Left ventricular chamber and wall mechanics in the presence of concentric geometry

The sodium borate relieves the hypertrophic damage induced during pregnancy, it improves contractibility, reduces oxidative stress and stimulates cell proliferation

INTRODUCTION

Fetal and postnatal hypertrophy develop in response to such different exposures or illnesses the mother suffers during gestation as anti-infectious and physical agents, obesity, hypertension, diabetes, and even advanced maternal age. This gives rise to high comorbidities in the newborn; therefore, looking for alternatives that contribute to cardiac homeostasis is quite necessary to inhibit the overgrowth of myocytes. Boron-derivative compounds could play a key role in exerting a repairing effect on chronic cardiac damage induced during gestation.

METHODOLOGY

The cardiotoxic effect of 6.4, 12 and 100 mg/kg of sodium tetraborate administered by oral delivery route to healthy pregnant mice was assessed. After that, the use of the chemical compound was tested in the treatment of pregnant mice previously subjected to isoproterenol (fetal hypertrophy model) on the fifth day post coitus. Prior to the sacrifice of the pups of mice an electrocardiography (ECG) was done. Morphological and histological changes of heart were assessed in newborn pups. As a damage marker, the concentration of p38 nitrogen-activated protein kinases were evaluated by using Western Blot and the levels of malondialdehyde (MDA) as well as glutathione antioxidants (GSH) and glutathione peroxidase (GPx) were tested by spectrometry. Moreover, the mRNA expression for early response genes (c-jun, c-fos y c-myc), late response (GATA-4, Mef2c, NFAT) and heart damage (ANP and BNP) was measured by qPCR real time.

RESULTS

The supply of 6,4 and 12 mg/kg-sodium tetraborate favored ventricular remodeling with histological alterations. By comparison, 100 mg/kg of sodium tetraborate administered during the fetal stage did not alter neither the cardiac morphology of six-week old pups nor the p38/P-p38MAPK ratio remained the same and no oxidative stress was observed. When pregnant females treated with isoproterenol were treated with 100 mg/kg sodium tetraborate during the fetal stage, an improvement in contractility was detected in the pups with an actual reduction in myocardial fibrosis and oxidative stress, but cardiac mass increased. In addition, the expression levels of c-jun, c-myc, GATA-4, MEF2c and ANP mRNA declined in comparison with CTR. However, the hypertrophic damage mechanism was sustained by c-fos, NFAT and BNP expressions.

CONCLUSIONS

The set of results achieved suggests that high concentrations of sodium tetraborate have no cardiotoxic effects. Furthermore, sodium tetraborate mitigates hypertrophy induced during pregnancy, thereby improving contractibility, reducing oxidative stress and stimulating cell proliferation. Therefore, sodium tetraborate could be an excellent prophylactic treatment administered by delivery oral route during pregnancy when there is a risk of developing fetal left ventricular hypertrophy (LVH).

Total coronary atherosclerotic plaque burden is associated with myocardial ischemia in non-obstructive coronary artery disease

AIM

Whether the total coronary atherosclerotic plaque burden is independently associated with myocardial ischemia in non-obstructive coronary artery disease (CAD) is not well established. We aimed to test the association of total plaque burden quantified by coronary computed tomography angiography (CCTA) with myocardial ischemia in patients with chronic coronary syndrome and non-obstructive CAD.

METHODS

We included 125 patients (age 62 ± 9 years, 58% women) with chronic coronary syndrome and non-obstructive CAD (stenosis < 50%) by CCTA, who were grouped according to presence or absence of myocardial ischemia by myocardial contrast stress echocardiography. Total plaque burden was quantified by CCTA as the total plaque volume in the main coronary arteries, and positive remodelling was defined as remodelling index > 1.10.

RESULTS

Patients with myocardial ischemia (n = 66) had higher total plaque burden (847 ± 245 mm3 vs. 758 ± 251 mm3, p = 0.049) and higher left ventricular (LV) mass index (42.1 ± 9.9 g/m2.7 vs. 37.3 ± 8.0 g/m2.7, p = 0.004), while age, sex, prevalence of hypertension, diabetes, calcium score and positive remodelling did not differ between the groups (all p > 0.05). In multivariable regression analysis, total plaque burden remained associated with presence of myocardial ischemia (OR 1.02, 95% CI 1.00-1.04, p = 0.045) independent of age, sex, hypertension, diabetes, LV mass index, coronary calcium score and positive remodelling.

CONCLUSION

Total coronary artery plaque burden by CCTA was independently associated with myocardial ischemia in patients with non-obstructive CAD. Whether plaque quantification is useful for clinical management of patients with non-obstructive CAD should be tested in prospective studies.ClinicalTrials.gov: Identifier NCT01853527.

Interrelation between midwall mechanics and longitudinal strain in newly diagnosed and never-treated hypertensive patients without clinically defined hypertrophy

BACKGROUND

In hypertensive patients, an impairment of midwall myocardial mechanics was described in presence of left ventricular (LV) concentric geometry. Under these circumstances, also LV longitudinal dysfunction was found.

PURPOSE

Our aim was to evaluate longitudinal and circumferential systolic function and correlations between these two functional components in newly diagnosed hypertensive patients without clinically defined LV hypertrophy (LVH). One hundred and thirty-eight newly diagnosed, never-treated hypertensive patients without LVH and a control group of 105 healthy normotensive individuals underwent two-dimensional and speckle tracking echocardiography. Global longitudinal strain (GLS) was derived (in absolute value) and midwall fractional shortening (MFS) computed. In addition, the hypertensive population was divided into two groups according to GLS: normal GLS (≥20%, n = 94) and reduced GLS (<20%, n = 44).

RESULTS

Hypertensive patients had lower MFS (P < 0.001) and GLS (P < 0.0001) than healthy controls. By dividing hypertensive patients according to GLS thresholds of normalcy, MFS was lower in patients with GLS less than 20% (P < 0.0001) while no significant difference was found in LV geometry, ejection fraction and diastolic parameters in comparison with patients with GLS at least 20%. In the pooled hypertensive population, GLS resulted positively related to MFS (r = 0.33, P < 0.0001). By a multiple linear regression analysis, after adjusting for female sex, age, BMI, circumferential end-systolic stress, average e', ejection fraction and relative wall thickness, MFS remained independently associated with GLS (β = 0.222, P < 0.005).

CONCLUSION

In newly diagnosed and never-treated hypertensive patients without LVH, an early LV systolic dysfunction is testified by the reduction of both MFS and GLS. These two parameters resulted independently associated after adjusting for several confounders.

Risk stratifying asymptomatic left ventricular systolic dysfunction in the community: beyond left ventricular ejection fraction

AIMS

Midwall fractional shortening (MWFS) is a measure of left ventricular (LV) systolic function that is more reliable in case of concentric LV geometry compared to LV ejection fraction (LVEF). We hypothesized that MWFS might predict heart failure (HF) and death in a high-risk asymptomatic population, beyond other echocardiographic parameters.

METHODS AND RESULTS

Among 4047 subjects aged ≥55/≤80 years followed by 10 general practitioners in northern Italy, the DAVID-Berg study prospectively enrolled 623 asymptomatic outpatients at increased risk for HF. Baseline evaluation included clinical visit, electrocardiogram, N-terminal pro-brain natriuretic peptide (NT-proBNP), and echocardiogram. Mean age of the population was 69 ± 7 years, 56% were men, 88% had hypertension, mean LVEF was 61 ± 9%, and mean MWFS 16.2 ± 3.3. During a median follow-up of 5.7 years, 95 subjects experienced HF/death events. At Cox analysis, lower MWFS was the only echocardiographic parameter, among structural/functional ones, associated with higher risk of HF/death [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.84-0.95, Padjusted < 0.001]. The risk of HF/death related to clinical data and NT-proBNP (baseline model) was reclassified by echocardiography only when MWFS was included into the model (baseline C-statistics 0.761; adding conventional structural/functional echocardiographic data 0.776, P = 0.09; adding MWFS 0.791, P = 0.007). Compared to subjects with normal LVEF and MWFS, only subjects with combined systolic dysfunction (11% of the population) were at higher risk (P = 0.001 for both abnormal; P > 0.24 for either LVEF or MWFS abnormal).

CONCLUSION

DAVID-Berg data suggest to include MWFS assessment in clinical practice, a simple and reliable echocardiographic parameter able to improve risk stratification in subjects at high risk for HF.

Influence of Left Ventricular Stroke Volume on Incident Heart Failure in a Population With Preserved Ejection Fraction (from the Strong Heart Study)

At a given level of left ventricular (LV) systolic function, LV pump performance (assessed by stroke index [SVi]) may differ, depending on LV size. We evaluated whether low SVi may be considered a marker of risk for incident congestive heart failure (HF), independent of LV geometry and systolic function, assessed by ejection fraction (EF) or midwall fractional shortening (MFS), in a large population-based sample with normal EF. Clinical and echocardiographic data from the second Strong Heart Study (SHS) examination, including 2,885 American Indians (59 ± 8 years; 63% women) with normal EF (EF ≥51% in men and EF ≥55% in women) and without prevalent HF or significant valve disease, were analyzed. Low SVi was defined as SVi ≤22 ml/m^2.04. Low SVi was more common among men and associated with lower body mass index, systolic blood pressure, LV mass index, left atrial dimension, EF, and MFS and with higher relative wall thickness. During a mean 12-year follow-up, 209 participants developed HF and 246 had acute myocardial infarction. In Cox regression analysis, low SVi was associated with higher risk of incident HF (hazard ratio 1.38; 95% confidence interval 1.06 to 1.80), independently of age, gender, body mass index, heart rate, hypertension, prevalent cardiovascular disease, left atrial dimension index, LV mass index, LV concentric geometry, EF or MFS, and abnormal wall motion, also accounting for myocardial infarction as a competing risk event. In conclusion, in the SHS, low SVi was associated with higher incident rate of HF, independently of LV geometry and systolic function and other major confounders.

The Relationship Between Left Ventricular Wall Thickness, Myocardial Shortening, and Ejection Fraction in Hypertensive Heart Disease: Insights From Cardiac Magnetic Resonance Imaging

Hypertensive heart disease is often associated with a preserved left ventricular ejection fraction despite impaired myocardial shortening. The authors investigated this paradox in 55 hypertensive patients (52±13 years, 58% male) and 32 age- and sex-matched normotensive control patients (49±11 years, 56% male) who underwent cardiac magnetic resonance imaging at 1.5T. Long-axis shortening (R=0.62), midwall fractional shortening (R=0.68), and radial strain (R=0.48) all decreased (P<.001) as end-diastolic wall thickness increased. However, absolute wall thickening (defined as end-systolic minus end-diastolic wall thickness) was maintained, despite the reduced myocardial shortening. Absolute wall thickening correlated with ejection fraction (R=0.70, P<.0001). In multiple linear regression analysis, increasing wall thickness by 1 mm independently increased ejection fraction by 3.43 percentage points (adjusted β-coefficient: 3.43 [2.60-4.26], P<.0001). Increasing end-diastolic wall thickness augments ejection fraction through preservation of absolute wall thickening. Left ventricular ejection fraction should not be used in patients with hypertensive heart disease without correction for degree of hypertrophy.

Obesity and hypertensive heart disease: focus on body composition and sex differences

There is evidence that hypertension is frequently associated with overweight/obesity even in kids and adolescents. Either conditions influence development of left ventricular (LV) hypertrophy (LVH), through different biological and hemodynamic mechanisms: obesity is conventionally thought to elicit a coherent growth of LV chamber dimensions and myocardial wall thickness (eccentric LV geometry), whereas a more accentuated increase in wall-thickness (concentric LV geometry) is attributed to hypertension. While during youth these differences are visible, proportion of LV concentric geometry, the most harmful LV geometric pattern, sharply raises in obese individuals during middle age, and becomes the most frequent geometric patterns among obese-hypertensive individuals. Two conditions with elevated hemodynamic impact, severe obstructive sleep apnea and masked hypertension contribute to the development of such a geometric pattern, but non-hemodynamic factors, and specifically body composition, also influence prevalence of concentric LV geometry. Contrasting a general belief, it has been observed that adipose mass strongly influences LV mass, particularly in women, especially when fat-free mass is relatively deficient. Thus, though blood pressure control is mandatory for prevention and reduction of LVH in obese hypertensive patients, without reduction of visceral adiposity regression of LVH is difficult. Future researches should be addressed on (1) assessing whether LVH resulting from alteration of body composition carries the same prognosis as pressure overload LVH; (2) defining tissue characterization of the hypertrophic heart in obese-hypertensive patients; (3) evaluating whether assessment of hemodynamic loading conditions and biological markers can help defining management of the association of obesity with hypertension.

Left ventricular hypertrophy on long-term cardiovascular outcomes in patients with ST-elevation myocardial infarction

BACKGROUND

Left ventricular hypertrophy (LVH) had been associated with increased adverse cardiovascular events in hypertensive patients. Prognostic significance of LVH in patients with ST-elevation myocardial infarction (STEMI) is not established. This study aimed to investigate prognostic impact of LVH on the patients with STEMI.

METHODS

We analyzed the data and clinical outcomes of 30-day survivors with STEMI who underwent successful coronary intervention from 2003 to 2009. Definition of LVH was LV mass index (LVMI) >115 g/m(2) in male and >95 g/m(2) in female. Patients were classified into a LVH group and a non-LVH group. Occurrence of major adverse cardiovascular events (MACE; death, recurrent MI, target vessel revascularization (TVR)) within 5 years was evaluated.

RESULTS

We enrolled 418 patients and mean follow-up duration was 43 ± 17 months. Two hundred and fourteen patients (51%) had LVH. The survival of the patients with LVH was significantly worse than the patients without LVH (log-rank p = 0.024). In a multivariate regression model, the presence of LVH was independently associated with increased risk for all-cause mortality (OR, 2.37; 95% CI, 1.096-5.123, p = 0.028). When the end points were analyzed based on LVH severity, all-cause mortality was significantly correlated with LVH severity (p = 0.011). The severe LVH was independently associated with increased risk for all-cause mortality (OR, 5.110; 95% CI, 1.454-17.9, p = 0.001).

CONCLUSION

LVH was associated with increased rate of adverse clinical outcomes in 30-day survivors after STEMI, who underwent successful coronary intervention.

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.

S, A.K. A, A.K. D, Garg B, Goel A. Impact of prehypertension on left ventricular structure, function and geometry

BACKGROUND

Awareness of prevalence, determinants, and prognosis of asymptomatic untreated prehypertension is still lacking especially in India and subcontinent. The present study was to assess the effects of prehypertension on structure, function and geometrical pattern of left ventricle on the basis of left ventricular mass (LVM), left ventricular mass indexed to height (LVMI/Ht), and relative wall thickness (RWT) recorded by echocardiography based on the American society of echocardiography (ASE) convention.

METHODS

The study population included prehypertensives (n 61; 31 M, 30 F) and normotensives (n 38; 19 M, 19 F) between age 25 and 65 years, and were assessed by echocardiography.

RESULTS

It was observed that the stroke volume (SV), cardiac output (CO), cardiac index (CI), body mass index (BMI), body surface area (BSA), were found to be little elevated but was not significant in hypertensive females compared to normotensives. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), pulse pressure (PP), mean arterial pressure (MAP), end systolic stress (ESS), and end isovolumetric systolic stress (EISS) were significantly elevated (p<0.001) in female prehypertensives compared to normotensives. Left ventricular mass (LVM) was significantly (p< 0.05) elevated, indicating alterations in cardiac morphology and functions even during prehypertensive stage. However, in prehypertensive males, SBP, DBP, HR, PP, MAP, ESS, and EISS were significantly (<0.001) raised; ejection fraction (EF%) and fractional fibre shortening (FS%) were noted to be within normal range in both sexes. Prehypertensive males showed changes in left ventricular geometry in the form of concentric remodeling (CR-3.44%), eccentric hypertrophy (EH-3.44%) and concentric hypertrophy (CH-13.79%). Prehypertensive females showed (CR-6.45%), (EH-3.22%) and (CH-6.4%).

CONCLUSION

Such findings carry prognostic implication and require further population survey involving a larger group. Early diagnosis of prehypertension will help to take necessary preventive measures to reduce mainly the future cardiovascular complications. The care of prehypertensive subjects should include, to reduce the afterload in order to improve the left ventricular contractile state as early as possible. So it is advisable to do routine echocardiography after the age of 40 years.

Expression of N-cadherin proteins in myocardial hypertrophy in rats

The aim of the present study was to examine the expression of N-cadherin in the myocardial tissues of isoproterenol-induced myocardial hypertrophy in rats. In addition, the present study provided morphological data to investigate the signal transduction mechanisms of myocardial hypertrophy and reverse myocardial hypertrophy. A myocardial hypertrophy model was established by subcutaneously injecting isoprenaline into healthy adult Sprague-Dawley rats. The myocardial tissue was collected, embedded in conventional paraffin, sectioned and stained with hematoxylin and the pathological changes were observed. The expression and distribution of N-cadherin were detected by immunohistochemistry (IHC) and the changes in mRNA expression of N-cadherin in the myocardial tissues of rats were detected by reverse transcription polymerase chain reaction. Image analysis software was used to quantitatively analyze the expression of N-cadherin. The IHC and immunofluorescence results showed that there was no statistically significant difference between the experimental and control groups in the positive expression of N-cadherin. Furthermore, mRNA expression of N-cadherin, in the myocardial tissues of rats, was consistent with the IHC and immunofluorescence results. Thus, N-cadherin may have a significant function in the occurrence and development of myocardial hypertrophy.

Change in cardiac geometry and function in CKD children during strict BP control: a randomized study

BACKGROUND AND OBJECTIVES

Left ventricular hypertrophy (LVH) and abnormal systolic function are present in a high proportion of children with CKD. This study evaluated changes in left ventricular (LV) geometry and systolic function in children with mild to moderate CKD as an ancillary project of the Effect of Strict Blood Pressure Control and ACE Inhibition on Progression of Chronic Renal Failure in Pediatric Patients trial.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Echocardiograms and ambulatory BP monitoring were performed at baseline and at 1- or 2-year follow-up in 84 patients with CKD and 24-hour mean BP above the 50th percentile and/or receiving fixed high-dose angiotensin converting enzyme inhibition and randomized to conventional or intensified BP control.

RESULTS

LVH prevalence decreased from 38% to 25% (P<0.05). Changes in LV mass index (LVMI) were restricted to patients with LVH at baseline (-7.9 g/m(2.7); P<0.02). Changes in LVMI were independent of randomization, reduction in BP, hemoglobin, and estimated GFR. A significant increase in midwall fractional shortening was observed in the total cohort (P<0.05), and was greater in the intensified group compared with the conventional BP control group (12%±1.9% versus 8%±1.5%; P=0.05). In multivariate analysis, improvement in myocardial function was associated with reduction in BP (r=-0.4; P<0.05), independently of LVMI reduction.

CONCLUSIONS

In children with CKD, angiotensin converting enzyme inhibition with improved BP control, LVH regression, and improved systolic function was observed within 12 months. Lowering BP to the low-normal range led to a slightly more marked improvement in myocardial function but not in LVMI.

Usefulness of the left ventricular myocardial contraction fraction in healthy men and women to predict cardiovascular morbidity and mortality

We sought to determine whether depressed myocardial contraction fraction (MCF; ratio of left ventricular [LV] stroke volume to myocardial volume) predicts cardiovascular disease (CVD) events in initially healthy adults. A subset (n = 318, 60 ± 9 years old, 158 men) of the Framingham Heart Study Offspring cohort free of clinical CVD underwent volumetric cardiovascular magnetic resonance imaging in 1998 through 1999. LV ejection fraction (EF), mass, and MCF were determined. "Hard" CVD events consisted of cardiovascular death, myocardial infarction, stroke, or new heart failure. A Cox proportional hazards model adjusting for Framingham Coronary Risk Score was used to estimate hazard ratios for incident hard CVD events for gender-specific quartiles of MCF, LV mass, and LVEF. The lowest quartile of LV mass and highest quartiles of MCF and EF served as referents. Kaplan-Meier survival plots and log-rank test were used to compare event-free survival. MCF was greater in women (0.58 ± 0.13) than in men (0.52 ± 0.11, p <0.01). Nearly all participants (99%) had EF ≥0.55. During an up to 9-year follow-up (median 5.2), 31 participants (10%) developed an incident hard CVD event. Lowest-quartile MCF was 7 times more likely to develop a hard CVD (hazard ratio 7.11, p = 0.010) compared to the remaining quartiles, and increased hazards persisted even after adjustment for LV mass (hazard ratio 6.09, p = 0.020). The highest-quartile LV mass/height 2.7 had a nearly fivefold risk (hazard ratio 4.68, p = 0.016). Event-free survival was shorter in lowest-quartile MCF (p = 0.0006) but not in lowest-quartile LVEF. In conclusion, in a cohort of adults initially without clinical CVD, lowest-quartile MCF conferred an increased hazard for hard CVD events after adjustment for traditional CVD risk factors and LV mass.

Cardiac geometry and function in diabetic or prediabetic adolescents and young adults: the Strong Heart Study

OBJECTIVE

The aim of this study was to evaluate whether diabetes (DM) and impaired fasting glucose (IFG) were associated with early alterations in left ventricular geometry and function in a large population of adolescents and young adults independently of major confounders.

RESEARCH DESIGN AND METHODS

We analyzed echocardiographic data of 1,624 14- to 39-year-old participants (mean age 26.6 ± 7.7 years; 57% female) without prevalent cardiovascular disease from the fourth Strong Heart Study examination; 179 (11%) participants had DM and 299 (18%) had IFG.

RESULTS

Participants with DM and IFG were older and more often obese and hypertensive than participants with normal fasting glucose (NFG) (all P < 0.05). After adjustment for age, sex, systolic blood pressure, and body fat, diabetic and IFG participants had higher left ventricular mass index than those with NFG (41.5 ± 8.7 and 39.6 ± 9.2 vs. 35.6 ± 7.8 g/m(2.7)) and reduced stress-corrected midwall shortening (98 ± 8.6 and 99 ± 7.5 vs. 101 ± 8.5%; all P < 0.05). The prevalence of left ventricular hypertrophy was higher in DM (20%) and IFG (17%) than in NFG participants (12%; P < 0.05). Compared with the other groups, DM was also associated with higher prevalence of inappropriate left ventricular mass, concentric geometry, and more diastolic abnormalities independently of covariates (all P < 0.05).

CONCLUSIONS

In a population of adolescents and young adults, DM is independently associated with early unfavorable cardiovascular phenotype characterized by increased left ventricular mass, concentric geometry, and early preclinical systolic and diastolic dysfunction; early cardiovascular alterations are also present in participants with prediabetes.

Left ventricular hypertrophy, geometric patterns and clinical correlates among treated hypertensive Nigerians

Background:

Left ventricular hypertrophy can be due to various reasons including hypertension. It constitutes an increased cardiovascular risk. Various left ventricular geometric patterns occur in hypertension and may affect the cardiovascular risk profile of hypertensive subjects.

Methods:

One hundred and eighty eight hypertensive participated in this study. Left ventricular hypertrophy was diagnosed by echocardiography. Relative wall thickness was derived by 2 × PWT/LVIDd. Subjects were arbitrarily categorized according to the duration of hypertension. Statistical analysis was done using SPSS 15.0.

Results:

The mean age of the study population was 55.95±10.71 years. Subjects who had hypertension for >5 years were more likely to be older and had a lower ejection fraction, larger left ventricular diastolic internal dimension than those with duration of hypertension <5 years. Concentric remodeling was the commonest left ventricular geometric pattern among the hypertensive subjects closely followed by normal left ventricular geometry. Concentric hypertrophy and eccentric hypertrophy were rare among the study population.Left ventricular geometry was associated mainly with left ventricular chamber and wall dimensions.

Conclusion:

Concentric remodeling is the commonest pattern of left ventricular geometric pattern of the left ventricle among hypertensive subjects. Left ventricular geometry is associated with the chamber and wall dimensions. Eccentric hypertrophy is associated with the lowest left ventricular systolic function and therefore possibly an herald to progressive systolic impairment.

Left ventricular hypertrophy increases cardiovascular risk independently of in-office and out-of-office blood pressure values

OBJECTIVES

Previous studies have shown that left ventricular hypertrophy (LVH) represents a cardiovascular risk factor independently of clinic blood pressure (BP). The present study was aimed at determining the impact of LVH on the incidence of cardiovascular morbid and fatal events taking into account not only classical risk factors but also home and ambulatory BP values, which have been shown to have an important independent prognostic impact.

METHODS

In 1716 patients belonging to the 'Pressioni Arteriose Monitorate E Loro Associazioni' population of Monza, we quantified left ventricular mass index and identified LVH by standard cutoff values. We also measured clinic, home and 24-h ambulatory BPs together with serum glucose and lipids.

RESULTS

During a follow-up of 148 months, the rate of fatal and nonfatal (hospitalizations) cardiovascular events as well as of all-cause death was markedly greater (four-fold to five-fold) in patients as compared with those without LVH. In LVH individuals, the increased risk remained significant even when data were adjusted for a large number of other confounding factors including home BP, 24-h mean BP and ambulatory BP. Results were similar when left ventricular mass was indexed by height and body surface area. A 10% increase in left ventricular mass index was associated with a significant increase in cardiovascular risk or all-cause deaths. In multivariate analysis, left ventricular mass index was always an independent predictor of cardiovascular events and death for any cause.

CONCLUSION

Our data provide evidence that LVH is an important risk factor even when the contribution of different BPs to risk is fully taken into account.

Inappropriate left ventricular mass in children and young adults with chronic renal insufficiency

Increased left ventricular (LV) mass (M) in children with chronic renal insufficiency (CRI) might represent an adaptive mechanism to compensate for increased workload. We hypothesized that in children with CRI, pre-dialysis, values of left ventricular mass (LVM) exceed compensatory values for individual cardiac load. Complete anthropometric characteristics, biochemical profile and echocardiograms were obtained for 33 children with CRI, pre-dialysis (age 1-23 years, mean 12.2 +/- 5.0 years), and 33 age- and gender-matched healthy controls. LV dimensions, wall thicknesses and volume were measured. Endocardial and midwall shortening, ejection fraction, LVM, LVM index, relative wall thickness, circumferential wall stress and excess LVM (as ratio of observed LVM to value predicted from body size, gender and cardiac workload) were analysed. Patients with CRI showed higher values of LVM index, resulting in higher prevalence of LV hypertrophy (36.3% vs 9%, P < 0.05). The ratio of excess LVM was greater in patients with CRI than in healthy controls (126 +/- 19% and 103 +/- 13%, respectively, P < 0.001). LV ejection fraction, midwall fractional shortening and stress-corrected midwall shortening were lower in patients with CRI than in controls. We concluded that, in children with CRI, the values of LVM are higher than those needed to sustain individual cardiac load than in healthy controls, a condition associated with LV hypertrophy and reduced systolic performance.

Serum cardiac troponin T in patients hospitalized with heart failure is associated with left ventricular hypertrophy and systolic dysfunction

BACKGROUND

Cardiac troponin T (cTnT) is a highly sensitive and specific marker of acute myocardial infarction. Serum cTnT is also slightly elevated in patients with severe heart failure and is associated with left ventricular hypertrophy (LVH) in patients treated with haemodialysis. In this study serum cTnT concentrations and echocardiographic findings were investigated in heart failure patients without acute coronary syndrome. cTnT was also compared with other cardiac markers and plasma levels of brain natriuretic peptide (BNP).

METHODS

Twenty-six patients hospitalized with heart failure were included in the study. Echocardiographic measurements and blood sampling were carried out 12-36 h after admission. Serum cTnT (3rd generation assay), cardiac troponin I (cTnI), creatine kinase MB (CKMB) and CK were measured. Plasma BNP was analysed using the Shionoria assay. LVH was defined as left ventricular mass index (LVMI) > 125 g/m for males and > 110 g/m for females. Left ventricular systolic function was estimated from the mitral annulus motion (AV-mean LV).

RESULTS

Median cTnT was 0.012 (< 0.010-0.032) microg/L. Sixty-two percent of the patients (16 of 26) had elevated serum cTnT >or= 0.010 micro/L. cTnT was positively correlated with CKMB (rho = 0.40, p = 0.04) and BNP (rho = 0.43, p = 0.03), but not with cTnI and CK. A negative correlation was found between cTnT and AV-mean LV (rho = -0.58, p = 0.007), and there was a positive correlation between cTnT and LVMI (rho = 0.44, p = 0.03). No other analyte was correlated to LVMI.

CONCLUSIONS

Serum cTnT but not cTnI was associated with left ventricular dysfunction and LVH in patients hospitalized with heart failure. This explains why cTnT tends to be slightly elevated in patients with heart failure without symptoms of acute myocardial ischaemia.

Cardiac disease in children with mild-to-moderate chronic kidney disease

PURPOSE OF REVIEW

Studies in pediatric populations may provide sensitive insights into the prevalence, evolution and underlying mechanisms of cardiovascular complications of chronic kidney disease, without confounding factors such as aging and diabetes. This review reflects on recent echocardiographic studies assessing left-ventricular mass, geometry and function in children with mild-to-moderate chronic kidney disease.

RECENT FINDINGS

A cross-sectional assessment of a large pediatric cohort established a 33% prevalence of left-ventricular hypertrophy in children with chronic kidney disease stages 2-4. Concentric and eccentric geometry are found equally frequently, suggesting variable contributions of enhanced left-ventricular preload and afterload and/or nonhemodynamic mechanisms. Concentric left-ventricular hypertrophy is frequently associated with systolic dysfunction as evidenced by impaired circumferential shortening at the myocardial midwall level. Left-ventricular mass and dysfunction tend to be inversely correlated with glomerular filtration rate. Furthermore, male sex, obesity, anemia and inflammation appear to be associated with left-ventricular hypertrophy, whereas blood pressure shows surprisingly little association with left-ventricular mass, geometry or function.

SUMMARY

Significant abnormalities of cardiac morphology and function are observed in children with early chronic kidney disease, demonstrating a marked intrinsic impact on the cardiovascular system. Regular echocardiographic screening appears indicated in the pediatric population with chronic kidney disease.

Increased left ventricular mass in pre-liver transplantation cirrhotic patients

OBJECTIVE

Severe liver disease is associated with abnormalities in cardiac geometry and function. We aimed to assess the prevalence of these abnormalities and to determine if they represent an adaptation of the heart to the haemodynamic overload associated with liver dysfunction.

METHODS

Seventy cirrhotic patients underwent standard Doppler echocardiography, as a screening evaluation for liver transplantation, and were compared with 70 normal subjects matched for age and sex. The values of echocardiographically measured left ventricular mass (LVM) were compared with those predicted from individual haemodynamic load, sex and height, which represent the compensatory values. LVM was considered inappropriately high when the observed/predicted LVM ratio was >128%.

RESULTS

Cirrhotic patients had higher LVM index (40.6 +/- 11.2 vs. 36.3 +/- 7.7 g/m; P = 0.009)), similar values of ejection fraction, but lower intrinsic wall mechanics (P < 0.01) compared to controls. The observed/predicted LVM ratio was also significantly increased (117.7 +/- 30.2 vs. 106.5 +/- 16.8%; P < 0.01) and prevalence of inappropriate LVM was almost three-fold higher in cirrhotic patients (27.7 vs. 10.0%; P < 0.05) than in controls. Cirrhotic patients also presented mild impairment of left ventricular systolic function, documented by lower values of midwall shortening.

CONCLUSIONS

Patients with severe liver disease have LVM values exceeding the compensatory needs to sustain haemodynamic overload, associated with subclinical systolic dysfunction.

Abnormal regional myocardial deformation properties and increased aortic stiffness in normotensive patients with aortic coarctation despite successful correction: an ABPM, standard echocardiography and strain rate imaging study

The long-term follow-up data subsequent to a successful repair of AoC (aortic coarctation) show that life expectancy remains reduced. Previous standard echocardiographic studies have demonstrated normal or increased systolic cardiac function in patients following successful repair of AoC. SR (strain rate) imaging is a new technique able to detect subclinical myocardial abnormalities. In the present study we investigated whether young patients (without hypertension, as assessed using ambulatory blood pressure monitoring and an exercise test) following successful AoC repair already have abnormal myocardial deformation properties, and the relationship of the deformation properties with aortic stiffness. We studied 166 subjects, 83 AoC non-hypertensive patients (mean age 12+/-4 years) a number of years after successful repair of AoC and 83 age- and sex-matched subjects as controls. Peak systolic SR (1/s) for both regional longitudinal and radial function was assessed. The aortic stiffness index was calculated from the echocardiographically derived thoracic aortic diameters, and the measurement of blood pressure was obtained by cuff sphygmomanometry. The LV (left ventricular) ejection fraction was significantly increased in AoC patients, whereas regional longitudinal SRs were significantly reduced (-1.1+/-0.9 compared with -2+/-0.5, P<0.0001) in patients. The aortic stiffness index was significantly increased in AoC patients (12+/-9, P<0.0001). At multilinear regression analysis, age at repair (P=0.005; coefficient, -0.201; S.E.M., 0.027) and the aortic stiffness index (P=0.0029; coefficient, 0.334; S.E.M., 0.423) predicted longitudinal SR. Despite the presence of a successful repair for AoC, in the absence of hypertension, longitudinal deformation properties were significantly impaired. Moreover, the degree of longitudinal SR impairment was correlated with age at repair and aortic stiffness. Early repair can delay the onset of hypertension in postcoarctectomy patients, but cannot prevent the innate structural and functional abnormalities of the aorta and their deleterious effect on myocardial deformation properties.

Dyslipidaemia in type II diabetic mice does not aggravate contractile impairment but increases ventricular stiffness

AIMS

Type II diabetes, often associated with abdominal obesity, frequently leads to heart failure. Clinical and epidemiological evidence suggests that supplemental dyslipidaemia and hypertension, as clustered in the metabolic syndrome, aggravate the cardiovascular outcome. The differential impact of type II diabetes and the metabolic syndrome on left ventricular function, however, remains incompletely defined.

METHODS AND RESULTS

We studied left ventricular function in vivo using pressure-volume analysis in obese diabetic mice with leptin deficiency (ob/ob) and obese diabetic dyslipidemic mice with combined leptin and low-density lipoprotein-receptor deficiency (DKO). ob/ob and DKO mice developed a diabetic cardiomyopathy, characterized by impaired contractility and relaxation, from the age of 24 weeks onwards. This was-at least partially-explained by increased apoptosis and disturbed Ca(2+) reuptake in the sarcoplasmic reticulum (SR) in both mouse models. DKO, but not ob/ob, developed increased end-diastolic ventricular stiffness, paralleled by increased left ventricular myocardial fibrosis. Cardiac output was preserved in ob/ob mice by favourable loading conditions, whereas it decreased in DKO mice.

CONCLUSIONS

Type II diabetes in mice leads to impaired contractility and relaxation due to disturbed Ca(2+) reuptake in the SR, but only when dyslipidaemia and hypertension are superimposed does vascular-ventricular stiffening increase and left ventricular myocardial fibrosis develop.

Multi-parameter in vivo cardiac magnetic resonance imaging demonstrates normal perfusion reserve despite severely attenuated beta-adrenergic functional response in neuronal nitric oxide synthase knockout mice

AIMS

The role of neuronal nitric oxide synthase (nNOS) in regulating contractile function remains controversial, and in regulating myocardial perfusion is uninvestigated. We used magnetic resonance imaging (MRI) to phenotype nNOS(-/-) and wild-type (WT) mice regarding left ventricular (LV) structure, baseline function, beta-adrenergic responsiveness, and perfusion reserve.

METHODS AND RESULTS

Cine MRI showed higher LV mass to end-diastolic volume ratio (2.3 +/- 0.2 mg/microL nNOS(-/-) vs. 1.7 +/- 0.1 mg/microL WT; P=0.032) and LV ejection fraction (64.9 +/- 2.1% nNOS(-/-) vs. 55.8 +/- 1.1% WT; P = 0.003) in nNOS(-/-). Myocardial tagging demonstrated similar baseline systolic circumferential strain (Ecc) in nNOS(-/-) and WT. With dobutamine, the normal change in Ecc was nearly absent in nNOS(-/-) (-0.5 +/- 0.3% nNOS(-/-) vs. -2.2 +/- 0.3% WT; P = 0.001), and the systolic strain rate (dEcc/dt) response to dobutamine seen in WT was reduced in nNOS(-/-) (-29 +/- 13%/s nNOS(-/-) vs. -106+/-16%/s WT; P = 0.001). Diastolic strain rate increased significantly with dobutamine only in WT. Arterial spin labelling showed that baseline perfusion and perfusion reserve with either dobutamine or an adenosine receptor agonist are normal in nNOS(-/-).

CONCLUSION

MRI provides non-invasive in vivo evidence that nNOS does not play a role in basal contractile function or myocardial perfusion, but is required for increasing cardiac inotropy and lusitropy upon beta-adrenergic stimulation.

Reduced systolic myocardial function in children with chronic renal insufficiency

Increased left ventricular (LV) mass in children with chronic renal insufficiency (CRI) might be adaptive to sustain myocardial performance in the presence of increased loading conditions. It was hypothesized that in children with CRI, LV systolic function is impaired despite increased LV mass (LVM). Standard echocardiograms were obtained in 130 predialysis children who were aged 3 to 18 yr (59% boys) and had stages II through IV chronic kidney disease and in 130 healthy children of similar age, gender distribution, and body build. Systolic function was assessed by measurement of fractional shortening at the endocardial (eS) and midwall (mS) levels and computation of end-systolic stress (myocardial afterload). The patients with CRI exhibited a 6% lower eS (33.1 +/- 5.5 versus 35.3 +/- 6.1%; P < 0.05) and 10% lower mS (17.8 +/- 3.1 versus 19.7 +/- 2.7%; P < 0.001) than control subjects in the presence of significantly elevated BP, increased LVM, and more concentric LV geometry. Whereas the decreased eS was explained entirely by augmented end-systolic stress, mS remained reduced after correction for myocardial afterload. The prevalence of subclinical systolic dysfunction as defined by impaired mS was more than five-fold higher in patients with CRI compared with control subjects (24.6 versus 4.5%; P < 0.001). Systolic dysfunction was most common (48%) in patients with concentric hypertrophy and associated with lower hemoglobin levels. CRI in children is associated with impaired intrinsic LV contractility, which parallels increased LVM.

Isolated left ventricular diastolic dysfunction: implications for exercise left ventricular performance in patients without congestive heart failure

OBJECTIVE

Clinical relevance of left ventricular (LV) diastolic dysfunction in the absence of congestive heart failure (CHF) and LV systolic dysfunction is not fully established.

METHODS

Asymptomatic outpatients, sedentary, with cardiovascular risk factors but no history of cardiovascular events, underwent echocardiographic evaluation of LV structure and function by standard Doppler, color M-mode, and Doppler tissue methods, and exercise testing with simultaneous noninvasive assessment of LV stroke index and cardiac index. LV ejection fraction less than 50% and significant valvular disease or stress test suggestive of coronary disease were additional exclusion criteria.

RESULTS

In 70 patients selected (40 +/- 10 years old, 63% men, 34% hypertensive, 34% diabetic, 4% diabetic and hypertensive, 11% with LV hypertrophy), LV diastolic dysfunction was detected in 26%, which was associated with hypertension, higher LV mass index, lower systolic function, lower peak exercise heart rate, and chronotropic reserve (all P < .05), and with lower peak exercise stroke index and cardiac index (both covariates adjusted P < .05), but not with lower peak exercise metabolic equivalents (P > .5). Abnormal LV relaxation was independently correlated with lower peak exercise cardiac index and stroke index (both P < .05). Peak exercise systolic and cardiac indices were comparable between patients with CHF risk factors (74%) versus those without.

CONCLUSIONS

Isolated LV diastolic dysfunction was independently associated with lower peak exercise LV systolic performance in patients without CHF. Its diagnosis may provide a target for aggressive CHF risk management.

Impact of Obesity on Cardiac Geometry and Function in a Population of Adolescents

OBJECTIVES

The goal here was to examine left ventricular (LV) geometry and function in a large, unselected group of adolescents with different degrees of abnormal body build, and verify whether possibly higher LV mass is compensatory for increased cardiac workload.

BACKGROUND

There is little information on how much the excess of body weight impacts LV geometry and function in populations of adolescents.

METHODS

Anthropometric, laboratory, and Doppler echocardiographic parameters of cardiac geometry and function were obtained in 460 adolescent participants (age 14 to 20 years, 245 female participants, 27 hypertensive, 10 with diabetes) from the Strong Heart Study. Body build was classified based on 85th and 95th percentiles of body mass index (BMI)-for-age charts.

RESULTS

Range of BMI was 16.3 to 56.5 kg/m2 (28.8 +/- 8.3 kg/m2); 114 participants (24.9%) fell within the 85th percentile of BMI distribution (normal weight [NW]), 113 (24.6%) fell between 85th and 95th percentile (overweight [OW]), and 223 (48.5%) fell above the 95th percentile (obese [OB]). Obese participants were older than OW and NW subjects (p < 0.01), without differences in heart rate. Both OW and OB had greater LV diameter and mass than NW (all p < 0.05). Left ventricular hypertrophy was more prevalent in the OB (33.5%) and OW (12.4%), as compared with NW participants (3.5%; p < 0.001), largely compensating increased cardiac workload. However, OB subjects had four-fold higher probability of carrying an LV mass exceeding values compensatory for their cardiac workload (p < 0.001), a feature associated with lower ejection fraction, myocardial contractility, and greater force developed by left atrium to complete LV filling (all p < 0.05).

CONCLUSIONS

While in OW adolescents increased levels of LV mass are appropriate to compensate their higher hemodynamic load, in OB increase in LV mass exceeds this need and is associated with mildly reduced LV myocardial performance and increased left atrial force to contribute to LV filling.

Load-sensitive measures may overestimate global systolic function in the presence of left ventricular hypertrophy: a comparison with load-insensitive measures

Transgenic animal models have provided a vital insight into the pathogenesis of cardiovascular disease, but functional cardiac assessment is often limited by high heart rates and small heart size. We hypothesized that in the presence of concentric left ventricular (LV) hypertrophy (LVH), load-sensitive measures of contractility may be misinterpreted as overestimating global cardiac function, because the normal function of excess sarcomeres may displace a greater volume of blood during contraction. Conductance catheter technology was used to evaluate pressure-volume (P-V) relationships as a load-insensitive method of assessing cardiac function in vivo in 18-wk-old heterozygous (mRen-2)27 transgenic rats (a model of LVH), compared with age-matched Sprague-Dawley (SD) controls. Anesthetized animals underwent echocardiography followed by P-V loop analysis. Blood pressure, body weight, and heart rate were higher in the Ren-2 rats ( P < 0.05). Load-sensitive measures of systolic function, including fractional area change, fractional shortening, ejection fraction, and positive peak rate of LV pressure development, were greater in the Ren-2 than control animals ( P < 0.05). Load-insensitive measures of systolic function, including the preload recruitable stroke work relationship and the end-systolic P-V relationship, were not different between Ren-2 and SD rats. Regional wall motion assessed by circumferential shortening velocity suggested enhanced circumferential fiber contractility in the Ren-2 rats ( P = 0.02), but tissue Doppler imaging, used to assess longitudinal function, was not different between groups. Although conventional measures suggested enhanced systolic function in the Ren-2 rat, load-insensitive measures of contractility were not different between Ren-2 and SD animals. These findings suggest that the normal range of values for load-sensitive indexes of contractility needs to be altered according to the degree of LVH. To accurately identify changes in systolic function, we suggest that a combination of echocardiography with assessment of load-insensitive measures be used routinely.

Left ventricular geometric patterns in newly presenting Nigerian hypertensives: an echocardiographic study

Background

Hypertension is a global problem and it is prevalent in Nigeria. Left ventricular hypertrophy is a major complication of hypertension with risk of sudden death and arrhythmias among others. Abnormal left ventricular geometric patterns also increase the burden of morbidity and mortality. It is therefore important to know the different left ventricular geometric patterns in Nigerian hypertensives because of their prognostic significance.

Methods

One hundred (100) newly presenting hypertensives (53 males and 47 females) and 100 controls (53 males and 47 females) were recruited for the study. All were subjected to clinical evaluation and full echocardiographic examination was performed according to the ASE recommendation. The relative wall thickness and the presence or absence of echocardiographic left ventricular hypertrophy were used to determine the various geometric patterns

Results

The mean age of the hypertensive subjects was 56.06 (± 7.68) years while that of the control subjects was 56.10 (± 7.68) years. There was no significant difference in the mean ages of the two groups. In the hypertensive subjects 28% had normal geometry, 26% had concentric remodeling, 28% had concentric hypertrophy and 18% had eccentric hypertrophy. In the control group, 86% had normal geometry, 11% had concentric remodeling, 3% had eccentric hypertrophy and none had concentric hypertrophy. There was statistical significance when the geometric patterns of the hypertensive and controls were compared (χ² = 74.30, p value < 0.0001).

Conclusion

The study showed that only 28% of the hypertensive subjects had normal LV geometric pattern while 86% of the normal subjects had normal geometry. There is need for longitudinal studies in order to prognosticate the various geometric patterns.

Cine MR Imaging of Myocardial Contractile Impairment in Patients with Hypertrophic Cardiomyopathy Attributable to Asp175Asn Mutation in the α-Tropomyosin Gene

PURPOSE

To prospectively investigate the relationship between myocardial contractile impairment and left ventricular (LV) hypertrophy measured at cardiac magnetic resonance (MR) imaging in patients with hypertrophic cardiomyopathy (HCM) caused by the substitution of aspartic acid 175 with asparagine (ie, Asp175Asn mutation) in the alpha-tropomyosin gene (TPM1).

MATERIALS AND METHODS

The study protocol was approved by the hospital ethics committee, and all subjects gave written informed consent. LV mass, maximal LV wall thickness, and myocardial fractional thickening during systole were measured at cine MR imaging in 24 subjects (11 male, 13 female; mean age, 42 years; age range, 17-68 years) with the Asp175Asn mutation in TPM1 and in 17 healthy volunteers (eight men, nine women; mean age, 38 years; age range, 23-60 years). The proportion of hypokinetic LV segments was calculated as the number of LV segments with fractional thickening of less than 30% divided by the total number of segments measured. Anthropometric and biochemical correlates of LV hypertrophy were determined. Univariate and multiple linear regression analyses were used to investigate the association of the proportion of hypokinetic segments and other correlates of LV hypertrophy with LV mass and maximal wall thickness.

RESULTS

The proportion of hypokinetic segments was higher in patients with HCM than in control subjects (37% +/- 20 [standard deviation] vs 12% +/- 12, P < .001). In stepwise multiple regression analysis, the proportion of hypokinetic segments accounted for 42% (P < .001); the LV end-diastolic volume, for 24% (P = .003); and male sex, for 10% (P = .014) of the variability in LV mass in patients with HCM. The proportion of hypokinetic LV segments, which accounted for 48% of the variability in LV maximal wall thickness (P < .001), was the only variable significantly associated with maximal wall thickness.

CONCLUSION

The extent of myocardial contractile impairment is strongly and independently related to LV mass and maximal wall thickness in patients with HCM attributable to the Asp175Asn mutation in TPM1.

Early Target Organ Damage and Its Reversibility: The Heart

Left ventricular hypertrophy (LVH) represents not only an adaptation to increased load, but also a risk factor and a marker of risk of cardiovascular diseases. It may be detected early in the development of the disease by electrocardiography or echocardiography. LVH is often associated to abnormalities of systolic and diastolic function, and its presence clearly predisposes not only to cardiac ischemia and to congestive heart failure, but also to a higher incidence of stroke. A large number of clinical and experimental studies have shown that long-term antihypertensive treatment may be associated with regression of LVH. Long-term antihypertensive treatment is associated with a progressive decrease of LV mass. Differences on reduction of LV mass using different classes of antihypertensive drugs for the same decrease of blood pressure are usually mild, although the effect on cardiac structure and tissue composition are probably not the same. In fact, not only the quantity of left ventricular mass, but also its quality (i.e., collagen content, contractile machinery) should be evaluated and improved by treatment. The incidence of cardiovascular events in hypertensive patients is clearly related to the value of LV mass achieved during treatment; in fact, a reduction in LVH by antihypertensive treatment is associated with improvement in outcome and with decrease of the risk of cardiovascular morbidity and mortality, even independently from changes of other risk factors, including blood pressure. In patients with LVH at baseline, the decrease of LV mass is associated with a number of pathophysiological changes such as 1) improved systolic performance at the midwall, 2) possible improvement of diastolic filling, 3) autonomic nervous system changes toward normalization, 4) possible reduction or ventricular arrhythmias and 5) coronary reserve improvement. All these changes might explain an improvement of clinical prognosis in hypertensive patients. Ongoing studies will more precisely assess the quantitative relation between development or regression of LV mass, improvement of systolic and diastolic function and incidence of cardiovascular events. At present time detection, prevention and reversal of LVH represent a major goal in the management of hypertensive patients.

Usefulness of the assessment of the appropriateness of left ventricular mass to detect left ventricular systolic and diastolic abnormalities in absence of echocardiographic left ventricular hypertrophy: the LIFE study

Conventional definitions of left ventricular (LV) hypertrophy do not account for interindividual differences in loading conditions. We may define LV mass as inappropriately high when exceeding 128% of theoretical values predicted by gender, height(2.7), and stroke work, which explain up to 82% of the variability of LV mass in normal reference subjects. In 652 participants in the Losartan Intervention For Endpoint reduction in hypertension study without clinically overt cardiovascular disease or diabetes, we investigated whether inappropriately high LV mass is associated with relevant LV abnormalities independent of traditional definition of LV hypertrophy (ie, LV mass index >116 g/m(2) in men and >104 g/m(2) in women). The study sample was divided into three groups: patients with inappropriately high LV mass but without LV hypertrophy were compared to patients with LV hypertrophy and to patients with appropriate LV mass and without LV hypertrophy. Patients with inappropriately high but nonhypertrophic LV mass had higher body mass index and relative wall thickness, and lower LV myocardial systolic function, than patients with appropriate LV mass or patients with LV hypertrophy. In multivariate analyses, inappropriately high LV mass was independently associated with lower myocardial systolic function independent of LV hypertrophy and other covariates. Inappropriately high LV mass was also associated with prolonged isovolumic relaxation time and lower mitral E/A ratio independent of covariates. In conclusion, inappropriately high LV mass was associated with relevant, often preclinical, manifestations of cardiac disease in the absence of traditionally defined echocardiographic LV hypertrophy and concentric geometry.

Left ventricular hypertrophy differences in male professional runners and in young patients suffering from mild hypertension

AIMS

This study was executed to evaluate left ventricular (LV) geometry, diastolic and systolic function assessed by B- and M-mode and pulsed Doppler echocardiography in a group of professional sprinter runners (group I), in young patients suffering from mild hypertension (group II) and in control young adults (group III). Twenty-one male sprinter runners were checked during a period of training and compared with 19 young patients suffering from mild hypertension and 15 healthy controls matched for gender and body size.

FINDINGS

LV septum thickness, LV posterior wall thickness, LV ejection fraction, LV shortening fraction, midwall fractional shortening and stroke volume were significantly higher in runners compared to hypertensive patients and controls (p < 0.001). A significant increase of diastolic function parameters of the early peak flow velocity, E, and the early/late diastolic wave ratio, E/A, and in the isovolumic relaxation time or in the E velocity deceleration time wave was observed in hypertensive patients when compared to runners and controls (p < 0.05). The study of the pulmonary venous flow revealed a significant increase in the early systolic flow velocity, S, in hypertensive patients compared to runners (p < 0.05); the late diastolic flow velocity, D, appeared to be similar in all groups, while atrial backward flow velocity, Ar, was higher in group I and II respect to control (p < 0.001).

CONCLUSIONS

Our data indicate that LV concentric hypertrophy in sportsmen is associated with improvement of systolic and diastolic performance, whereas diastolic dysfunction can occurs even in the early stages of hypertension in young patients, in whom an alteration in the LV filling appears even in absence of systolic dysfunction and evident concentric myocardial hypertrophy.

Peak exercise oxygen uptake and left ventricular systolic and diastolic function and arterial mechanics in healthy young men

Echocardiography can be used to estimate myocardial contractility by the assessment of the circumferential end-systolic stress-corrected left ventricular (LV) fractional shortening measured at midwall level (stress-corrected MWS). Whether stress-corrected MWS at rest predicts exercise peak oxygen uptake (peak VO(2)) is unknown. Also, it is not known whether the propagation rate of the early LV filling wave (E wave propagation rate, V(p)), a new pre-load insensitive index of LV diastolic function, and echocardiographically assessed indices of arterial stiffness correlate to peak VO(2). Accordingly, we performed echocardiographic studies and exercise tests with respiratory gas analysis in 15 young healthy male subjects (mean age 27 years, range 18-36). Neither stress-corrected-MWS ( r=0.20, P=NS) nor ejection fraction ( r=-0.05, P=NS) correlated significantly with peak VO(2). Adjustment for age and resting heart rate had no effect on the results. In separate multiple regression models adjusting for standard covariates (age, LV size and heart rate), peak VO(2) correlated with V(p) (beta=0.98, P<0.01), as well as with E/A (beta=0.85, P<0.01), and with the isovolumic relaxation time (indicator of LV relaxation) (beta=-0.59, P<0.05). Arterial stiffness indices showed no significant relation to peak VO(2). We conclude that in young healthy male subjects, resting myocardial contractility and arterial stiffness are not significant correlates of peak VO(2), whereas LV diastolic function, and in particular V(p), influences the variability of peak VO(2).

Left Ventricular Geometry and Hypotension in End-Stage Renal Disease: A Mechanical Perspective

ABSTRACT. Hemodynamic and nonhemodynamic factors are implicated in the maintenance and aggravation of left ventricular (LV) hypertrophy in ESRD. Functional consequences of LV geometry are of substantial importance in patients who undergo dialysis and may contribute to explain the negative outcome related to LV hypertrophy, also in patients without overt coronary heart disease (CHD). Whereas most patients with eccentric LV hypertrophy have systolic dysfunction and the underlying CHD imposes progression of their disease, when overt CHD does not occur to remodel left ventricle, concentric LV geometry is more prevalent in ESRD and functional consequences are different. Concentric LV geometry is very sensitive to abrupt changes of cardiac loading conditions because of increased LV stiffness. Dialysis-related decrease in LV filling pressure reduces Starling forces recruitment and causes a fall in stroke volume as a result of reduced preload. This fall cannot be compensated by increased contractility, as myocardial mechanics is impaired in concentric LV geometry and no functional reserve can be used. When adequate increase in heart rate is not achieved to compensate reduced stroke volume, cardiac output substantially decreases and hypotension occurs. Occurrence of hypotension in the context of concentric LV geometry might contribute to reduce repeatedly coronary blood flow supply in the stiff and thick myocardium and might accelerate myocardial structural deterioration seen in ESRD. E-mail: simogi@unina.it

Gender differences in left ventricular chamber and midwall systolic function in normotensive and hypertensive adults

OBJECTIVE

Whether left ventricular (LV) systolic function differs between healthy men and women independent of afterload, LV geometry, age, heart rate and body size is disputed.

METHODS

We studied 517 clinically healthy adults without history of cardiovascular or endocrinal disease (age range 20-70, 274 with essential arterial hypertension). Echocardiography was used to assess LV geometry and systolic function both at endocardial and midwall levels.

RESULTS

Normotensive and hypertensive women had higher LV systolic function at endocardial and midwall levels independent of afterload. After adjustment for age, body surface area, heart rate and LV geometry, LV systolic function remained higher in women than in men in hypertensive and normotensive subjects. In a second set of multivariate analyses adjusting for age, body mass index, LV geometry and heart rate, women had significantly higher LV systolic function than men, both among normotensive and hypertensive subjects. In a reference group of 95 subjects with optimal blood pressure and normal body mass index (mean age 34 +/- 10; 32 men) extracted from the study sample, lower limits (5th percentile) of parameters of LV systolic function were higher in women than in men. Use of gender-specific partition values revealed that subnormal LV chamber function was uncommon in overweight, normotensive subjects as well as in hypertensive subjects; vice versa, stress-corrected midwall dysfunction was frequently subnormal in both normotensive, overweight (14%, mostly women) and in hypertensive subjects (18%, mostly men). At the opposite end of the spectrum, gender-specific supranormal, stress-corrected LV systolic chamber function (> 95th percentile of the distribution in the reference group) was relatively frequent in both overweight, normotensive (14%) and in hypertensive subjects (27%).

CONCLUSIONS

Clinically healthy hypertensive and normotensive women have higher LV chamber and midwall systolic function than men, independent of left ventricular geometry, body size, age and heart rate. Use of gender-specific partition values to define subnormal and supranormal LV systolic function revealed that, both in hypertensive and overweight normotensive subjects, subnormal LV chamber function was uncommon, whereas stress-corrected LV chamber systolic function was frequently supranormal. Vice versa, myocardial contractility was subnormal in approximately one-sixth of asymptomatic, normotensive overweight and of hypertensive subjects, with potentially unfavorable prognostic impact.

Left ventricular structural and functional characteristics in Cushing's syndrome

OBJECTIVES

This study was designed to evaluate left ventricular (LV) anatomy and function in patients with Cushing's syndrome.

BACKGROUND

A high prevalence of LV hypertrophy and concentric remodeling has been reported in Cushing's syndrome, although no data have been reported on LV systolic and diastolic function.

METHODS

Forty-two consecutive patients with Cushing's syndrome and 42 control subjects, matched for age, gender, and blood pressure, were studied. Left ventricular mass index (LVMI) and relative wall thickness (RWT) were measured by echocardiography, endocardial and midwall fractional shortening (FS) were assessed, and diastolic filling was measured by Doppler transmitral flow.

RESULTS

The RWT was significantly greater in Cushing patients than in controls. Left ventricular hypertrophy and concentric remodeling were observed in 10 and 26 patients with Cushing's syndrome, respectively. In Cushing patients, midwall FS was significantly reduced compared with controls (16.2 +/- 3% vs. 21 +/- 4.5%, p = 0.01). The ratio of transmitral E and A flow velocities was reduced and E deceleration time was prolonged in Cushing patients compared with controls (p = 0.03 and p < 0.001, respectively).

CONCLUSIONS

In patients with Cushing's syndrome, cardiac structural changes are associated with reduced midwall systolic performance and with diastolic dysfunction that may contribute to the high risk of cardiovascular events observed in these patients.

Pulse pressure/stroke index and left ventricular geometry and function: the LIFE Study

OBJECTIVE

To evaluate the relationship between arterial stiffness estimated by the pulse pressure/stroke index ratio (PP/SVi) and prognostically relevant abnormalities of left ventricular geometry and function.

METHODS

Baseline data from the echocardiographic substudy of the Losartan Intervention For Endpoint (LIFE) Reduction in Hypertension Study were used. Patients involved in the present study had stage II-III hypertension and electrocardiographic left ventricular hypertrophy; those with a history of coronary heart disease or segmental wall motion abnormalities were excluded. Plasma glucose, total and high-density lipoprotein (HDL) cholesterol and creatinine concentrations and urinary albumin/creatinine were assessed by standard methods.

RESULTS

The study sample (n = 667) was subdivided into tertiles of PP/SVi. With greater PP/SVi, age, proportion of women and prevalence of type 2 diabetes, systolic and mean blood pressures were greater, whereas body mass index, body height and diastolic blood pressure were lower. Total and HDL cholesterol, creatinine and albuminuria did not differ among the three groups. After adjustment for age, sex and body size, greater PP/SVi was related to concentric left ventricular geometry, but showed a weak negative relationship to left ventricular mass and aortic root diameter; the prevalence of aortic fibrocalcification and left atrial diameter did not differ among tertiles of PP/SVi. PP/SVi was related to greater left ventricular end-systolic stress; stress-corrected left ventricular chamber function was greater with greater PP/SVi, whereas myocardial contractility did not differ significantly among the three groups. Greater PP/SVi was related to greater mitral E-wave/A-wave ratio and shorter isovolumic relaxation time independently of age, sex, left ventricular geometry, systolic function and other confounders.

CONCLUSION

Increased estimated arterial stiffness is associated with concentric left ventricular geometry and with diastolic left ventricular abnormalities suggestive of increased diastolic left ventricular stiffness.