Cardiac arrhythmias in arterial hypertension

Association between blood pressure levels and premature atrial contractions in patients with hypertension

BACKGROUND

High blood pressure (BP) induces left atrial structural and functional remodeling that increases susceptibility to atrial arrhythmia. We hypothesized that lower systolic BP (SBP) levels are associated with a lower prevalence of premature atrial contractions (PACs) in patients with hypertension.

METHODS

This analysis included 4,697 participants (mean age 62±13.1 years, 50% women, 25.6% blacks) with hypertension from the Third National Health and Nutrition Examination Survey who did not have a prior history of cardiovascular disease (CVD). Multivariable logistic regression was used to examine the cross-sectional association between SBP and prevalence of PACs ascertained from 12-lead resting electrocardiograms. Multivariable Cox proportional hazard analysis was used to examine the association between baseline PACs and CVD mortality.

RESULTS

Approximately 1.6% (n=74) of participants had baseline PACs. Patients with SBP ≤140 mmHg had a lower prevalence of PACs than those with SBP ≥140 mmHg (1.1% vs. 1.9%, p-value=0.01). In a multivariable logistic regression model, each 10 mmHg decrease in SBP was associated with a 12% lower odds of PACs (OR (95%CI): 0.88 (0.77-0.99)). During 14 years of follow-up, 645 CVD deaths occurred. In a multivariable-adjusted Cox model, presence of PACs was associated with a 78% increased risk of CVD mortality (HR (95%CI): 1.78 (1.23-2.60)).

CONCLUSIONS

In patients with hypertension, lower SBP levels are associated with a lower prevalence of PACs, and presence of PACs is associated with a higher risk of CVD mortality risk. These findings highlight the potential role of BP lowering in the management of cardiac arrhythmias.

Incidence and prevalence of hypertension in 18-40-year-old patients referred for palpitations with normal cardiac monitor findings

Sixteen percent of patients referred for cardiology evaluation are found to have no cause for palpitations. Studies show that hypertension intricately influences "heart rate" and "contractility,?" the key components of "palpitation." While the prevalence of hypertension is 22.4% in 18-39-year-olds, the relationship between palpitations and hypertension remains unknown in this age group. In our study, we assessed the incidence and prevalence of hypertension over 5 years in 18-40-year-olds referred for palpitations who had no known arrhythmic cause for palpitations between January 1, 206 and December 31, 2017. We found that over a period of 2.2 (0.7-4.1) years, an additional 56% patients were diagnosed with stage 1 (65/130) and stage 2 (28/130) hypertension, increasing the prevalence from 16% at the start of the study period to 72% at the end of the study period (p < .0001). Hypertensive patients were obese (BMI: 29 [24-36] kg/m2 vs. 25 [22-31] kg/m2; p = .03), used nonsteroidal anti-inflammatory drugs (NSAIDs) (62 vs. 35%; p = .04), had a stronger family history of hypertension (55 vs. 4%; p < .0001) and exhibited higher systolic (124[120-130] mmHg vs. 112[108-115] mmHg; p < .0001) and diastolic (80[76-83] mmHg vs. 72[69-75] mmHg; p < .0001) blood pressures. Hypertension is commonly diagnosed in 18-40-year-old predominantly white female patients referred for palpitations without a known arrhythmic cause. The possibility of untreated hypertension causing palpitations in this cohort needs further evaluation.

Searching for the Best Machine Learning Algorithm for the Detection of Left Ventricular Hypertrophy from the ECG: A Review

Background: Left ventricular hypertrophy (LVH) is a powerful predictor of future cardiovascular events. Objectives: The objectives of this study were to conduct a systematic review of machine learning (ML) algorithms for the identification of LVH and compare them with respect to the classical features of test sensitivity, specificity, accuracy, ROC and the traditional ECG criteria for LVH. Methods: A search string was constructed with the operators "left ventricular hypertrophy, electrocardiogram" AND machine learning; then, Medline and PubMed were systematically searched. Results: There were 14 studies that examined the detection of LVH utilizing the ECG and utilized at least one ML approach. ML approaches encompassed support vector machines, logistic regression, Random Forest, GLMNet, Gradient Boosting Machine, XGBoost, AdaBoost, ensemble neural networks, convolutional neural networks, deep neural networks and a back-propagation neural network. Sensitivity ranged from 0.29 to 0.966 and specificity ranged from 0.53 to 0.99. A comparison with the classical ECG criteria for LVH was performed in nine studies. ML algorithms were universally more sensitive than the Cornell voltage, Cornell product, Sokolow-Lyons or Romhilt-Estes criteria. However, none of the ML algorithms had meaningfully better specificity, and four were worse. Many of the ML algorithms included a large number of clinical (age, sex, height, weight), laboratory and detailed ECG waveform data (P, QRS and T wave), making them difficult to utilize in a clinical screening situation. Conclusions: There are over a dozen different ML algorithms for the detection of LVH on a 12-lead ECG that use various ECG signal analyses and/or the inclusion of clinical and laboratory variables. Most improved in terms of sensitivity, but most also failed to outperform specificity compared to the classic ECG criteria. ML algorithms should be compared or tested on the same (standard) database.

Estimating Left Ventricular Mass from the Electrocardiogram across the Spectrum of LV Mass from Normal to Increased LV Mass in an Older Age Group

Objectives

To examine the relationship of QRS voltages and left ventricular (LV) mass across the spectrum of individuals with different LV mass.

Methods

Twenty QRS voltage measurements or combinations were determined in a consecutive series of 159 adults with an ECG and echocardiogram without previous myocardial infarction, left or right bundle branch block, pre-excitation, or electronic pacemaker.

Results

The four strongest and significant correlations between QRS and LV mass were S in V4, deepest S wave in any precordial lead plus S in V4, S in V3, and S in V3 plus R in AVL times QRS duration. For men, the strength of the relationships were S in V3 (F = 33.8), deepest S wave in any precordial lead plus S V4 (F = 33.7), S in V3 plus R aVL (F = 29.9), S in V4 (F = 29.79), and deepest S in precordial leads (F = 17.9). The R wave in AVL alone did not correlate with LV mass. Criteria using the R wave in lateral precordial leads did not correlate as strongly with LV mass. For women, only S in V4 significantly correlated with LV mass. Overall, the R wave voltage in limb leads (AVL I or II) did not correlate with precordial S wave amplitudes. Univariate and multivariate analysis showed that some but not all QRS voltages correlated with each other. In multivariate analysis, using only single variables and not combination of QRS variables, the only significant relationship between QRS voltage and left ventricular mass was for men the S in V3 (p = 0.04) and for women S in V4 (p = 0.016) and R in V6 (p = 0.04).

Conclusion

The S wave in V3 and V4 correlate most strongly with LV mass while the R wave in limb leads, including AVL, do not correlate.

Beta-blockers in Hypertensive Left Ventricular Hypertrophy and Atrial Fibrillation Prevention

BACKGROUND

Hypertensive left ventricular hypertrophy (HTN LVH) is a key risk factor for atrial fibrillation (AF).

OBJECTIVE

To evaluate the possible role of beta-blockers (BBs) in addition to a renin-angiotensinaldosterone system (RAAS) blocker in AF prevention in patients with HTN LVH.

METHODS

We performed a PubMed, Elsevier, SAGE, Oxford, and Google Scholar search with the search items 'beta blocker hypertension left ventricular hypertrophy patient' from 2013-2023. In the end, a 'snowball search', based on the references of relevant papers as well as from papers that cited them was performed.

RESULTS

HTN LVH is a risk factor for AF. In turn, AF substantially complicates HTN LVH and contributes to the genesis of heart failure (HF) with preserved ejection fraction (HFpEF). The prognosis of HFpEF is comparable with that of HF with reduced EF (HFrEF), and, regardless of the type, HF is associated with five-year mortality of 50-75%. The antiarrhythmic properties of BBs are wellrecognized, and BBs as a class of drugs are - in general - recommended to decrease the incidence of AF in HTN.

CONCLUSION

BBs are recommended (as a class) for AF prevention in several contemporary guidelines for HTN. LVH regression in HTN - used as a single criterion for the choice of antihypertensive medication - does not capture this protective effect. Consequently, it is worth studying how meaningful this antiarrhythmic action (to prevent AF) of BBs is in patients with HTN LVH in addition to a RAAS blocker.

Symptoms in Hypertensive Patients Presented to the Emergency Medical Service: A Comprehensive Retrospective Analysis in Clinical Settings

BACKGROUND

Hypertension is a prevalent condition with a variety of accompanying symptoms. Gender differences, specific blood pressure readings, and early signs of organ complications present intricate interplays in hypertensive individuals.

OBJECTIVE

This study aimed to investigate the relationship between hypertension and its accompanying symptoms, emphasizing gender-specific differences and potential indicators of organ complications.

METHODS

Data from 2002 participants were analyzed from a retrospective study, focusing on the presentation of symptoms, blood pressure values, and potential organ complications associated with these symptoms.

RESULTS

Of the participants, 68.8% were women with an average age of 69. Women were, on average, 8 years older than men. The average systolic blood pressure (SBP) was 188 mmHg. High-blood pressure was accompanied by symptoms in 84.9% of participants. Among those with an SBP > 180 mmHg, headaches were reported by 24.7%, and dizziness by 15.7%. Interestingly, as SBP increased, heart palpitations reports diminished with a mere 4.8% of those with SBP > 180 mmHg noting this symptom. Younger men exhibited increased chest pain and heart palpitations, while younger women more commonly reported headaches and nausea/vomiting. A significant relationship was identified between pulse pressure (PP) and symptoms, with dizziness in women and chest pain/discomfort in men being most pronounced.

CONCLUSIONS

The study underlines the importance of in-depth research on hypertensive individuals for improved symptom recognition and management. The data highlight the gender and age-specific symptom presentations and their correlation with blood pressure metrics, suggesting a need for patient-specific intervention strategies.

The relationship between epicardial adipose tissue thickness and arrhythmias in patients with hypertension: a 3.0T cardiac magnetic resonance study

OBJECTIVES

To investigate the relationship between epicardial adipose tissue (EAT) thickness using cardiac magnetic resonance imaging (CMR) and arrhythmias in hypertensive patients.

METHODS

Fifty-four hypertensive patients with arrhythmias (HTN [arrhythmias+]), 79 hypertensive patients without arrhythmias (HTN [arrhythmias-]), and 39 normal controls were retrospectively enrolled. EAT thickness was measured on cine images. Analysis of covariance with Bonferroni's post hoc correction, Pearson or Spearman analysis, receiver operating characteristic curve, and intraclass correlation coefficient analysis were performed.

RESULTS

All hypertensive patients had impaired left ventricular (LV) and left atrial (LA) myocardial deformation, and HTN (arrhythmias+) patients displayed higher LV myocardial native T1, LA volume index, and increased EAT thickness than HTN (arrhythmias-) patients and normotensive controls. The presence of LV late gadolinium enhancement (LGE) was higher in hypertensive patients with arrhythmias than in those without arrhythmias. EAT thickness metrics significantly correlated with age, systolic blood pressure, body mass index, triglycerides and high-density lipoprotein levels, LV mass index and native T1 (all p < 0.05). EAT thickness parameters were able to differentiate hypertensive patients with arrhythmias from those without arrhythmias and normal controls, and the right ventricular free wall had the highest diagnostic performance.

CONCLUSION

An accumulation of EAT thickness could further induce cardiac remodeling, promote myocardial fibrosis, and exaggerate function in hypertensive patients with arrhythmias.

ADVANCES IN KNOWLEDGE

CMR-derived EAT thickness metrics could be a useful imaging marker for differentiating hypertensive patients with arrhythmias, which might be a potential target for the prevention of cardiac remodeling and arrhythmias.

Epigenetic Mechanisms Involved in Inflammaging-Associated Hypertension

PURPOSE OF REVIEW

This review summarizes the involvement of inflammaging in vascular damage with focus on the epigenetic mechanisms by which inflammaging-induced hypertension is triggered.

RECENT FINDINGS

Inflammaging in hypertension is a complex condition associated with the production of inflammatory mediators by the immune cells, enhancement of oxidative stress, and tissue remodeling in vascular smooth muscle cells and endothelial cells. Cellular processes are numerous, including inflammasome assembly and cell senescence which may involve mitochondrial dysfunction, autophagy, DNA damage response, dysbiosis, and many others. More recently, a series of noncoding RNAs, mainly microRNAs, have been described as possessing epigenetic actions on the regulation of inflammasome-related hypertension, emerging as a promising therapeutic strategy. Although there are a variety of pharmacological agents that effectively regulate inflammaging-related hypertension, a deeper understanding of the epigenetic events behind the control of vessel deterioration is needed for the treatment or even to prevent the disease onset.

Therapeutic Feasibility of the Natural Products in the Heart Complaints: An Overview

Heart pain is the most frequent complaint leading patients to seek medical help. Functional heart symptoms, especially chest pain, are prevalent and, according to the International Classification of Diseases (ICD-10), are described as "somatoform autonomous functional disorders of the cardiovascular system." The problem lies in the fact that pain does not always have a somatic background, that is, it may be related to crucial underlying heart disease. The population does not know how to differentiate somatic pain from significant ischemic symptoms, and based on the patient's complaints, traditional medicine ends up treating other underlying cardiac diseases. Many unsuccessful unconventional therapies have been proposed in recent years, including herbal medicines that seek to disrupt the disease's pathogenesis. The present review summarizes research carried out in the last 5 years on natural products' heart complaints, including myocardial ischemia, arrhythmia, and heart failure. Several herbal medicines may be used as a replacement or complementary treatment strategy. A total of 17 medicinal plants have shown promising results in preclinical studies. However, human clinical trials are scarce; only two have been presented. Generally, the data are bland, and many issues have been raised about herbal therapies' safety, efficacy, and mode of action. Besides, relevant clinical trials, future perspectives, and possible clinical applications are discussed.

Epicardial adipose tissue predicted prolonged QTc interval in patients with arterial hypertension

Introduction: It is important to identify those at higher risk for ventricular arrhythmia among hypertensive patients. Epicardial adipose tissue (EAT) leads to electromechanical changes in the heart by endocrine and paracrine effects with cytokines and mediators. Higher amount of EAT carries the risk of QT prolongation. Therefore, we investigated the association between EAT thickness and QTc interval in patients with arterial hypertension. Methods: A total of 230 patients who previously diagnosed with arterial hypertension between February 2019 to March 2020 were included in the study. Patients with atrial fibrillation, U-wave, atrioventricular block, left anterior or posterior fascicular block, right bundle branch block, left bundle branch block, and taking QT-prolonging medication were excluded. The corrected QT (QTc) interval was calculated with Bazzet's formula following the calculated QT interval in the semi-automatic application tool. EAT was measured at the point on the free wall of the right ventricle using transthoracic echocardiography. Results: The mean age was 62.1 ± 11.4 years and 95 (41.3%) of the patients were male. QTc was over 450 ms were considered as the prolonged interval. Both groups were similar in terms of age (p = .862), gender (p = .265) and other demographic characteristics. Left ventricle mass index (LVMI) (82.5 ± 29.5 vs 91.9 ± 32.6 g/1.7.m², p = .051) and EAT thickness (5.3 ± 2.3 vs 6.6 ± 2.6 mm, p = .001) were higher in the prolonged QTc group. Serum potassium (K) level was lesser in the prolonged QTc group (4.2 ± 0.39 vs 4.1 ± 0.4 mmol/mL, p = .005). Multivariate Cox regression analysis revealed that EAT thickness [OR = 1.227, 95% CI: 1.081-1.393, p = .002] and serum K level [OR = 0.348, 95% CI: 0.157-0.772, p = .009] predicted the prolonged QTc interval, independently. Conclusion: EAT thickness predicted prolonged QTc interval in patients with arterial hypertension. Patients with higher amount of EAT should be followed by closely monitoring to prevent arrhythmic events that may develop in the future. In addition, medications that have a potential effect on QTc interval prolongation may be carefully used in patients with higher EAT thickness.