Association of aldosterone with left ventricular mass in hypertension: interaction with plasma fibrinogen levels

Prevention and treatment of hypertensive left ventricular hypertrophy

PURPOSE OF REVIEW

Left ventricular (LV) hypertrophy (LVH) is a well recognized target organ adaptation to longstanding uncontrolled hypertension and other cardiovascular risk factors. It is also a strong and independent predictor of many cardiovascular disorders.

RECENT FINDINGS

This focused review explores the current concepts in screening, diagnosis, prevention, and treatment of LVH in patients with hypertension. Currently, the primary screening and diagnostic tools for LVH are ECG and 2D echocardiography. Implementing machine learning in the diagnostic modalities can improve sensitivity in the detection of LVH. Lifestyle modifications, blood pressure control with antihypertensive therapy, and management of comorbidities aid in preventing and reversing LV remodeling.

SUMMARY

LVH is a common and often silent complication of hypertension. Prevention and reversal of LV remodeling are crucial for cardiovascular risk reduction in patients with hypertension.

Aldosterone Effect on Cardiac Structure and Function

BACKGROUND

Cardiac remodelling could be a key mechanism in aldosteronemediated cardiovascular morbidity and mortality. Experimental and clinical evidence has demonstrated that aldosterone causes cardiac structural remodelling and dysfunction by its profibrotic and pro-hypertrophic effects, which result mainly from the direct effects on myocardial collagen deposition, inflammation, and oxidative stress. Clinical studies have investigated the aldosterone effects on the heart in different clinical conditions, including general population, essential hypertension, primary aldosteronism, heart failure, and atrial fibrillation. Robust findings indicate that aldosterone or the activation of the cardiac mineralocorticoid receptor can cause damage to myocardial tissue by mechanisms independent of the blood pressure, leading to tissue hypertrophy, fibrosis, and dysfunction.

CONCLUSION

Aldosterone-mediated cardiovascular morbidity and mortality mainly result from cardiac structural and functional alterations. In different clinical settings, aldosterone can induce cardiac structural remodelling and dysfunction via several pathological mechanisms, including cardiac fibrosis, inflammation, and oxidative stress. Aldosterone antagonists could effectively decrease or reverse the detrimental aldosterone-mediated changes in the heart.

Targeting subclinical organ damage in obstructive sleep apnea: a narrative review

Subclinical abnormalities in cardiac and vascular structure reflect the adverse effects triggered by a variety of risk factors on the cardiovascular (CV) system thereby representing an intermediate step in the cardiovascular continuum; such alterations are recognized as reliable markers of increased cardiovascular risk in different clinical settings including obstructive sleep apnea (OSA). The mechanisms underlying subclinical organ damage (OD) in the OSA setting are multifactorial. Hypoxemia and hypercapnia, induced by repeated collapses of upper airways, have been suggested to trigger a cascade of events such as activation of the sympathetic tone, renin-angiotensin-aldosterone system leading to endothelial dysfunction, vasoconstriction, myocardial and vascular remodeling, and hypertension. Furthermore, coexisting non-haemodynamic alterations such as increased oxidative stress, release of inflammatory substances, enhanced lipolysis and insulin resistance have been reported to play a role in the pathogenesis of both cardiac and extra-cardiac OD. In this article we reviewed available evidence on the association between OSA and subclinical cardiac (i.e., left and right ventricular hypertrophy, left atrial dilatation) and extra-cardiac organ damage (i.e., carotid atherosclerosis, arterial stiffness, microvascular retinal changes, and microalbuminuria). This association is apparently stronger for cardiac and carotid subclinical damage than for other markers (i.e., arterial stiffness and retinal changes) and mostly evident in the setting of severe OSA.

Hemodynamic and Non-Hemodynamic Components of Cardiac Remodeling in Primary Aldosteronism

OBJECTIVES

Patients with primary aldosteronism (PA) have cardiac remodeling due to hemodynamic and non-hemodynamic causes. However, component analysis of cardiac remodeling and reversal in PA patients is lacking. We investigated components of cardiac remodeling and reversal after adrenalectomy in patients with aldosterone-producing adenoma (APA).

METHODS

This study prospectively enrolled 304 APA patients who received adrenalectomy and 271 with essential hypertension (EH). Clinical, biochemical and echocardiographic data were collected in both groups and 1 year after surgery in the APA patients. The hemodynamic and non-hemodynamic components of left ventricular (LV) remodeling were represented by predicted left ventricular mass index (LVMI) (pLVMI) and inappropriately excessive LVMI (ieLVMI, defined as LVMI-pLVMI).

RESULTS

After propensity score matching, 213 APA and 213 EH patients were selected. APA patients had higher hemodynamic (pLVMI) and non-hemodynamic (ieLVMI) components of LV remodeling than EH patients. In multivariate analysis, baseline pLVMI was correlated with systolic blood pressure (SBP) and serum potassium, whereas ieLVMI was correlated with log plasma aldosterone concentration but not blood pressure. Post-operative echocardiography was available in 207 patents and showed significant decreases in both pLVMI and ieLVMI after adrenalectomy. In multivariate analysis, ΔpLVMI was correlated with SBP, ΔSBP, and pre-operative pLVMI, whereas ΔieLVMI was correlated with Δlog aldosterone-to-renin ratio (ARR) and pre-operative ieLVMI.

CONCLUSIONS

This study concluded that extensive cardiac remodeling in APA patients occurs through hemodynamic and non-hemodynamic causes. Adrenalectomy can improve both hemodynamic and non-hemodynamic components of LV remodeling. Regressions of pLVMI and ieLVMI were correlated with decreases in blood pressure and ARR, respectively.

Left ventricular mass reduction and hypertrophy regression following renal artery revascularization: a meta-analysis

AIM

Few echocardiographic studies have focused on regression of left ventricular hypertrophy (LVH) in patients with renal artery stenosis after revascularization, with inconsistent results. We performed a systematic meta-analysis of these studies in order to offer a comprehensive information on this topic.

METHODS

The PubMed, OVID-MEDLINE, and Cochrane library databases were analyzed to search English-language articles published from 1 January 1990 up to 31 March 2020. Studies were identified by crossing the following terms: 'renal artery stenosis', 'renovascular hypertension', 'fibromuscular dysplasia', 'renal artery stenting', 'renal artery surgery' with 'cardiac damage', 'hypertensive heart disease' 'left ventricular mass', 'left ventricular hypertrophy', 'echocardiography'.

RESULTS

A total of 726 hypertensive patients with renal artery stenosis (mean age 61 years, 64% men, 98% treated, 10% with fibromuscular dysplasia) were included in 13 studies. Baseline and postintervention pooled mean LVM values were 220 ± 15 and 203 ± 19 g, respectively (SMD -0.24 ± 0.06, CI -0.37 to -0.21, P<0.0001); corresponding values for LV mass index were 129.0 ± 6 and 115 ± 7 g/m, respectively (SMD -0.28 ± 0.04, CI -0.36 to 0.21, P < 0.0001). Renal revascularization was associated with a 40% lower risk of LVH. This trend was accompanied by a reduction in the number of antihypertensive drugs (SMD -0.27 ± 0.04, CI -0.37 to 0.17, P < 0.0001).

CONCLUSION

The present meta-analysis suggests that renal artery revascularization added to antihypertensive therapy promotes a favourable effect on LV structure, as reflected by a significant decrease in absolute and indexed LV mass index as well by a lower risk of LVH. Limitations include: high prevalence of modest renal artery stenosis (≥50%); small sample of fibromuscular dysplasia; lack of randomized design of most studies.

Renal artery stenosis and left ventricular hypertrophy: an updated review and meta-analysis of echocardiographic studies

AIM

Data on left ventricular hypertrophy (LVH) in patients with renal artery stenosis (RAS) and its regression following renal revascularization are scanty. We performed a meta-analysis to provide comprehensive information on this clinically relevant issue.

METHODS

Full articles providing data on: LVH, as assessed by echocardiography, in RAS patients as compared with essential hypertensive counterparts; changes of left ventricular (LV) mass index after renal artery revascularization were considered.

RESULTS

A total of 905 study participants (RAS = 446, essential hypertensive = 459) of both sex were included in nine studies. Pooled LV mass index was higher in RAS than in essential hypertensive patients (140.4 ± 11.1 g/m versus 121.8 ± 6.2 g/m, standard mean difference being 0.41 ± 0.07 [95% confidence interval (CI) 0.27-0.51, P < 0.001]. Among 360 RAS patients undergone renal revascularization from eight studies, baseline and post-intervention pooled mean LV mass index values were 129.0 ± 10.2 g/m and 115.5 ± 9.9 g/m, respectively, the standard mean difference being-0.36 ± 0.06 (95% CI from -0.47 to -0.25, P < 0.001). These findings were unaffected by publication bias or single study effect.

CONCLUSION

Our meta-analysis indicates that RAS patients have an increased likelihood of LVH compared with essential hypertensive counterparts and renal artery revascularization has a beneficial effect on LV structure, as reflected by a significant decrease in LV mass index.

Long-Term Renal and Cardiac Outcomes after Stenting in Patients with Resistant Hypertension and Atherosclerotic Renal Artery Stenosis

BACKGROUND/AIMS

Atherosclerotic renal artery stenosis (ARAS) is frequently detected in patients with resistant hypertension (RHTN), but the evidence supporting the utility of renal revascularization in these patients is limited. This prospective, observational study investigates the outcomes of renal stenting in patients with RHTN and hemodynamically significant ARAS.

METHODS

Fifty-four patients with RHTN were selected because of angiographic evidence of ARAS >70% and were followed for 4 years after renal stenting. Renal function and echocardiographic variables were assessed at baseline and during follow-up.

RESULTS

Blood pressure decreased rapidly after renal stenting and was normalized in 67% of patients at six months, with significant reduction in the number of antihypertensive drugs. Creatinine clearance increased in 39% of patients, decreased in 52%, and remained stable in the remaining 9%, with an average value that had a nonsignificant decrease during follow-up. Urinary albumin excretion did not change throughout the study. After 4 years, left ventricular (LV) wall thickness and concentric geometry decreased significantly and variables of LV diastolic function improved.

CONCLUSION

In patients with RHTN, stenting of hemodynamically significant ARAS decreases blood pressure, preserves renal function in a substantial proportion of patients, and improves LV structure and function, suggesting the opportunity for timely identification of ARAS in these patients.

Uric Acid and New Onset Left Ventricular Hypertrophy: Findings From the PAMELA Population

BACKGROUND

The association between serum uric acid (SUA) and left ventricular hypertrophy (LVH) is controversial and the ability of SUA in predicting incident LVH remains unsettled. Thus, we evaluated the relationship of SUA with new-onset echocardiographic LVH over a 10-year period in subjects of the general population enrolled in the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study.

METHODS

The study included 960 subjects with normal LV mass index (LVMI) at baseline echocardiographic evaluation and a readable echocardiogram at the end of follow-up. Cut-points for LVH were derived from reference values of the healthy fraction of the PAMELA population.

RESULTS

Over a 10-year period, 258 participants (26.9%) progressed to LVH. The incidence of new-onset LVH increased from the lowest (23%) to intermediate (25%) and the highest baseline SUA tertile (32%). After adjusting for confounders (not including body mass index (BMI)), each 1 mg/dl increase in SUA entailed a 26% higher risk of incident LVH. Adjusted odd ratio of LVH risk in the highest SUA tertile was 96% higher than in the lowest tertile (odds ratio (OR) = 1.966, 95% CI = 1.158-3.339, P = 0.0123). Correction for BMI reduced the magnitude and statistical significance of ORs.

CONCLUSIONS

The study shows that SUA is a predictor of long-term echocardiographic changes from normal LVMI to LVH in a community sample. Thus, life-style and pharmacologic measures aimed to reduce SUA levels may concur to preventing LVH development in the general population.

Salt, Aldosterone, and Parathyroid Hormone: What Is the Relevance for Organ Damage?

Structured interventions on lifestyle have been suggested as a cost-effective strategy for prevention of cardiovascular disease. Epidemiologic studies demonstrate that dietary salt restriction effectively decreases blood pressure, but its influence on cardiovascular morbidity and mortality is still under debate. Evidence gathered from studies conducted in patients with primary aldosteronism, essential hypertension, or heart failure demonstrates that long-term exposure to elevated aldosterone results in cardiac structural and functional changes that are independent of blood pressure. Animal experiments and initial clinical studies indicate that aldosterone damages the heart only in the context of an inappropriately elevated salt status. Recent evidence suggests that aldosterone might functionally interact with the parathyroid hormone and thereby affect calcium homeostasis with important sequelae for bone mineral density and strength. The interaction between aldosterone and parathyroid hormone might have implications also for the heart. Elevated dietary salt is associated on the one hand with increased urinary calcium excretion and, on the other hand, could facilitate the interaction between aldosterone and parathyroid hormone at the cellular level. This review summarizes the evidence supporting the contribution of salt and aldosterone to cardiovascular disease and the possible cardiac and skeletal consequences of the mutual interplay between aldosterone, parathyroid hormone, and salt.

Association of Post-Saline Load Plasma Aldosterone Levels With Left Ventricular Hypertrophy in Primary Hypertension

BACKGROUND

Left ventricular hypertrophy (LVH) is an independent risk factor for cardiovascular morbidity in hypertension. Current evidence suggests a contribution to LVH of plasma aldosterone levels that are inappropriately elevated for the salt status. The aim of this study was to investigate whether inappropriate modulation of aldosterone production by a saline load is associated with left ventricular (LV) mass in hypertensive patients.

METHODS

In 90 hypertensive patients free of clinically relevant cardiovascular complications in whom secondary forms of hypertension were ruled out, we performed a standard intravenous saline load (0.9% NaCl, 2 l in 4 hours) with measurement of plasma aldosterone and active renin at baseline and end of infusion. Bi-dimensional echocardiography was performed for the assessment of cardiac morphology and function.

RESULTS

LVH was present in 19% of patients who had significantly worse renal function and higher body mass, blood pressure, and plasma aldosterone levels measured both at baseline and after the saline load than patients without LVH. LV mass was directly related to age, body mass, systolic blood pressure, duration of hypertension, baseline, and post-saline load plasma aldosterone levels and inversely to glomerular filtration. Multivariate regression analysis showed independent correlation of LV mass with body mass, systolic blood pressure, and plasma aldosterone levels measured after intravenous saline load, but not at baseline.

CONCLUSIONS

In patients with hypertension, aldosterone levels measured after intravenous saline load are related to LV mass independent of age, body mass, and blood pressure, suggesting that limited ability of salt to modulate aldosterone production could contribute to LVH.

Aldosterone and Left Ventricular Remodeling

Experimental and clinical evidence obtained in the last 2 decades clearly indicates that protracted exposure to inappropriately elevated aldosterone levels causes significant changes in left ventricular structure and function. Animal studies have demonstrated that aldosterone induces myocardial inflammatory changes and fibrosis in the presence of a high salt diet. Moreover, the effects of aldosterone on the heart have been investigated in different clinical conditions. These conditions include systolic and diastolic heart failure, essential hypertension, and primary aldosteronism that offers a unique clinical model to study the cardiac effects of excess aldosterone because these effects are isolated from those of the renin-angiotensin axis. A relatively clear picture is emerging from these studies with regard to aldosterone-related changes in left ventricular mass and geometry. Conversely, no direct effect of aldosterone on left ventricular diastolic function can be demonstrated and improvement of diastolic function obtained in some studies that have employed mineralocorticoid receptor blockers could result from left ventricular mass reduction. Animal experiments demonstrate that effects of aldosterone on the left ventricle require high salt intake to occur, but the evidence of this contribution of salt to aldosterone-induced cardiac changes in humans remains weaker and needs further research. The article reviews the results of clinical studies addressing the role of aldosterone in regulation of LV remodeling and diastolic function, and focuses on the possible relevance of salt intake.

Association of electrocardiographic left ventricular hypertrophy with incident cardiovascular disease in Japanese older hypertensive patients

BACKGROUND

Our aim was to assess whether electrocardiographic left ventricular hypertrophy (ECG-LVH) is associated with a higher risk of cardiovascular disease (CVD) events, independent of 24-hour blood pressure (BP) and circulating levels of norepinephrine and hemostatic factors.

METHODS

In 514 older hypertensive patients (mean age 72.3 years; 37% men), we assessed ambulatory BP values, circulating levels of norepinephrine and hemostatic factors (plasma fibrinogen, prothrombin fragment 1+2 (F1+2), von Willebrand factor (vWF), and plasminogen activator inhibitor-1 (PAI-1)), and the presence or absence of ECG-LVH (Sokolow-Lyon voltage ≥ 3.5 mV). The incidence of CVD events (i.e., myocardial infarction and stroke) was prospectively ascertained.

RESULTS

During an average 41 months of follow-up (1,751 person-years), 43 stroke and 3 myocardial infarction events occurred. At baseline, patients with ECG-LVH had higher mean 24-hour BP (148.8/83.8mm Hg vs. 135.7/77.2mm Hg) and circulating norepinephrine levels (404.6 pg/ml vs. 336.3 pg/ml) compared to those without ECG-LVH; the differences remained unchanged after adjustment for age, gender, smoking status, presence of diabetes, and antihypertensive medication uses at follow-up time (all P < 0.01). Cox proportional hazards models suggested that the hazard ratio (HR; 95% confidence interval (CI)) of CVD events for those with ECG-LVH was 4.4 (2.3-8.2), and the association between ECG-LVH and incident CVD events remained significant after adjustment for high 24-hour BP (≥130/80mm Hg), nocturnal SBP, circulating norepinephrine and fibrinogen levels (HRs, 3.5-4.2, all P < 0.001).

CONCLUSIONS

In older hypertensive patients, ECG-LVH was associated with a higher risk of CVD events, independent of ambulatory BP parameters and circulating norepinephrine and fibrinogen levels.

Relationship between Plasma Aldosterone Levels and Left Ventricular Mass in Hypertensive Africans

Background. Hypertension is the most common cardiovascular disease worldwide and is a major cause of morbidity and mortality. Studies have suggested that the activity of the renin-angiotensin-aldosterone system play a major role in the target organ damage such as left ventricular hypertrophy occuring in hypertension. We sought to determine the relationship between plasma aldosterone and left ventricular mass in untreated African hypertensives. Methods. We recruited 82 newly diagnosed and untreated hypertensives and 51 normal controls. Measurements obtained included echocardiographic LV mass index, plasma aldosterone and renin. Results. The hypertensive subjects had lower renin levels (21.03[6.974] versus 26.66[7.592] ng.mL⁻¹, P = 0.0013), higher LV mass index (52.56[14.483] versus 42.02[8.315] g.m^−2.7P < 0.0001) when compared with the controls. There were no univariate associations between LV mass index and plasma aldosterone (r = 0.0179, P = 0.57) and between LV mass index and plasma renin (r = 0.0887, P = 0.61). In a multivariate model involving LV mass index and age, sex, body mass index (BMI), plasma aldosterone, plasma renin and systolic blood pressure (SBP), only age (P = 0.008), BMI (P = 0.046), and SBP (P = 0.001) were independently associated with the LV mass index. Conclusions. In this group of hypertensive Africans, there is no independent association of plasma aldosterone with LV mass. The height of the blood pressure, the body mass index and the age of the subjects determined the LV mass.