Left ventricular hypertrophy is a predictor of cardiovascular events in elderly hypertensive patients: Hypertension in the Very Elderly Trial

Obesity and Risk of Incident Left Ventricular Hypertrophy in Community-Dwelling Populations With Hypertension: An Observational Study

BACKGROUND

The aim of this study was to evaluate the association between obesity and risk of incident left ventricular hypertrophy (LVH) in community-dwelling populations with hypertension and investigate whether this association would be attenuated by a lower achieved systolic blood pressure (SBP).

METHODS AND RESULTS

We used the EMINCA (Echocardiographic Measurements in Normal Chinese Adults) criteria, which were derived from healthy Chinese populations to define LVH. A total of 2069 participants with hypertension and without LVH (obesity 20.4%) were included. The association between obesity and risk of incident LVH was evaluated using Cox proportional hazard models and stratified by achieved follow-up SBP levels (≥140, 130-139, and <130 mm Hg). These analyses were also assessed using the American Society of Echocardiography/European Association of Cardiovascular Imaging criteria, which were derived from European populations to define LVH. After a median follow-up of 2.90 years, the rates of incident LVH in the normal-weight, overweight, and obese groups were 13.5%, 20.3%, and 27.8%, respectively (P<0.001). In reference to normal weight, obesity was associated with increased risk of incident LVH (adjusted hazard ratio [aHR], 2.51 [95% CI, 1.91-3.29]), which was attenuated when achieved SBP was <130 mm Hg (aHR, 1.78 [95% CI, 0.99-3.19]). This association remained significant when achieved SBP was ≥140 mm Hg (aHR, 3.45 [95% CI, 2.13-5.58]) or at 130 to 139 mm Hg (aHR, 2.32 [95% CI, 1.23-4.36]). Differences in these findings were noted when LVH was defined by the American Society of Echocardiography/European Association of Cardiovascular Imaging criteria.

CONCLUSIONS

Obesity was associated with incident LVH and an SBP target <130 mm Hg might be needed to attenuate this risk in patients with hypertension and obesity.

Is there a change in the appropriateness of admission after patients were admitted? Evidence from four county hospitals in rural China

Objective

This study aims to investigate the changes in admission appropriateness after patients were admitted and provide a reference for physicians to make admission decisions and for the supervision of medical service behavior by the medical insurance regulatory department.

Methods

Medical records of 4,343 inpatients were obtained based on the largest and most capable public comprehensive hospital in four counties in central and western China for this retrospective study. The binary logistic regression model was employed to examine the determinants of changes in admission appropriateness.

Results

Nearly two-in-thirds (65.39%) of the 3,401 inappropriate admissions changed to appropriate at discharge. Age, type of medical insurance, medical service type, severity of the patient upon admission, and disease category were found to be associated with the changes in the appropriateness of admission. Older patients (OR = 3.658, 95% CI [2.462-5.435]; P < 0.001) were more likely to go from "inappropriate" to "appropriate" than younger counterparts. Compared with circulatory diseases, the case evaluated as "appropriate" at discharge was more frequent in the urinary diseases (OR = 1.709, 95% CI [1.019-2.865]; P = 0.042) and genital diseases (OR = 2.998, 95% CI [1.737-5.174]; P < 0.001), whereas the opposite finding was observed for patients with respiratory diseases (OR = 0.347, 95% CI [0.268-0.451]; P < 0.001) and skeletal and muscular diseases (OR = 0.556, 95% CI [0.355-0.873]; P = 0.011).

Conclusions

Many disease characteristics gradually emerged after the patient was admitted, thus the appropriateness of admission changed. Physicians and regulators need to take a dynamic view of disease progression and inappropriate admission. Aside from referring to the appropriateness evaluation protocol (AEP), they both should pay attention to individual and disease characteristics to make a comprehensive judgment, and strict control and attention should be paid to the admission of respiratory, skeletal, and muscular diseases.

Left ventricular hypertrophy and incident cognitive decline in older adults with hypertension

The association between raised blood pressure and increased risk of subsequent cognitive decline is well known. Left ventricular hypertrophy (LVH), as a marker of hypertensive target organ damage, may help identify those at risk of cognitive decline. We assessed whether LVH was associated with subsequent cognitive decline or dementia in hypertensive participants aged ≥80 years in the randomized, placebo-controlled Hypertension in the Very Elderly Trial. LVH was assessed using 12-lead electrocardiography (ECG) based on the Cornell Product (CP-LVH), Sokolow-Lyon (SL-LVH), and Cornell Voltage (CV-LVH) criteria. The Mini-Mental State Examination (MMSE) was used to assess cognitive function at baseline and annually. A fall in MMSE to <24 or an annual fall of >3 points were defined as cognitive decline and triggered dementia screening (Diagnostic Statistical Manual IV). Death was defined as a competing event. Fine-Gray regression models were used to examine the relationship between baseline LVH and cognitive outcomes. There were 2645 in the analytical sample, including 201 (7.6%) with CP-LVH, 225 (8.5%) SL-LVH and 251 (9.5%) CV-LVH. CP-LVH was associated with increased risk of cognitive decline, subdistribution hazard ratio (sHR)1.3 (95% confidence interval (CI) 1.01-1.67) in multivariate analyses. SL-LVH and CV-LVH were not associated with cognitive decline (sHR1.06 (95% CI 0.82-1.37) and sHR1.13 (95% CI 0.89-1.43), respectively). LVH was not associated with dementia. LVH may be related to subsequent cognitive decline, but evidence was inconsistent depending on ECG criterion and there were no associations with incident dementia. Additional work is needed to understand the relationships between blood pressure, LVH assessment and cognition.

Association of rate pressure product trajectories at an early age with left ventricular hypertrophy in midlife: a prospective cohort study

The joint effect of blood pressure (BP) and heart rate (HR) on cardiovascular disease is unclear. Rate pressure product (RPP), the product of systolic BP and HR, is assessed in this study. This study aimed to determine the longitudinal patterns of RPP from childhood to adulthood and to explore the relationship between RPP trajectories in early life and left ventricular hypertrophy (LVH) in midlife. We included individuals with 3 or more RPP values from 7 visits over a 30-year follow-up period in the Hanzhong Adolescent Hypertension Study cohort to fit trajectory groups and performed logistic regression to evaluate the relative risk of developing LVH. Three discrete trajectories in RPP were identified among 2412 participants assessed from childhood to middle-aged adulthood, which were tagged as "low stable," "moderate stable," and "moderate increasing". A higher waist-to-hip ratio, smoking, alcohol consumption, hypertension, diabetes, and hyperlipidemia were associated with increased RPP trajectories. The Cornell voltage product was positively correlated with RPP in 2017 and was higher in the moderate-stable and moderate-increasing groups than in the low-stable group in RPP trajectories. Compared with the low-stable group, the ORs of LVH were 1.65 (1.13, 2.92) for the moderate-stable and 3.56 (2.26, 5.44) for the moderate-increasing group. Subjects with moderate-stable and moderate-increasing trajectories showed higher probabilities of LVH at an elderly age than those in the low stable trajectory group even after adjusting for multiple cardiovascular risk factors. RPP trajectories are identifiable from childhood and are associated with LVH in midlife. Monitoring RPP trajectories from early life may be an effective approach to predict cardiovascular health status later in life.

Autophagy and pressure overload-induced cardiac hypertrophy

Autophagy plays an important role in the pathogenesis of cardiovascular diseases. Dysregulation of autophagy may have a huge effect on cardiac hypertrophy induced by overload pressure although reports on autophagy and cardiac hypertrophy have been contradictory. Some studies showed that autophagy activation attenuated cardiac hypertrophy. However, others suggested that inhibition of autophagy would be protective. Different research models or different pathways involved could be responsible for it. Cardiac hypertrophy may be alleviated through regulation of autophagy. This review aims to highlight the pathways and therapeutic targets identified in the prevention and treatment of cardiac hypertrophy by regulating autophagy.

Left ventricular and atrial remodelling in hypertensive patients using thresholds from international guidelines and EMINCA data

AIMS

To investigate differences in the prevalence of left ventricular (LV) and left atrial (LA) remodelling in hypertensive patients using various thresholds defined by international guidelines and data from the Echocardiographic Measurements in Normal Chinese Adults (EMINCA) study and different indexation methods.

METHODS AND RESULTS

LV mass (LVM), relative ventricular wall thickness, and LA volume (LAV) were measured using 2D echocardiography in 612 healthy volunteers selected from the EMINCA study population and 306 adult Chinese patients with hypertension who were age- and gender-matched using propensity score-matched analysis. LVM and LAV values were indexed to body surface area (BSA), height2.7, height1.7, and height2 recommended by guidelines or investigators. Using a previously reported method, LV geometry was divided into normal geometry, concentric remodelling, eccentric hypertrophy, and concentric hypertrophy. The prevalence of LV hypertrophy (LVH) and LV geometric patterns in hypertensive patients were compared using different thresholds and indexation methods. Echocardiographic thresholds from guidelines and healthy volunteers exhibited notable differences, particularly for LAV indexed to height2 and for LVM indexed to height1.7, which resulted in a significantly lower prevalence of LA dilatation and LVH in healthy volunteers. The total proportion of abnormal LV geometric patterns was significantly lower with thresholds from healthy volunteers than from guidelines when LVM was indexed to BSA, height1.7, and height2,7.

CONCLUSION

Using current echocardiographic thresholds and indexing methods recommended by guidelines may lead to significant misdiagnosis of LA dilatation, and abnormal LV geometry in Chinese patients with hypertension, and thresholds based on ethnic-specific normal echocardiographic reference values and an accurate indexing algorithm are warranted.

Pharmacotherapy for hypertension-induced left ventricular hypertrophy

BACKGROUND

Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension-induced LVH.

OBJECTIVES

To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension-induced LVH.

SEARCH METHODS

Cochrane Hypertension's Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with at least 12 months' follow-up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension-induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all-cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence.

MAIN RESULTS

We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow-up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention-to-treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add-on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low-certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low-certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low-certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low-certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low-certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions.

AUTHORS' CONCLUSIONS

We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low-certainty evidence requires that caution be used when interpreting the findings. High-quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension-induced LVH are warranted.

Hydrochlorothiazide Reduces Cardiac Hypertrophy, Fibrosis and Rho-Kinase Activation in DOCA-Salt Induced Hypertension

BACKGROUND

Thiazides are one of the most common antihypertensive drugs used for hypertension treatment and hydrochlorothiazide (HCTZ) is the most frequently used diuretic for hypertension treatment. The Rho/Rho-kinase (ROCK) path plays a key function in cardiovascular remodeling. We hypothesized that in preclinical hypertension HCTZ reduces myocardial ROCK activation and consequent myocardial remodeling.

METHODS

The preclinical model of deoxycorticosterone (DOCA)-salt hypertension was used (Sprague-Dawley male rats). After 3 weeks, in 3 different groups: HCTZ, the ROCK inhibitor fasudil or spironolactone was added (3 weeks). After 6 weeks myocardial hypertrophy and fibrosis, cardiac levels of profibrotic proteins, mRNA levels (RT PCR) of pro remodeling and pro oxidative molecules and ROCK activity were determined.

RESULTS

Blood pressure, myocardial hypertrophy and fibrosis were reduced significantly by HCTZ, fasudil and spironolactone. In the heart, increased levels of the pro-fibrotic proteins Col-I, Col-III and TGF-β1 and gene expression of pro-remodeling molecules TGF-β1, CTGF, MCP-1 and PAI-1 and the pro-oxidative molecules gp91phox and p22phox were significantly reduced by HCTZ, fasudil and spironolactone. ROCK activity in the myocardium was increased by 54% (P < 0.05) as related to the sham group and HCTZ, spironolactone and fasudil, reduced ROCK activation to control levels.

CONCLUSIONS

HCTZ reduced pathologic LVH by controlling blood pressure, hypertrophy and myocardial fibrosis and by decreasing myocardial ROCK activation, expression of pro remodeling, pro fibrotic and pro oxidative genes. In hypertension, the observed effects of HCTZ on the myocardium might explain preventive outcomes of thiazides in hypertension, specifically on LVH regression and incident heart failure.

Performance of the Electrocardiogram in the Diagnosis of Left Ventricular Hypertrophy in Older and Very Older Hypertensive Patients

BACKGROUND

Left ventricular hypertrophy (LVH) is an important cardiovascular risk factor, regardless of arterial hypertension. Despite the evolution of imaging tests, the electrocardiogram (ECG) is still the most used in the initial evaluation, however, with low sensitivity.

OBJECTIVE

To evaluate the performance of the main electrocardiographic criteria for LVH in elderly and very elderly hypertensive individuals.

METHODS

In a cohort of hypertensive patients, ECGs and doppler echocardiographies (ECHO) were performed and separated into three age groups: <60 years, Group I; 60-79 years Group II; and ≥80 years, Group III. The most used electrocardiographic criteria were applied for the diagnosis of LVH: Perugia; Pegaro-Lo Presti; Gubner-Ungerleider; Narita; (Rm+Sm) x duration; Cornell voltage; Cornell voltage duration; Sokolow-Lyon voltage; R of aVL ≥11 mm; RaVL duration. In evaluating the performance of these criteria, in addition to sensitivity (Sen) and specificity (Esp), the "Diagnostic Odds Ratios" (DOR) were analyzed. We considered p-value <0.05 for the analyses, with two-tailed tests.

RESULTS

In 2,458 patients, LVH was present by ECHO in 781 (31.7%). In Groups I and II, the best performances were for the criteria of Narita, Perugia, (Rm+Sm) x duration, with no statistical differences between them. In Group III (very elderly) the Perugia criteria and (Rm+Sm) x duration had the best performances: Perugia [44,7/89.3; (Sen/Esp)] and (Rm+Sm) duration [39.4%/91.3%; (Sen/Esp), p<0.05)], with the best PAIN results:6.8. This suggests that in this very elderly population, these criteria have greater discriminatory power to separate patients with LVH.

CONCLUSION

In very elderly hypertensive patients, the Perugia electrocardiographic criteria and (Rm+Sm) x duration showed the best diagnostic performance for LVH.

Protective Effects of Thyroid Hormone Deprivation on Progression of Maladaptive Cardiac Hypertrophy and Heart Failure

Purpose: Thyroid hormones (TH) play a central role for cardiac function. TH influence heart rate and cardiac contractility, and altered thyroid function is associated with increased cardiovascular morbidity and mortality. The precise role of TH in onset and progression of heart failure still requires clarification. Methods: Chronic left ventricular pressure overload was induced in mouse hearts by transverse aortic constriction (TAC). One week after TAC, alteration of TH status was induced and the impact on cardiac disease progression was studied longitudinally over 4 weeks in mice with hypo- or hyperthyroidism and was compared to euthyroid TAC controls. Serial assessment was performed for heart function (2D M-mode echocardiography), heart morphology (weight, fibrosis, and cardiomyocyte cross-sectional area), and molecular changes in heart tissues (TH target gene expression, apoptosis, and mTOR activation) at 2 and 4 weeks. Results: In diseased heart, subsequent TH restriction stopped progression of maladaptive cardiac hypertrophy and improved cardiac function. In contrast and compared to euthyroid TAC controls, increased TH availability after TAC propelled maladaptive cardiac growth and development of heart failure. This was accompanied by a rise in cardiomyocyte apoptosis and mTOR pathway activation. Conclusion: This study shows, for the first time, a protective effect of TH deprivation against progression of pathological cardiac hypertrophy and development of congestive heart failure in mice with left ventricular pressure overload. Whether this also applies to the human situation needs to be determined in clinical studies and would infer a critical re-thinking of management of TH status in patients with hypertensive heart disease.

Clinical applicability and diagnostic performance of electrocardiographic criteria for left ventricular hypertrophy diagnosis in older adults

Recently, a new ECG criterion, the Peguero-Lo Presti (PLP), improved overall accuracy in the diagnosis of left ventricular hypertrophy (LVH)—compared to traditional ECG criteria, but with few patients with advanced age. We analyzed patients with older age and examined which ECG criteria would have better overall performance. A total of 592 patients were included (83.1% with hypertension, mean age of 77.5 years) and the PLP criterion was compared against Cornell voltage (CV), Sokolow-Lyon voltage (SL) and Romhilt-Estes criteria (cutoffs of 4 and 5 points, RE4 and RE5, respectively) using LVH defined by the echocardiogram as the gold standard. The PLP had higher AUC than the CV, RE and SL (respectively, 0.70 vs 0.66 vs 0.64 vs 0.67), increased sensitivity compared with the SL, CV and RE5 (respectively, 51.9% [95% CI 45.4–58.3%] vs 28.2% [95% CI 22.6–34.4%], p < 0.0001; vs 35.3% [95% CI 29.2–41.7%], p < 0.0001; vs 44.4% [95% CI 38.0–50.9%], p = 0.042), highest F1 score (58.3%) and net benefit for most of the 20–60% threshold range in the decision curve analysis. Overall, despite the best diagnostic performance in older patients, the PLP criterion cannot rule out LVH consistently but can potentially be used to guide clinical decision for echocardiogram ordering in low-resource settings.

Correlations of circulating miR-26b level with left ventricular hypertrophy and cardiac function in elderly patients with hypertension

Objectives:

To study the correlations of circulating miR-26b level with left ventricular hypertrophy (LVH) and cardiac function in elderly patients with hypertension.

Methods:

A total of 132 eligible patients were divided into low and high miR-26b level groups. Their baseline clinical data and biochemical indices were compared. The correlations between miR-26b level and echocardiographic parameters were studied by Pearson’s analysis. Factors affecting LVH were explored by multivariate logistic regression analysis. The role of miR-26b in diagnosing LVH was predicted by receiver operating characteristic curve.

Results:

The relative expression level of miR-26b was 4.56-16.93, with a median of 7.62. The two groups had similar baseline clinical data and biochemical indices (P>0.05). Compared with high miR-26b level group, interventricular septal thickness (IVST), left ventricular posterior wall thickness (LVPWT), left ventricular mass index (LVMI) and number of LVH cases in low miR-26b level group significantly increased (P<0.05), and mitral ratio of peak early to late diastolic filling velocity (E/A) decreased (P<0.05). Circulating miR-26b level was negatively correlated with IVST, LVPWT and LVMI (P<0.0001), and positively correlated with E/A (P<0.0001). The proportion of cardiac hypofunction cases in low miR-26b level group significantly exceeded that of high miR-26b level group (P<0.05). Age and increased IVST, LVPWT and LVMI were independent risk factors for LVH (P<0.05), and elevated miR-26b level was a protective factor (P<0.05). AUC was 0.836, and the optimal cutoff value was 8.83, with high sensitivity and specificity.

Conclusions:

MiR-26b level is negatively correlated with LVH and positively correlated with left ventricular diastolic function in elderly hypertensive patients. It is a protective factor for LVH complicated with diastolic dysfunction and a potential biomarker for diagnosis.

The Groningen electrocardiographic criteria for left ventricular hypertrophy: a sex-specific analysis

The sensitivity of electrocardiogram (ECG) criteria to detect left ventricular hypertrophy (LVH) is low, especially in women. We determined sex-specific sensitivities of ECG-LVH criteria, and developed new criteria, using cardiovascular magnetic resonance imaging (CMR). Sensitivities of ECG-LVH criteria were determined in participants of the UK Biobank (N = 3632). LVH was defined when left ventricular mass was > 95% confidence interval (CI) according to age and sex. In a training cohort (75%, N = 2724), sex-specific ECG-LVH criteria were developed by investigating all possible sums of QRS-amplitudes in all 12 leads, and selecting the sum with the highest pseudo-R² and area under the curve to detect LVH. Performance was assessed in a validation cohort (25%, N = 908), and association with blood pressure change was investigated in an independent cohort. Sensitivities of ECG-LVH criteria were low, especially in women. Newly developed Groningen-LVH criterion for women (Q_V2 + R_I + R_V5 + R_V6 + S_V2 + S_V4 + S_V5 + S_V6) outperformed all ECG-LVH criteria with a sensitivity of 42% (95% CI 35-49%). In men, newly developed criterion ((R_I + R_V5 + S_II + S_V2 + S_V6) × QRS duration) was equally sensitive as 12-lead sum with a sensitivity of 44% (95% CI 37-51%) and outperformed the other criteria. In an independent cohort, the Groningen-LVH criteria were strongest associated with change in systolic blood pressure. Our proposed CMR sex-specific Groningen-LVH criteria improve the sensitivity to detect LVH, especially in women. Further validation and its association with clinical outcomes is warranted.

Atrial fibrillation and the risk of cardiovascular disease and mortality in the Hypertension in the Very Elderly Trial

OBJECTIVE

To assess the prognostic value of electrocardiographic atrial fibrillation in older hypertensive people in the randomized, placebo-controlled Hypertension in the Very Elderly Trial.

METHODS

Hypertension in the Very Elderly Trial randomized 3845 hypertensive people aged 80 years and over, 3273 with electrographic data on the presence or absence of atrial fibrillation at baseline and without established cardiovascular disease. Multivariate Cox proportional hazard models were used to estimate hazard ratios with 95% confidence intervals (CIs) for all-cause mortality, incident fatal and nonfatal major cardiovascular events, all-stroke and all-heart failure. The mean follow-up time was 2.1 years.

RESULTS

Baseline prevalence of atrial fibrillation was 5.8%. Compared with people without atrial fibrillation at baseline, after adjustments the presence of atrial fibrillation was associated with increased risk of mortality (hazard ratio = 2.49, 95% CI = 1.80-3.44, P < 0.001), of nonfatal and fatal cardiovascular events (hazard ratio = 2.47, 95% CI = 1.71-3.55, P < 0.001), all-stroke (hazard ratio = 2.47, 95% CI = 1.34-4.56, P = 0.004) and all-heart failure (hazard ratio 2.33, 95% CI = 1.10-4.93, P = 0.027).

CONCLUSION

Atrial fibrillation is an important risk factor to consider when assessing older hypertensive adults as it is associated with increased risk of mortality, nonfatal and fatal cardiovascular events, stroke and heart failure.

The differential effects of anemia on mortality in young and elderly end-stage renal disease patients

Background

The aim of this study was to compare the effect of anemia on clinical outcomes according to age in patients with end-stage renal disease (ESRD).

Methods

A total of 3,409 patients from the Clinical Research Center for ESRD were included and divided into three groups by age: age < 40 (n = 488), 40 ≤ age < 60 (n = 1,650), and age ≥ 60 (n = 1,271). We compared overall and cardiovascular mortality, and all-cause and cardiovascular hospitalization according to mean hemoglobin (Hb) concentration.

Results

Among participants ≥ 60 years of age, the Hb < 10 g/dL group had greater all-cause mortality (adjusted hazard ratio [HR], 2.098; 95% confidence interval [CI], 1.567-2.808; P < 0.001) than the 10 ≤ Hb < 12 g/dL group, whereas among participants < 40 years of age, the Hb ≥ 12 g/dL group had greater mortality than the 10 ≤ Hb < 12 g/dL group. Moreover, in participants ≥ 60 years of age, the HR for all-cause hospitalization for the Hb < 10 g/dL group was significantly greater than that of the 10 ≤ Hb < 12 g/dL group (HR, 1.472; 95% CI, 1.057-2.051; P = 0.022), whereas it was significantly lower in the Hb ≥ 12 g/dL group (HR, 0.544; 95% CI, 0.362-0.820; P = 0.004) However, among participants < 40 years of age, the incidence of all-cause hospitalization did not differ according to the Hb concentration (HR, 1.273; 95% CI, 0.814-1.991; P = 0.290 for the Hb < 10 g/dL group; reference, 10 ≤ Hb < 12 g/dL; HR, 0.787; 95% CI, 0.439-1.410; P = 0.265 for Hb ≥ 12 g/dL group).

Conclusion

The impact of anemia on mortality was more significant in elderly ESRD patients. Strict monitoring and management of anemia should be required for elderly ESRD patients.

Prediction of stroke with electrocardiographic left ventricular hypertrophy in hypertensive patients: A meta-analysis

BACKGROUND

Electrocardiographic left ventricular hypertrophy (LVH) has been used to predict adverse prognosis in hypertensive patients. This meta-analysis aimed to investigate the association between LVH using the different electrocardiographic criteria in patients with hypertension.

METHODS

A comprehensive literature search was performed PubMed and Embase databases up to September 1, 2019. Observational studies evaluating the association between electrocardiographic LVH (Cornell voltage, Cornell product or Sokolow-Lyon voltage) at baseline and risk of stroke among hypertensive patients were selected. The risk ratio (RR) with 95% confidence interval (CI) was pooled for patients with electrocardiographic LVH versus without LVH.

RESULTS

Seven studies enrolling 58,098 hypertensive patients were included. When compared those with or without LVH patients showed that the pooled RR of stroke was 1.63 (95% CI 1.38-1.93) for Cornell voltage criteria, 1.41 (95% CI 1.07-1.86) for Cornell product criteria, and 1.42 (95% CI 1.20-1.69) for Sokolow-Lyon voltage criteria, respectively. However, the predictive significance of Cornell product criteria was not reliable in the sensitivity analysis.

CONCLUSIONS

Baseline electrocardiographic LVH detecting by Sokolow-Lyon or Cornell voltage criteria can predict the development of stroke in hypertensive patients. Use of electrocardiographic LVH can improve stroke risk stratification in hypertensive patients.

Electrocardiographic left ventricular hypertrophy and mortality in an oldest-old hypertensive Chinese population

Purpose

Previous studies have identified that electrocardiographic pattern of left ventricular hypertrophy (ECG LVH) is associated with mortality, but studies of its correlation in the oldest-old hypertensive population is extremely limited. We investigated the correlation between ECG LVH and mortality in a hypertensive Chinese population aged 80 years and older.

Patients and methods

In this study, we included 284 Chinese participants older than 80 years. All included participants with hypertension (sitting systolic blood pressure [BP] 160 to 200 mmHg; sitting diastolic BP <110 mmHg) were ascertained at the baseline. ECG LVH was defined as a Sokolow-Lyon voltage calculated as the amplitude of SV1+ (max RV5 or RV6) greater than 3.5 mV. We categorized participants into two groups by the status of baseline ECG LVH. We used Cox regression models to calculate hazard ratio (HRs) for mortality due to ECG LVH, including cardiovascular mortality and all-cause mortality.

Results

In this study, with a 28-month median follow-up, a total of 35 (12.3%) patients died; 21 of those died due to cardiovascular causes. Compared with participants without ECG LVH, there was an increased risk of cardiovascular mortality in participants with ECG LVH (adjusted HR 4.25 [95% confidence interval [CI], 1.50–12.06]) but ECG LVH did not predict all-cause mortality (adjusted HR 2.31 [95% CI, 0.93–5.72]).

Conclusion

Our study shows that ECG LVH predicts the risk of cardiovascular mortality in an oldest-old hypertensive Chinese population.

[Therapy of patients with the high risk of arterial hypertension with the use of telmisartan]

AIM

The study assesses the effects of therapy based on the use of telmisartan in patients with arterial hypertension and stable angina on the clinical and functional indicators of the cardiovascularvascular system.

MATERIAL AND METHODS

52 patients with a combination of arterial hypertension (AH) I and II stages and coronary artery disease II with the mean age 63.5 ± 5.4 years (79% males and 21% of females) were enrolled in the trial. The duration of AH and CAD were 17.5±3.8 and 12.5±3.1 accordingly. All patients took a daily 80 mg dose of telmisartan. The efficacy of treatment was estimated in 3,6 and 12 months.

RESULTS

The use of telmisartan in complex treatment of high-risk patients with AH has led to decreasing blood pressure to the target level, increasing exercise tolerance (walking the distance from 315.5 m to 410.2 m in 6 minutes). 12 months of therapy based on telmisartan showed significant decrease in left hy‑ pertrophy ventricle (LV myocardial mass index on average by 10.4%), a decrease in the total duration of depression ST segment from 9.6±2.9 to 2.7±1.5 mm and a decrease in the depth of depression from 1.5±0.3 mm to 0.3±0.09 mm, with a trend towards decrease in the number of episodes of ST-segment depression, as well as the absence of a significant change in heart rate. After 12 months of en‑ dothelium-dependent vasodilation therapy, the condition of 31 (60%) patients improved, and 18 (35%) patients showed the tendency to improvement. The tests with reactive hyperemia conducted after 12 months of treatment revealed decreased linear velocity of blood flow in the brachial artery on average by 17%.

CONCLUSION

The use of telmisartan in complex therapy improves the quality of life according to the EQ-VAS questionnaire by 25 points after 12 months of therapy, contributes to lowering blood pressure in 96% of patients, reduc‑ ing myocardial hypertrophy, endothelial dysfunction and severity of ischemic manifestations (reducing the need for nitroglycerin intake to an average of 0,5 inhalations, as well as a decrease in the ST segment depression of 40% after 12 months of therapy).

Hydrochlorothiazide and alternative diuretics versus renin-angiotensin system inhibitors for the regression of left ventricular hypertrophy: a head-to-head meta-analysis

BACKGROUND

Found in 36-41% of hypertension, elevated left ventricular mass (LVM) independently predicts cardiovascular events and total mortality. Conversely, drug-induced regression of LVM predicts improved outcomes. Previous studies have favored renin-angiotensin system inhibitors (RASIs) over other antihypertensives for reducing LVM but ignored differences among thiazide-type diuretics. From evidence regarding potency, cardiovascular events, and electrolytes, we hypothesized a priori that 'CHIP' diuretics [CHlorthalidone, Indapamide and Potassium-sparing Diuretic/hydrochlorothiazide (PSD/HCTZ)] would rival RASIs for reducing LVM.

METHOD AND RESULTS

Systematic review yielded 12 relevant double-blind randomized trials. CHIPs were more closely associated with reduced LVM than HCTZ (P = 0.004), indicating that RASIs must be compared with each diuretic separately. Publication bias favoring RASIs was corrected by cumulative analysis. For reducing LVM, HCTZ tended to be less effective than RASIs. However, the following surpassed RASIs: chlorthalidone Hedge's G: -0.37 (95% CI -0.72 to -0.02), P = 0.036; indapamide -0.20 (-0.39 to -0.01), P = 0.035; all CHIPs combined (with 61% of patients in one trial) -0.25 (-0.41to -0.09), P = 0.002. Statistical significance (P < 0.05) did not depend on any one trial. CHIPs reduction in LVM was 37% greater than that from RASIs. CHIPs superiority tended to increase with trial duration, from a negligible effect at 0.5 year to a maximal effect at 0.9-1.0 years: -0.26 (-0.43 to -0.09), P = 0.003. Fifty-eight percent of patients had information on echocardiographic components of LVM: relative to RASIs, CHIPs significantly reduced end-diastolic LV internal dimension (EDLVID): -0.18 (-0.36 to -0.00), P = 0.046. Strength of evidence favoring CHIPs over RASIs was at least moderate.

CONCLUSION

In these novel results in patients with hypertension, CHIPs surpassed RASIs for reducing LVM and EDLVID.

Consistency of left ventricular hypertrophy diagnosed by electrocardiography and echocardiography: the Northern Shanghai Study

Background

Left ventricular hypertrophy (LVH) is one of the preclinical manifestations of hypertensive target organ damage (TOD). However, it remains unclear which electrocardiographic criterion perform better in diagnosing LVH.

Purpose

To investigate the consistency of LVH diagnosed by electrocardiography (ECG) and echocardiography (ECHO). Taking LVH by ECHO as reference, to compare three different ECG criteria (Sokolow-Lyon, Cornell and Cornell Product criteria) and find the best ECG indicator for identifying LVH in community-based elderly Chinese.

Patients and methods

Echocardiography and electrocardiography were applied to define LVH in 1789 elderly Chinese aged >65 years old in communities located at the northern Shanghai. Echocardiographic LVH (ECHO-LVH) was defined by left ventricular mass indexed for Body Surface Area (LVM/BSA) or for height^2.7 (LVM/height^2.7). Electrocardiographic LVH (ECG-LVH) was defined by Sokolow-Lyon (SL), Cornell and Cornell Product (CP) criteria. ECHO-LVH was defined by LVM/BSA≥125 g/m² in male or ≥110 g/m² in female (LVH1); LVM/BSA≥115 g/m² in male, or ≥95 g/m² in female (LVH2) and LVM/height^2.7 ≥51 g/m^2.7 in male or ≥47 g/m^2.7 in female (LVH3).

Results

As compared with SL and Cornell criteria, CP had the greatest correlation coefficient in the association with echocardiography-defined LVH, except for LVM/BSA in men. Of note, CP criterion had the greatest area under curve of ROC than Cornell criterion and the SL index, not only in total population but also in subgroups classified by blood pressure.

Conclusion

In ECG-LVH criteria, CP criterion complies better than SL index and Cornell criterion in assessing cardiac hypertrophy.

Hydrochlorothiazide vs chlorthalidone, indapamide, and potassium-sparing/hydrochlorothiazide diuretics for reducing left ventricular hypertrophy: A systematic review and meta-analysis

Left ventricular hypertrophy develops in 36%-41% of hypertensive patients and independently predicts cardiovascular events and total mortality. Moreover, drug-induced reduction in left ventricular mass (LVM) correlates with improved prognosis. The optimal thiazide-type diuretic for reducing LVM is unknown. Evidence regarding potency, cardiovascular events, sodium, and potassium suggested the hypothesis that "CHIP" diuretics (CHlorthalidone, Indapamide, and Potassium-sparing diuretic/hydrochlorothiazide [PSD/HCTZ]) would reduce LVM more than HCTZ. Systematic searches of five databases were conducted. Among the 38 randomized trials, a 1% reduction in systolic blood pressure (SBP) predicted a 1% reduction in LVM, P = 0.00001. CHIP-HCTZ differences in reducing LVM differed across trials (ie, heterogeneity), making interpretation uncertain. However, among the 28 double-blind trials, heterogeneity was undetectable, and HCTZ reduced LVM (percent reduction [95% CI]) by -7.3 (-10.4, -4.2), P < 0.0001. CHIP diuretics surpassed HCTZ in reducing LVM: chlorthalidone -8.2 (-14.7, -1.6), P = 0.015; indapamide -7.5 (-12.7, -2.3), P = 0.005; and all CHIP diuretics combined -7.7 (-12.2, -3.1), P < 0.001. The comparison of PSD/HCTZ with HCTZ had low statistical power but favored PSD/HCTZ: -6.0 (-14.1, +2.1), P = 0.149. Thus, compared to HCTZ, CHIP diuretics had twice the effect on LVM. CHIP diuretics did not surpass HCTZ in reducing systolic or diastolic blood pressure: -0.3 (-5.0, +4.3) and -1.6 (-5.6, +2.4), respectively. The strength of evidence that CHIP diuretics surpass HCTZ for reducing LVM was high (GRADE criteria). In conclusion, these novel results have demonstrated that CHIP diuretics reduce LVM 2-fold more than HCTZ among hypertensive patients. Although generally related to LVM, blood pressure fails to explain the superiority of CHIP diuretics for reducing LVM.

How does pressure overload cause cardiac hypertrophy and dysfunction? High-ouabain affinity cardiac Na+ pumps are crucial

Left ventricular hypertrophy is frequently observed in hypertensive patients and is believed to be due to the pressure overload and cardiomyocyte stretch. Three recent reports on mice with genetically engineered Na⁺ pumps, however, have demonstrated that cardiac ouabain-sensitive α₂-Na⁺ pumps play a key role in the pathogenesis of transaortic constriction-induced hypertrophy. Hypertrophy was delayed/attenuated in mice with mutant, ouabain-resistant α₂-Na⁺ pumps and in mice with cardiac-selective knockout or transgenic overexpression of α₂-Na⁺ pumps. The latter, seemingly paradoxical, findings can be explained by comparing the numbers of available (ouabain-free) high-affinity (α₂) ouabain-binding sites in wild-type, knockout, and transgenic hearts. Conversely, hypertrophy was accelerated in α₂-ouabain-resistant (R) mice in which the normally ouabain-resistant α₁-Na⁺ pumps were mutated to an ouabain-sensitive (S) form (α₁^S/Sα₂^R/R or "SWAP" vs. wild-type or α₁^R/R α₂^S/S mice). Furthermore, transaortic constriction-induced hypertrophy in SWAP mice was prevented/reversed by immunoneutralizing circulating endogenous ouabain (EO). These findings show that EO and its receptor, ouabain-sensitive α₂, are critical factors in pressure overload-induced cardiac hypertrophy. This complements reports linking elevated plasma EO to hypertension, cardiac hypertrophy, and failure in humans and elucidates the underappreciated role of the EO-Na⁺ pump pathway in cardiovascular disease.