV concentricity, a precursor to heart failure. Further study into the role of VF in LV remodeling as a potential therapeutic target is warranted.

Relationship of Systolic Blood Pressure and Body Mass Index With Left Ventricular Mass and Mass Index in Adolescents

Prevalence of hypertension (HT) is growing among children and adolescents. Its diagnosis is commonly ignored as it does not produce any end-organ damage in adolescents. We evaluated whether the blood pressure (BP) and confounding factors were related to myocardial mass increase; an earlier representative of HT; among adolescents. We have demonstrated that heart rate, body mass index (BMI), left ventricular mass (LVM), interventricular septum, and LV mass indexed to body surface area (BSA) and height significantly increased as the category of BP increased. We have also showed that the systolic BP (SBP), diastolic BP (DBP), and BMI were significantly correlated with the LVM and LVM indexed to BSA and height. Linear regression analysis revealed a significant relationship between SBP, BMI, and LVM, LVM indexed to BSA and height. Hypertension may cause myocardial hypertrophy even at a young age. Height is an alternative and practical way of determining the left ventricular mass index (LVMI) in adolescents. The BMI is significantly related to LVM and LVMI as well as SBP and DBP are. The results support that overweight and obesity should be controlled strictly in the management of HT in a young population.

Prescribing Medication Versus Promoting Behavioural Change: A Trial of the Use of Lifestyle Management to Replace Drug Treatment of Hypertension in General Practice

Antihypertensive drug therapy may reverse the cardiac and vascular structural changes associated with sustained hypertension. This may enable appropriate blood pressure levels to be maintained with milder forms of therapy (such as lifestyle interventions) which will minimise any potential adverse effects of pharmacological therapy. The HEART project was conducted in the general practice setting and aimed to determine whether lifestyle strategies, such as increased physical activity and dietary modification, could be substituted for drug therapy in patients who had been well controlled on antihypertensive medication. In addition to objective measures of blood pressure and risk factor outcomes, attitudes and perceptions of general practitioners (GPs) and patients involved in the trial were assessed through focus group discussion and personal interviews. Of the 44 patients recruited to the trial, 41 (93%) participated in structured interviews of 20–40 minutes duration conducted in person or by telephone. Of 78 GPs working in the western suburbs of Melbourne who were approached about the trial, 50% were willing to participate. Of these, 13 (34%) recruited study patients. Of these 13, 10 (77%) participated in a 2-hour focus group discussion which was audiotaped for later transcription and analysis. Despite being enthusiastic about lifestyle interventions in principle, nearly all of these GPs felt resistant to the concept of withdrawing medication in well-controlled subjects. They were generally surprised to see that many patients (15 of 20 patients: 75%) were able to maintain appropriate blood pressure levels following drug therapy withdrawal and adoption of minimal lifestyle changes. GPs felt that the patients' eagerness to come off medication was the major incentive for patients to participate in the trial. This was corroborated by many patients indicating a desire not to be taking any medication. The majority of patients reported making minor changes in lifestyle behaviours leading to most being able to remain off therapy or to have drug dosage requirements reduced. The major barriers to maintaining lifestyle change were family and work stresses and the perception of the intervention not being treated as a therapy thus not at the same level of importance as a treatment method as drug therapy. It appears that a select group of hypertensive patients, highly motivated by the prospect of drug therapy withdrawal, were interested in and willing to trial a lifestyle behaviour change approach for their blood pressure management. The majority reported that they had been able to adopt small but meaningful changes in exercise and dietary habits through the provision of stand-alone self-help materials and support from their GP. Of these patients, 75% remained normotensive without drug therapy after a 9-month follow-up period.

Childhood obesity increases left-ventricular mass irrespective of blood pressure status

Adults with a left-ventricular mass index (LVMI) in grams normalized to height in meters(2.7) (LVMI g/m(2.7)) >51 g/m(2.7) are more prone to cardiovascular and cerebrovascular events. We delineated the odds for cardiac structural sequelae amongst apparently normal white and African-American (AA) children with varying body mass indices (BMI) and office blood pressures. A total of 2,071 children with normal echocardiograms were categorized into risk groups based on BMI and systolic blood pressures (SBPs). Predictors of cardiac sequelae examined were age, sex, race, and z-scores (z) for BMI, SBP, and diastolic blood pressure. Cardiac sequelae measures included (LVMI g/m(2.7)) >51 g/m(2.7), (LVMI) (g/m(2.7)) z, left atrial size (LA(ht)) (mm) z, and relative wall thickness z. Mean age was 14 ± 2 years with 56 % being male and 13 % being AA. Children were divided into "controls" (n = 1,059) and risk groups based on BMI and SBP. Odds ratio for LVMI (g/m(2.7)) > 51.0 g/m(2.7), varied from 5.3 up to 8.5 in children with increased BMI. Both increased BMI and SBP z were associated with increased LVMI (g/m(2.7)) z; however, BMI z had a stronger association. Increased BMI z and AA race were associated with greater LA(ht) (mm) z. AA controls had a nonsignificantly increased LVMI z and a significantly increased LA(ht) (mm) and RWT z. Being overweight or obese is associated with cardiac sequelae in children to the extent known to be associated with adverse outcomes in adults. Healthy AA children have unique cardiac structural differences.

Management of obesity cardiomyopathy

Obesity causes a variety of hemodynamic alterations that may lead to changes in cardiac structure and function. Although such abnormalities may occur in patients with mild-to-moderate obesity, they are most pronounced in those with morbid obesity. When these alterations produce congestive heart failure, obesity cardiomyopathy is said to be present. In this review, the authors will first discuss the pathogenesis and clinical manifestations of obesity cardiomyopathy and then describe the management of this clinical syndrome with emphasis on the effects of weight reduction.

Impact of bariatric surgery on cardiac structure, function and clinical manifestations in morbid obesity

Obesity results from the excessive accumulation of fat. Risk of premature death is doubled compared to nonobese individuals, and risk of death from cardiovascular disease is increased fivefold. In patients with morbid obesity, a variety of adaptations and alterations in cardiac structure and function occur in the individual, as an excess amount of adipose tissue accumulates. The high long-term failure rate of diet intervention is well acknowledged by the clinician. Surgery for severe obesity has evolved during the last 40 years. Many surgical techniques have been described and abandoned. Nevertheless, numerous different techniques are still in use today. Weight loss has beneficial impacts on functional and structural cardiac status and will be reviewed in this report.

Echocardiographic assessment of left ventricular geometric patterns in hypertensive patients in Nigeria

Left ventricular (LV) hypertrophy is an important predictor of morbidity and mortality in hypertensive patients, and its geometric pattern is a useful determinant of severity and prognosis of heart disease. Studies on LV geometric pattern involving large number of Nigerian hypertensive patients are limited. We examined the LV geometric pattern in hypertensive patients seen in our echocardiographic laboratory. A two-dimensional, pulsed, continuous and color flow Doppler echocardiographic evaluation of 1020 consecutive hypertensive patients aged between 18 and 91 years was conducted over an 8-year period. LV geometric patterns were determined using the relationship between the relative wall thickness and LV mass index. Four patterns of LV geometry were found: 237 (23.2%) patients had concentric hypertrophy, 109 (10.7%) had eccentric hypertrophy, 488 (47.8%) had concentric remodeling, and 186 (18.2%) had normal geometry. Patients with concentric hypertrophy were significantly older in age, and had significantly higher systolic blood pressure (BP), diastolic BP, and pulse pressure than those with normal geometry. Systolic function index in patients with eccentric hypertrophy was significantly lower than in other geometric patterns. Doppler echocardiographic parameters showed some diastolic dysfunction in hypertensive patients with abnormal LV geometry. Concentric remodeling was the most common LV geometric pattern observed in our hypertensive patients, followed by concentric hypertrophy and eccentric hypertrophy. Patients with concentric hypertrophy were older than those with other geometric patterns. LV systolic function was significantly lower in patients with eccentric hypertrophy and some degree of diastolic dysfunction were present in patients with abnormal LV geometry.

Obesity-related cardiorenal disease: the benefits of bariatric surgery

The inexorable increase in the prevalence of obesity is a global health concern, which will result in a concomitant escalation in health-care costs. Obesity-related metabolic syndrome affects approximately 25% of adults and is associated with cardiovascular and renal disease. The heart and kidneys are physiologically interdependent, and the pathological effects of obesity can lead to cardiorenal syndrome and, ultimately, kidney and heart failure. Weight loss can prevent or ameliorate obesity-related cardiorenal syndrome, but long-term maintenance of a healthy weight has been difficult to achieve through lifestyle changes or pharmacotherapy. Bariatric surgery offers both sustained weight loss and favourable metabolic changes, including dramatic improvements in glycaemic control and symptoms of type 2 diabetes mellitus. Procedures such as Roux-en-Y gastric bypass offer immediate multisystemic benefits, including bile flow alteration, reduced gastric size, anatomical gut rearrangement and altered flow of nutrients, vagal manipulation and enteric hormone modulation. In patients with cardiorenal syndrome, bariatric surgery also offers renoprotection and cardioprotection, and attenuates both kidney and heart failure by improving organ perfusion and reversing metabolic dysfunction. However, further research is required to understand how bariatric surgery acts on the cardiorenal axis, and its pioneering role in novel treatments and interventions for cardiorenal disease.

Treatment of hypertension in obese patients

Obesity is a global pandemic and with its rise, its associated co-morbidities are increasing in prevalence, particularly uncontrolled hypertension. Lifestyle changes should be an anchor for the management of obesity-related hypertension; however, they are difficult to sustain. Drug therapy is often necessary to achieve blood pressure control. Diuretics, inhibitors of the renin-angiotensin system, and dihydropyridine calcium channel blockers are often used as first trio, with subsequent additions of mineralocorticoid receptor antagonists and/or dual alpha/beta blocking agents. While a number of agents are currently available, 50 % of hypertensive patients remain uncontrolled. A number of novel drug and invasive therapies are in development and hold significant potential for the effective management of obesity-related hypertension.

New echocardiographic techniques in the evaluation of left ventricular function in obesity

OBJECTIVE

Obesity has reached global epidemic proportions and is associated with numerous comorbidities, including major cardiovascular (CV) diseases.

DESIGN AND METHODS

It has many adverse effects on hemodynamics and CV structure and function: it increases total blood volume and cardiac output, and the cardiac workload is greater. Typically, obese patients have a higher cardiac output but a lower level of total peripheral resistance at any given level of arterial pressure. Most of the increase in cardiac output in obesity is caused by stroke volume, although heart rate typically mildly increases also due to enhanced sympathetic activation.

RESULTS

Over the last few years, experimental investigations have unraveled some important pathogenetic mechanisms that may underlie a specific form of "obesity cardiomyopathy." Bariatric surgery represents an effective alternative to treat obesity when nonsurgical weight loss programs (diet + behavior modifications + regular exercise) have failed. A great numbers of questions are still open in the global comprehension of the pathophysiological interactions between obesity and heart.

CONCLUSION

Conventional two-dimensional Doppler echocardiography, integrated by relative new technological ultrasonic approaches, represents the reference technique to study and possibly clarify both the very complex hemodynamic changes induced by obesity and those relative to obesity treatment.

Joint statement of the European Association for the Study of Obesity and the European Society of Hypertension: obesity and difficult to treat arterial hypertension

Obese patients are prone to arterial hypertension, require more antihypertensive medications, and have an increased risk of treatment-resistant arterial hypertension. Obesity-induced neurohumoral activation appears to be involved. The association between obesity and hypertension shows large inter-individual variability, likely through genetic mechanisms. Obesity affects overall cardiovascular and metabolic risk; yet, the relationship between obesity and cardiovascular risk is complex and not sufficiently addressed in clinical guidelines. The epidemiological observation that obesity may be protective in patients with established cardiovascular disease is difficult to translate into clinical experience and practice. Weight loss is often recommended as a means to lower blood pressure. However, current hypertension guidelines do not provide evidence-based guidance on how to institute weight loss. In fact, weight loss influences on blood pressure may be overestimated. Nevertheless, weight loss through bariatric surgery appears to decrease cardiovascular risk in severely obese patients. Eventually, most obese hypertensive patients will require antihypertensive medications. Data from large-scale studies with hard clinical endpoints on antihypertensive medications specifically addressing obese patients are lacking and the morbidity from the growing population of severely obese patients is poorly recognized or addressed. Because of their broad spectrum of beneficial effects, renin-angiotensin system inhibitors are considered to be the most appropriate drugs for antihypertensive treatment of obese patients. Most obese hypertensive patients require two or more antihypertensive drugs. Finally, how to combine weight loss strategies and antihypertensive treatment to achieve an optimal clinical outcome is unresolved.

Primary prevention of heart failure

Most heart failure research and quality improvement efforts are targeted at treatment and secondary prevention of patients with manifest heart failure. This is distinct from coronary disease where primary prevention has been a focus for over three decades. Given the current importance and the projected worsening of heart failure epidemiology, a more focused effort on prevention is urgently needed.

Obesity and left ventricular dilatation in young adulthood: the Bogalusa Heart Study

BACKGROUND

Cardiac enlargement is an important predictor of adverse cardiovascular (CV) events. Left ventricular (LV) dilatation is a precursor both of LV dysfunction and clinical heart failure. The present study examines risk factors for LV dilatation among 832 young adults (341 male, 491 female) who participated in the Bogalusa Heart Study.

HYPOTHESIS

A unique set of risk factors predicts LV dilatation among young adults.

METHODS

Standard ventricular dimensions were determined by M-mode echocardiography and indexed to height using a standard method. LV dilatation was considered as the top 20th percentile of LV end-diastolic dimension indexed to height. Logistic regression models were used, stratified by race and sex, to assess the relationship of CV risk factors with quintile of LV end-diastolic dimension indexed to height.

RESULTS

The mean age (standard deviation) of men and women in the population was 36.4 years (3.9 years) and 35.9 years (4.6 years), respectively. In sex-specific models adjusted for age, race, systolic and diastolic blood pressure, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, and glycosylated hemoglobin, body mass index (BMI) was a significant predictor of LV dilatation in both men and women. The odds ratio (95% confidence interval) for a 1-unit change in BMI was 1.12 (1.02-1.19) in men and 1.09 (1.05-1.13) in women. Among men, triglyceride level was also significantly associated with LV dilatation (P=0.03), whereas among women there was no such association.

CONCLUSIONS

Our findings indicate that obesity is the most consistent predictor of LV dilatation in both men and women, whereas triglyceride level was a significant predictor among men only.

Metabolic syndrome and heart failure--the risk, paradox, and treatment

The constellation of obesity, hypertension, dyslipidemia, and insulin resistance-together referred to as metabolic syndrome (MetS)-is increasing in prevalence in the American population and also worldwide. The individual components of MetS and MetS as a whole increase the risk of heart failure, cardiovascular mortality, and all-cause mortality. Despite this adverse association, numerous studies have documented an obesity paradox, in which overweight and obese people with established cardiovascular disease, including hypertension, coronary heart disease, heart failure, and peripheral arterial disease, have a better prognosis than patients who are not overweight or obese. Current treatment strategies for these patients include weight loss, control of blood pressure and cholesterol levels, and treatment of hyperglycemia. Because of increasing evidence for the obesity paradox, some physicians question whether obesity should be treated when it is associated with heart failure. Several studies have shown improvement in left ventricular function and decreased mortality and morbidity from heart failure with weight loss and treatment of elevated blood pressure, cholesterol, and hyperglycemia. The most reasonable approach at this time appears to be weight loss and exercise, lowering blood pressure to less than 130/80 mm Hg, low-density lipoprotein (LDL) cholesterol to less than 100 mg/dL, and glycosylated hemoglobin levels to less than 7%.

Subclinical regional left ventricular dysfunction in obese patients with and without hypertension or hypertrophy

We investigated the impact of obesity on the abnormalities of systolic and diastolic regional left ventricular (LV) function in patients with or without hypertension or hypertrophy, and without heart failure. We studied 120 individuals divided into 6 groups of 20 patients (42 ± 6 years, 60 females) using standard and pulsed-wave tissue Doppler imaging (TDI) echocardiography, and heterogeneity index (HI): nonobese (I: no hypertension, no hypertrophy, control group; II: hypertension, no hypertrophy; III: hypertension and hypertrophy) and obese (IV: no hypertension, no hypertrophy; V: hypertension, no hypertrophy; VI: hypertension and hypertrophy). The criterion for obesity was BMI ≥30 kg/m2, for hypertension was blood pressure ≥ 140/90 mm Hg, for hypertrophy in nonobese was LV mass/body surface area (BSA) >134 g/m(2) (men) and >110 mg/m2 (women), and in obese was LV mass/height(2.7) >50 (men) and >40 (women). Obese groups had normal LV ejection fraction compared with nonobese groups, but decreased longitudinal and radial systolic myocardial peak velocities (S'), and early diastolic myocardial peak velocity (E'). Also, a great variability of E' and late diastolic myocardial peak velocity (A') from the longitudinal basal region was observed in obese groups (E'basal nonobese: 11 ± 7 vs. obese 19 ± 11, P < 0.001, A'basal nonobese: 7 ± 4 vs. obese 11 ± 7, P < 0.001). Our findings were more evident when comparing groups IV with V and VI, with the latter having concentric hypertrophy and obvious segmental systolic and diastolic dysfunctions. Subclinical myocardial alterations and increased variability of the velocities were observed in obese groups, especially with hypertension and hypertrophy, reflecting impaired regional LV relaxation, segmental atrial, and systolic dysfunctions.

Obesity in adolescence is associated with left ventricular hypertrophy and hypertension

BACKGROUND

Obesity is a risk factor for hypertension (HTN) and left ventricular hypertrophy (LVH). However, the association between obesity, HTN or LVH in adolescents has not been studied in a large population.

METHOD

Utilizing a database of screening echocardiograms, we assessed for the presence of LVH and HTN (defined as systolic blood pressure (SBP) > 140 mmHg or diastolic blood pressure (DBP) > 90 mmHg) in obese adolescents (BMI > 30) using univariate and multivariate analysis.

RESULTS

A total of 2072 subjects were identified between the ages of 13-19 years. LVH was significantly more prevalent in obese subjects (47/166 [28.3%] vs. nonobese subjects (99/1612 [6.1%]) with a P-value of <0.001. Using multivariate analysis adjusting for age, gender and blood pressure, obesity remained strongly associated with the presence of LVH (OR 4.51, CI: 2.83-7.19, P < 0.001). Elevated SBP and DBP were also strongly associated with obesity. SBP > 140 was present in 38% of obese subjects (54/142) versus 12.7% of nonobese subjects (172/1, 353). DBP > 90 was present in 10.6% of obese subjects (15/141) of versus 3.1% of nonobese subjects (42/1352). After adjustment for age, gender and LVH, obesity remained independently associated with HTN (for SBP > 140, OR 2.24, CI: 1.46-3.45, P < 0.001, and for DBP > 90, OR 2.10, CI: 1.063-4.17, P = 0.03).

CONCLUSION

Obese adolescents have a significantly higher prevalence of HTN and LVH. Our analysis suggests a direct negative effect of obesity on cardiovascular function starting early in teenage years. (Echocardiography 2011;28:150-153).

Impaired flow-mediated vasodilatation is associated with increased left ventricular mass in a multiethnic population. The Northern Manhattan Study

BACKGROUND

Increased left ventricular (LV) mass and endothelial dysfunction are important risk factors for cardiovascular mortality and morbidity. However, it is not clear whether endothelial dysfunction is associated with increased LV mass. We tested the hypothesis that impaired flow-mediated vasodilatation (FMD) is associated with increased LV mass in a population-based multiethnic cohort.

METHODS

As a part of the Northern Manhattan Study (NOMAS), we performed two-dimensional echocardiography and FMD assessment during reactive hyperemia by high-resolution ultrasonography in 867 stroke-free community participants. LV mass was calculated according to an established method. LV hypertrophy was defined as the 90th percentile of sex-specific LV mass indexed for body surface area among normal subjects. Multivariable models were used to test the association of FMD with LV mass.

RESULTS

In multiple linear regression analysis adjusting for age, sex, body mass index, systolic blood pressure, antihypertensive medications, low-density lipoprotein cholesterol, diabetes, smoking, hematocrit, and race-ethnicity, FMD was inversely associated with LV mass (beta = -1.21 +/- 0.56, P = 0.03). The association persisted after further adjustment for any component of blood pressure (systolic, mean, and pulse pressure). In univariate logistic regression analysis, each 1% decrease in FMD was associated with an 8% higher risk of LV hypertrophy (odds ratio 1.08, 95% confidence interval 1.03-1.13 per each FMD point P < 0.01).

CONCLUSIONS

Impaired FMD is associated with LV mass, independent of other factors associated with increased LV mass. Endothelial dysfunction might be a potential risk factor for LV hypertrophy.

Clinical impact of left ventricular hypertrophy and implications for regression

Left ventricular hypertrophy (LVH) is an independent risk factor and predictor of cardiovascular (CV) events and all-cause mortality. Patients with LVH are at increased risk for stroke, congestive heart failure, coronary heart disease, and sudden cardiac death. Left ventricular hypertrophy represents both a manifestation of the effects of hypertension and other CV risk factors over time as well as an intrinsic condition causing pathologic changes in the CV structure and function. We review the risk factors for LVH and its consequences, concentric remodeling, and its prognostic significance, clinical benefits and supporting evidence for LVH regression, and its implications for management. We conclude our review summarizing the various pharmacological and nonpharmacological therapeutic options approved for the treatment of hypertension and LVH regression and the supporting clinical trial data for these therapeutic strategies.

Early heart failure in the population. The study of men born in 1913

A cross-sectional analysis of characteristics possibly associated with congestive heart failure (CHF) was performed among 644 men, all 67 years of age and randomly selected from the general population. A total of 13% had symptoms and signs of overt CHF. Another 10% had early or "latent" CHF. Among overt CHF cases, 46% had hypertension, 55% coronary heart disease and 79% any one of these conditions. Among "latent" CHF cases, the corresponding proportions were 52%, 25% and 65%. Simple indices of left ventricular diastolic function and filling pressure as well as of pulmonary artery pressure were closer related to the CHF stage, than were measures of systolic left ventricular function. Smoking habits, hypertension, blood lipids, weight and other measures of body fat, blood glucose, and serum insulin were all correlated to CHF stage. In a multivariate analysis, smoking habits, hypertension, body weight, and serum insulin were independently and significantly correlated to CHF stage.

Impact of obesity on the risk of heart failure and its prognosis

Obesity is becoming a global epidemic in both children and adults, and it is associated with numerous comorbidities such as coronary heart disease, stroke/cerebrovascular disease, type 2 diabetes, hypertension, certain cancers, and sleep-disordered breathing. Over the past 2 decades, the incidence of and mortality from coronary heart disease and cardiovascular diseases has been continuously declining. In contrast, the incidence of and mortality from heart failure (HF) have been increasing, with HF diagnosed in approximately 5 million Americans and 550,000 new cases diagnosed each year and a death rate looming at 300,000 per year. Over the years, conventional risk factors including hypertension, type 2 diabetes, and dyslipidemia have been implicated for these unsavory statistics, and recently many studies have highlighted the important role of obesity as an independent risk factor for HF. Here, the authors review the available literature on the effects of overweight and obesity on a variety of cardiac structural adaptations and alterations, the effects on left ventricular systolic and diastolic function, and their role in the development and prognosis of HF. Numerous studies have demonstrated an "obesity paradox" regarding prognosis, however, in that obese patients with established HF tend to have a more favorable prognosis than do lean patients. Finally, the authors discuss the role of cardiopulmonary exercise testing in the risk stratification of obese patients with advanced HF.

Regular physical activity prevents development of left ventricular hypertrophy in hypertension

AIMS

The longitudinal relationship between aerobic exercise and left ventricular (LV) mass in hypertension is not well known. We did a prospective study to investigate the long-term effect of regular physical activity on development of LV hypertrophy (LVH) in a cohort of young subjects screened for Stage 1 hypertension.

METHODS AND RESULTS

We assessed 454 subjects whose physical activity status was consistent during the follow-up. Echocardiographic LV mass was measured at entry, every 5 years, and/or at the time of hypertension development before starting treatment. LVH was defined as an LV mass >/=50 g/m(2.7) in men and >/=47 g/m(2.7) in women. During a median follow-up of 8.3 years, 32 subjects developed LVH (sedentary, 10.3%; active, 1.7%, P = 0.000). In a logistic regression, physically active groups combined (n = 173) were less likely to develop LVH than sedentary group with a crude OR = 0.15 (CI, 0.05-0.52). After controlling for sex, age, family history for hypertension, hypertension duration, body mass, blood pressure, baseline LV mass, lifestyle factors, and follow-up length, the OR was 0.24 (CI, 0.07-0.85). Blood pressure declined over time in physically active subjects (-5.1 +/- 17.0/-0.5 +/- 10.2 mmHg) and slightly increased in their sedentary peers (0.0 +/- 15.3/0.9 +/- 9.7 mmHg, adjusted P vs. active = 0.04/0.06). Inclusion of changes in blood pressure over time into the logistic model slightly decreased the strength of the association between physical activity status and LVH development (OR = 0.25, CI, 0.07-0.87).

CONCLUSION

Regular physical activity prevents the development of LVH in young stage 1 hypertensive subjects. This effect is independent from the reduction in blood pressure caused by exercise.

WITHDRAWN: Dieting to reduce body weight for controlling hypertension in adults

BACKGROUND

As early as the 1920's, researchers noted a relationship between caloric restriction, weight loss and a decreased incidence of hypertension (Terry 1922, Preble 1923, Bauman 1928, Master 1929). In 1988 a meta-analysis of aggregate data from 12 prospective studies, including 5 randomized controlled trials (RCTs), found that on average each 1 kilogram decrease in body weight in obese hypertensive patients was associated with a 2.4 mm Hg systolic and 1.5 mm Hg diastolic decrease in blood pressure (Staessen 1988). Blood pressure reductions were not dependent upon degree of baseline obesity.This review aims to: 1) update the work of Staessen (Staessen 1988) looking specifically at randomized controlled trials, and 2) assess whether any of the trials assess effects of weight-reducing diets on clinical outcomes such as quality of life, morbidity or mortality.

OBJECTIVES

Evaluate whether weight-loss diets are more effective than regular diets or other antihypertensive therapies in controlling blood pressure and preventing morbidity and mortality in hypertensive adults.

SEARCH STRATEGY

MEDLINE and The Cochrane Library were searched through November 1997. Trials known to experts in the field were included through June 1998.

SELECTION CRITERIA

For inclusion in the review, trials were required to meet each of the following criteria: 1) randomized controlled trials with one group assigned to a weight-loss diet and the other group assigned to either normal diet or antihypertensive therapy; 2) ambulatory adults with a mean blood pressure of at least 140 mm Hg systolic and/or 90 mm Hg diastolic; 3) active intervention consisting of a calorie-restricted diet intended to produce weight loss (excluded studies simultaneously implementing multiple lifestyle interventions where the effects of weight loss could not be disaggregated); and 4) outcome measures included weight loss and blood pressure.

DATA COLLECTION AND ANALYSIS

Studies were dual abstracted by two independent reviewers using a standardized form designed specifically for this review. The primary mode of analysis was qualitative; graphs of effect sizes for individual studies were also used.

MAIN RESULTS

Eighteen trials were found. Only one small study of inadequate power reported morbidity and mortality outcomes. None addressed quality of life or general well being issues. In general, participants assigned to weight-reduction groups lost weight compared to control groups.Six trials involving 361 participants assessed a weight-reducing diet versus a normal diet. The data suggested weight loss in the range of 4% to 8% of body weight was associated with a decrease in blood pressure in the range of 3 mm Hg systolic and diastolic. Three trials involving 363 participants assessed a weight-reducing diet versus treatment with antihypertensive medications. These suggested that a stepped-care approach with antihypertensive medications produced greater decreases in blood pressure (in the range of 6/5 mm Hg systolic/diastolic) than did a weight-loss diet. Trials that allowed adjustment of participants' antihypertensive regimens suggested that patients required less intensive antihypertensive drug therapy if they followed a weight-reducing diet. Data was insufficient to determine the relative efficacy of weight-reduction versus changes in sodium or potassium intake or exercise.

AUTHORS' CONCLUSIONS

Weight-reducing diets in overweight hypertensive persons can affect modest weight loss in the range of 3-9% of body weight and are probably associated with modest blood pressure decreases of roughly 3 mm Hg systolic and diastolic. Weight-reducing diets may decrease dosage requirements of persons taking antihypertensive medications.

The impact of weight loss on cardiac structure and function in obese patients

BACKGROUND

Obesity frequently results in structural and physiologic changes in the cardiovascular system. Whether weight reduction leads to reversal of these changes is not well-established. This investigation sought to identify the effect of a weight reduction program on right and left ventricular structure and function.

METHODS

Sixty-two patients presenting to the eating disorders clinic at a single academic institution for weight loss programs were prospectively enrolled. Baseline and follow-up transthoracic echocardiograms were obtained after at least 10% weight reduction or 6 months after baseline echocardiogram. Complete 2-dimensional echocardiograms were performed with M-mode, flow Doppler, and tissue Doppler evaluation.

RESULTS

Patients lost an average of 28.2 +/- 3 kg over a period of 266 +/- 36 days. Left ventricular mass decreased significantly from 255.87 +/- 12 to 228 +/- 11 gm. There were no statistically significant changes in contractility or diastolic indices. The ratios of early-to-late diastolic mitral inflow velocities (E/A) increased from 1.30 +/- 0.05 to 1.32 +/- 0.06. The ratio of early mitral flow to early annular velocity (E/Em) also increased from 5.57 +/- 0.22 cm to 5.82 +/- 0.23 cm. Deceleration time increased from 213.26 +/- 5.3 s to 228.47 +/- 5.7 s.

CONCLUSIONS

Weight reduction is associated with decrease in left ventricular diastolic size and left ventricular mass. This weight reduction is not associated with statistically significant improvement in systolic or diastolic function.