Insulin resistance is an important determinant of left ventricular mass in the obese

Insulin Resistance/Hyperinsulinemia as an Independent Risk Factor That Has Been Overlooked for Too Long

Unfortunately, cardiovascular diseases and cancers are still the leading causes of death in developed and developing countries despite the considerable progress made in the prevention and treatment of diseases. Maybe we missed something? Insulin resistance (IR) with associated hyperinsulinemia (Hypein) is a silent pandemic whose prevalence is continually growing in developed and developing countries, now exceeding 51% of the general population. IR/Hypein, despite the vast scientific literature supporting its adverse action on the development of type 2 diabetes, cardiovascular alterations, tumors, neurological disorders, and cellular senescence, is not yet considered an independent risk factor and, therefore, is not screened in the general population and adequately treated. There are now numerous substances, drugs, and natural substances that, in association with the correction of a wrong lifestyle, can help to reduce IR/Hypein. We are convinced that the time has come to implement a prevention plan against this critical risk factor. Therefore, this manuscript aims to highlight IR/Hypein as an independent risk factor for type 2 diabetes, cardiovascular diseases, cancers, cellular senescence, and neuropsychiatric disorders, supporting our conviction with the available scientific literature on the topic.

The TRIB3 R84 variant is associated with increased left ventricular mass in a sample of 2426 White individuals

BACKGROUND

Prior studies in animal models showed that increased cardiac expression of TRIB3 has a pathogenic role in inducing left ventricular mass (LVM). Whether alterations in TRIB3 expression or function have a pathogenic role in inducing LVM increase also in humans is still unsettled. In order to address this issue, we took advantage of a nonsynonymous TRIB3 Q84R polymorphism (rs2295490), a gain-of-function amino acid substitution impairing insulin signalling, and action in primary human endothelial cells which has been associated with insulin resistance, and early vascular atherosclerosis.

METHODS

SNP rs2295490 was genotyped in 2426 White adults in whom LVM index (LVMI) was assessed by validated echocardiography-derived measures.

RESULTS

After adjusting for age and sex, LVMI progressively and significantly increased from 108 to 113, to 125 g/m2 in Q84Q, Q84R, and R84R individuals, respectively (Q84R vs. Q84Q, P = 0.03; R84R vs. Q84Q, P < 0.0001). The association between LVMI and the Q84R and R84R genotype remained significant after adjusting for blood pressure, smoking habit, fasting glucose levels, glucose tolerance status, anti-hypertensive treatments, and lipid-lowering therapy (Q84R vs. Q84Q, P = 0.01; R84R vs. Q84Q, P < 0.0001).

CONCLUSIONS

We found that the gain-of-function TRIB3 Q84R variant is significantly associated with left ventricular mass in a large sample of White nondiabetic individual of European ancestry.

The common characteristics and mutual effects of heart failure and atrial fibrillation: initiation, progression, and outcome of the two aging-related heart diseases

Atrial fibrillation (AF) and heart failure (HF) are common chronic diseases noted in humans. AF and HF share several risk factors, such as age, hypertension, obesity, diabetes, and dyslipidemia. They can interact with each other, while both their morbidity and mortality have been considerably increased. And AF and HF often occur together, suggesting a strong association between the two. However, the underlying mechanism behind this association is not well understood. Among them, aging is the most significant common risk factor, which represents an aging heart and is characterized by fibrosis and decreased number of cardiomyocytes, known as senescence-related cardiac remodeling for both atria and ventricles. Finally, it is proposed that cardiac remodeling is the key link between AF and HF.

Association between insulin resistance and left ventricular hypertrophy in asymptomatic, Black, sub-Saharan African, hypertensive patients: a case-control study

Background

Conflicting information exists regarding the association between insulin resistance (IR) and left ventricular hypertrophy (LVH). We described the associations between obesity, fasting insulinemia, homeostasis model assessment of insulin resistance (HOMA-IR), and LVH in Black patients with essential hypertension.

Methods

A case–control study was conducted at the Centre Médical de Kinshasa (CMK), the Democratic Republic of the Congo, between January and December 2019. Cases and controls were hypertensive patients with and without LVH, respectively. The relationships between obesity indices, physical inactivity, glucose metabolism and lipid disorder parameters, and LVH were assessed using linear and logistic regression analyses in simple and univariate exploratory analyses, respectively. When differences were observed between LVH and independent variables, the effects of potential confounders were studied through the use of multiple linear regression and in conditional logistic regression in multivariate analyses. The coefficients of determination (R²), adjusted odds ratios (aORs), and their 95% confidence intervals (95% CIs) were calculated to determine associations between LVH and the independent variables.

Results

Eighty-eight LVH cases (52 men) were compared against 132 controls (81 men). Variation in left ventricular mass (LVM) could be predicted by the following variables: age (19%), duration of hypertension (31.3%), body mass index (BMI, 44.4%), waist circumference (WC, 42.5%), glycemia (20%), insulinemia (44.8%), and HOMA-IR (43.7%). Hypertension duration, BMI, insulinemia, and HOMA-IR explained 68.3% of LVM variability in the multiple linear regression analysis. In the logistic regression model, obesity increased the risk of LVH by threefold [aOR 2.8; 95% CI (1.06–7.4); p = 0.038], and IR increased the risk of LVH by eightfold [aOR 8.4; 95 (3.7–15.7); p < 0.001].

Conclusion

Obesity and IR appear to be the primary predictors of LVH in Black sub-Saharan African hypertensive patients. The comprehensive management of cardiovascular risk factors should be emphasized, with particular attention paid to obesity and IR. A prospective population-based study of Black sub-Saharan individuals that includes the use of serial imaging remains essential to better understand subclinical LV deterioration over time and to confirm the role played by IR in Black sub-Saharan individuals with hypertension.

Negative Impact of Obesity on Ventricular Size and Function and Exercise Performance in Children and Adolescents With Repaired Tetralogy of Fallot

BACKGROUND

Up to 25% of children with congenital heart disease are obese, which may have negative physiologic consequences for patients with repaired tetralogy of Fallot (rTOF).

METHODS

Patients with rTOF who underwent cardiac magnetic resonance (CMR) imaging and cardiopulmonary exercise testing from 2007 to 2018 were reviewed. Complex rTOF patients were excluded. Obese patients (body mass index [BMI] ≥ 95th percentile) were compared with normal-weight patients (BMI < 85th percentile). CMR data were indexed to actual body surface area (aBSA), height, and BSA assuming ideal body weight (iBSA).

RESULTS

We compared 32 obese patients matched with 64 normal-weight patients. Obese vs normal-weight patients had significantly lower right (RV; median 45% [interquartile range 42%-48%] vs 52% [47%-55%]; P < 0.0001) and left (LV; 52% [47%-56%] vs 56% [54%-60%]; P < 0.0001) ventricular ejection fractions (EFs). There were no statistically significant differences regarding aBSA-indexed volumes of the RV or LV at either end-diastole (EDV) or end-systole (ESV). However, when indexed to either height or iBSA, obese patients had significantly greater RVEDV and LVEDV, greater LV mass, and higher RV and LV stroke volumes. Obese patients had lower peak oxygen consumption and oxygen consumption at anaerobic threshold. These results did not change after adjusting for degree of pulmonary regurgitation.

CONCLUSIONS

Obesity is associated with increased biventricular size, decreased biventricular EFs, and impaired exercise performance after rTOF. These data suggest a potential role for cardiac rehabilitation for weight management and to optimize fitness.

Left ventricular myocardial mass index and its correlates as an early marker of cardiovascular risk among nonobese normotensive Indian women with polycystic ovary syndrome: lessons from a cross-sectional study

OBJECTIVE

To quantitate left ventricular mass index (LVMI) and correlate it with inflammation, insulin resistance (IR) and serum androgen levels among nonobese normotensive women with polycystic ovary syndrome (PCOS).

DESIGN

Cross-sectional study SETTING: Tertiary care institute in North India PATIENTS: A total of 260 drug-naive women qualifying the Rotterdam 2003 criteria for diagnosis of PCOS and 250 apparently healthy women matched for age and body mass index (BMI).

INTERVENTIONS

Clinical, biochemical, hormonal, and inflammatory marker assessment was followed by estimation of LVM and LVMI by 2-dimensional echocardiography.

MAIN OUTCOME MEASURES

LVM and LVMI in nonobese, normotensive women with PCOS and its correlation with subinflammation, IR, and androgen excess.

RESULTS

Mean ages (28.08 ± 4.18 vs. 29.44 ± 6.33 years) and BMI (24.43 ± 4.15 vs. 23.92 ± 4.21 kg/m²) of cases vs. controls were comparable, as was blood pressure and plasma glucose (1 hour after oral glucose tolerance test [OGTT]). Women with PCOS had fewer menstrual cycles per year and higher Ferriman-Gallwey scores, plasma insulin, homeostasis model assessment of IR, total testosterone, plasma glucose (fasting and 2 hours after OGTT), serum high-sensitive C-reactive protein, tumor necrosis factor-α, and interleukin-6 than did the controls (P<.001). Significant differences were observed in LVM (101.50 ± 30.19 vs. 89.35 ± 27.57 g) and LVMI (63.60 ± 16.67 vs. 56.32 ± 10.84 g/m²) between women with PCOS and the controls (P<.001). Multivariate analysis revealed that proinflammatory markers and IR rather than hyperandrogenism correlated with LVMI.

CONCLUSION

We conclude that normotensive nonobese women with PCOS were more likely to have elevated mean LVMI than were healthy controls and it was positively correlated with proinflammatory markers and IR but not with androgen excess. Well-designed long-term follow-up studies with a larger cohort of subjects with comprehensive cardiovascular risk assessment are warranted to conclusively answer the question.

Cardiac and Metabolic Variables in Obese Dogs

Background

The etiology of obesity‐related cardiac dysfunction (ORCD) is linked to metabolic syndrome in people. Studies have indicated that obese dogs have components of metabolic syndrome, warranting evaluation for ORCD in obese dogs.

Objectives

To evaluate cardiac structure and function and metabolic variables in obese dogs compared to ideal weight dogs.

Animals

Forty‐six healthy, small‐breed (<25 pounds), obese dogs (n = 29) compared to ideal weight dogs (n = 17).

Methods

A cross‐sectional study of cardiac structure and function by standard and strain echocardiographic measurements and quantification of serum metabolic variables (insulin:glucose ratios, lipid analysis, adiponectin, inflammatory markers).

Results

Compared to the ideal weight controls, obese dogs had cardiac changes characterized by an increased interventricular septal width in diastole to left ventricular internal dimension in diastole ratio, decreased ratios of peak early to peak late left ventricular inflow velocities, and ratios of peak early to peak late mitral annular tissue velocities, and increased fractional shortening and ejection fraction percentages. The left ventricular posterior wall width in diastole to left ventricular internal dimension in diastole ratios were not significantly different between groups. Systolic blood pressure was not significantly different between groups. Obese dogs had metabolic derangements characterized by increased insulin:glucose ratios, dyslipidemias with increased cholesterol, triglyceride, and high‐density lipoprotein concentrations, decreased adiponectin concentrations, and increased concentrations of interleukin 8 and keratinocyte‐derived chemokine‐like inflammatory cytokines.

Conclusions and Clinical Importance

Compared to ideal weight controls, obese dogs have alterations in cardiac structure and function as well as insulin resistance, dyslipidemia, hypoadiponectinemia, and increased concentrations of inflammatory markers. These findings warrant additional studies to investigate inflammation, dyslipidemia, and possibly systemic hypertension as potential contributing factors for altered cardiac function.

Review: Obesity and cardiometabolic syndrome in children

The cardiometabolic syndrome is highly prevalent among overweight youth. The risk of developing the cardiometabolic syndrome is likely triggered or exacerbated by concurrent obesity, unhealthy lifestyle/eating habits, and hormonal changes (puberty). Current screening recommendations include measurement of blood pressure, fasting insulin and glucose, and total cholesterol. However, limiting assessments to these measures underestimates cardiometabolic risk in overweight youth, particularly minorities. Early identification of cardiometabolic risk in its incipient stages may justify early and more aggressive intervention to prevent progression and complications. This review provides rationale for additional assessments to determine cardiometabolic risk in overweight youth and recommends treatment options.

Comparison of echocardiographic findings with laboratory parameters in obese children

Aim The purpose of our study was to evaluate the association between insulin resistance and left ventricular size and function in obese children. Material and methods A total of 79 cases aged 10-16 years and diagnosed with obesity and 79 healthy and non-obese cases as controls were included in the study. Patient and control groups were divided into three groups in terms of age as group 1 (10-12 years), group 2 (12-14 years), and group 3 (14-16 years). Fasting blood glucose, lipid profile, and fasting insulin levels of the cases were assessed. Mitral valve E and A waves, left ventricular ejection fraction, fractional shortening, end-diastolic and end-systolic diameters, left atrium diameter, and septal wall thickness were measured using echocardiography.

RESULTS

Measurements of septal diastolic thicknesses, left atrium diameter, and left ventricular end-systolic diameter of all the three groups obtained by echocardiography were statistically higher compared with the controls. In all the patient groups, the mitral valve E/A ratio was >1. In groups 2 and 3, there was a positive correlation between fasting insulin levels and HOMA-IR and left ventricular end-systolic diameter, end-diastolic diameter, and septal systolic and diastolic wall thicknesses.

CONCLUSION

In paediatric obesity, identification of early cardiac changes will be significant in allowing early diagnosis and treatment of cardiovascular diseases.

Prenatal programming: adverse cardiac programming by gestational testosterone excess

Adverse events during the prenatal and early postnatal period of life are associated with development of cardiovascular disease in adulthood. Prenatal exposure to excess testosterone (T) in sheep induces adverse reproductive and metabolic programming leading to polycystic ovarian syndrome, insulin resistance and hypertension in the female offspring. We hypothesized that prenatal T excess disrupts insulin signaling in the cardiac left ventricle leading to adverse cardiac programming. Left ventricular tissues were obtained from 2-year-old female sheep treated prenatally with T or oil (control) from days 30-90 of gestation. Molecular markers of insulin signaling and cardiac hypertrophy were analyzed. Prenatal T excess increased the gene expression of molecular markers involved in insulin signaling and those associated with cardiac hypertrophy and stress including insulin receptor substrate-1 (IRS-1), phosphatidyl inositol-3 kinase (PI3K), Mammalian target of rapamycin complex 1 (mTORC1), nuclear factor of activated T cells -c3 (NFATc3), and brain natriuretic peptide (BNP) compared to controls. Furthermore, prenatal T excess increased the phosphorylation of PI3K, AKT and mTOR. Myocardial disarray (multifocal) and increase in cardiomyocyte diameter was evident on histological investigation in T-treated females. These findings support adverse left ventricular remodeling by prenatal T excess.

The relationship between left ventricular mass and insulin resistance in obese patients

Objective

In this study, we investigated the relationship between left ventricular mass and insulin resistance in obese patients.

Methods

A total of 90 subjects, 66 women, and 24 men, with an age range from 24 to 56 years, were enrolled in the study. Forty-nine patients were in the obesity group whose body mass index (BMI) was >29.9 kg/m² and 41 subjects were in the control group with a BMI <25 kg/m². All of them were normotensive, nondiabetic, and did not have any cardiovascular disease. They were not taking any medication. Weight, height, and waist circumference were measured and BMI was calculated. Plasma glucose, insulin, serum total, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, and triglyceride levels were measured, and insulin resistance was calculated via homeostasis model of assessment-estimated insulin resistance (HOMA-IR). Subjects were examined by echocardiography and left ventricular mass (LVM) and index (LVMI) were calculated with Devereux formula.

Results

Insulin levels, HOMA-IR, LVM, and LVMI were significantly higher in obesity group (p < 0.01). Fasting glucose, triglyceride, fasting insulin levels, and waist circumference did not correlate with LVMI.

Conclusion

In conclusion, though findings of the present study suggest increased left ventricular hypertrophy (LVH) in obese subjects compared to controls, it appears that the increased LVM or LVH is not linked to BMI and insulin resistance in this study population.

The Cardiovascular Effects of Obesity on Ventricular Function and Mass in Patients after Tetralogy of Fallot Repair

OBJECTIVES

To determine the cardiovascular effects of obesity on patients with tetralogy of Fallot (TOF) repair.

STUDY DESIGN

Ventricular performance measures were compared between obese (body mass index [BMI] ≥95%), overweight (85% ≤BMI <95%), and normal weight subjects (BMI <85%) in a retrospective review of patients with TOF who underwent cardiac magnetic resonance from 2005-2010. Significance was P < .05.

RESULTS

Of 260 consecutive patients with TOF, 32 were obese (12.3%), 48 were overweight (18.5%), and 180 were normal weight (69.2%). Biventricular mass was increased in obese compared with normal weight patients with right ventricular mass more affected than left ventricular mass. Obese patients demonstrated decreased biventricular end-diastolic volume (EDV) and stroke volume (SV) when indexed to body surface area (BSA) with an increased heart rate when compared with normal weight patients; cardiac index, ejection fraction, and pulmonary regurgitation fraction were similar. When indexed to ideal BSA, biventricular EDV and SV were similar. EDV and SV for overweight patients were nearly identical to normal weight patients with ventricular mass in between the other 2 groups.

CONCLUSIONS

Approximately 12% of patients after TOF repair referred for cardiac magnetic resonance in a tertiary referral center are obese with increased biventricular mass. Obese patients and normal weight patients have similar cardiac indices, however, when indexed to actual BSA, obese patients demonstrate decreased EDV and SV with increased heart rate and similar cardiac indices. When indexed to ideal BSA, no differences in biventricular volumes were noted.

Disease severity and staging of obesity: a rational approach to patient selection

The increasing prevalence of obesity places ever-increasing cost demands on healthcare systems. One million individuals are eligible for bariatric surgery in the UK, and yet less than 6000 bariatric procedures are performed annually. Bariatric surgery reverses or improves almost all the medical and psychosocial co-morbidities associated with obesity. Although the BMI is a simple method to estimate adiposity at a population level, it is relatively inaccurate within an individual and provides little-to-no indication of overall health status or disease severity. Staging systems overcome the inherent limitations of BMI and allow highly informed decision-making for an individual. At a societal level, this helps to identify those most likely to gain and maximise economic benefit. This review summarises the co-morbidities associated with obesity and the evidence for their improvement following surgery. The rationale for new staging criteria and appropriate patient selection are discussed.

Independent influence of overweight and obesity on the regression of left ventricular hypertrophy in hypertensive patients: a meta-analysis

Overweight and obesity are associated with adverse cardiovascular outcomes. However, the role of overweight and obesity in left ventricular hypertrophy (LVH) of hypertensive patients is controversial. The aim of the current meta-analysis was to evaluate the influence of overweight and obesity on LVH regression in the hypertensive population.Twenty-eight randomized controlled trials comprising 2403 hypertensive patients (mean age range: 43.8-66.7 years) were identified. Three groups were divided according to body mass index: normal weight, overweight, and obesity groups.Compared with the normal-weight group, LVH regression in the overweight and obesity groups was more obvious with less reduction of systolic blood pressure after antihypertensive therapies (P < 0.001). The renin-angiotensin system inhibitor was the most effective in regressing LVH in overweight and obese hypertensive patients (19.27 g/m, 95% confidence interval [15.25, 23.29], P < 0.001), followed by β-blockers, calcium channel blockers, and diuretics. In the stratified analysis based on blood pressure measurement methods and age, more significant LVH regression was found in 24-h ambulatory blood pressure monitoring (ABPM) group and in relatively young patients (40-60 years' old) group (P < 0.01).Overweight and obesity are independent risk factors for LVH in hypertensive patients. Intervention at an early age and monitoring by ABPM may facilitate therapy-induced LVH regression in overweight and obese hypertensive patients.

Left ventricular hypertrophy and insulin resistance in adults from an urban community in The Gambia: cross-sectional study

Objective

To determine the association between left ventricular hypertrophy and insulin resistance in Gambians.

Design

Cross-sectional study.

Setting

Outpatient clinics of Royal Victoria Teaching Hospital and Medical Research Council Laboratories in Banjul.

Participants

Three hundred and sixteen consecutive patients were enrolled from outpatient clinics. The data of 275 participants (89 males) were included in the analysis with a mean (± standard deviation) age of 53.7 (±11.9) years.

Interventions

A questionnaire was filled and anthropometric measurements were taken. 2-D guided M-mode echocardiography, standard 12-1ead electrocardiogram, fasting insulin and the oral glucose tolerance test were performed.

Main Outcome Measures

The Penn formula was used to determine the left ventricular mass index, 125 g/m² in males and 110 g/m² in females as the cut-off for left ventricular hypertrophy. Using the fasting insulin and fasting glucose levels, the insulin resistance was estimated by the homeostatic model assessment formula. Logistic regression analysis was used to determine the association between left ventricular hypertrophy and insulin resistance.

Results

The mean Penn left ventricular mass index was 119.5 (±54.3) and the prevalence of Penn left ventricular mass index left ventricular hypertrophy was 41%. The mean fasting glucose was 5.6 (±2.5) mmol/l, fasting insulin was 6.39 (±5.49) μU/ml and insulin resistance was 1.58 (±1.45). There was no association between Penn left ventricular mass index left ventricular hypertrophy and log of insulin resistance in univariate (OR = 0.98, 95% CI = 0.80 – 1.19, p = 0.819) and multivariate logistic regression (OR = 0.93, 95% CI = 0.76–1.15, p = 0.516) analysis.

Conclusion

No association was found in this study between left ventricular hypertrophy and insulin resistance in Gambians and this does not support the suggestion that insulin is an independent determinant of left ventricular hypertrophy in hypertensives.

Association of cardiac changes with serum adiponectin and resistin levels in obese and overweight children

OBJECTIVES

To investigate serum adiponectin and resistin levels in childhood obesity and their relationship with cardiac changes and insulin resistance.

METHODS

Seventy-one obese and 24 overweight children and 40 healthy children and adolescents were selected for the study. Height and weight measurements, BMI values and BMI SD score values were obtained for each individual. After blood pressure measurement, left ventricular wall thickness, left ventricular mass, stroke volume, cardiac output, systolic and diastolic functions of the left ventricle were measured using an M-mode, two dimensional color-coded echocardiography device. Blood samples of the individuals were obtained for fasting blood sugar, total blood cholesterol, triglyceride, low-density lipoprotein (LDL) cholesterol, very low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, insulin, C-peptide, adiponectin and resistin values.

RESULTS

Cholesterol and LDL values, homeostasis model assessment of insulin resistance, fasting insulin and fasting C-peptide values of the obese and overweight groups were higher (P<0.01). Adiponectin level (P<0.001) and resistin level (P<0.05) of the obese and overweight groups were lower than those of the control group (P<0.05). Echocardiographic evaluation showed diastolic dysfunction in addition to increased left ventricular wall thickness and left ventricle mass values in the obese and overweight children. We also detected a significant positive correlation among left ventricular mass, interventricular septum systolic diameter and resistin in obese children. Among the factors, resistin level was determined as an independent predictor of left ventricular mass in obese children.

CONCLUSION

In this study, even in asymptomatic obese and overweight children, cardiac structural and functional changes, such as increased left ventricular mass and diastolic dysfunction, were demonstrated. Although decreased adiponectin level was not related to cardiac changes, it was shown that decreased serum resistin levels in the obese cases lead to left ventricle hypertrophy.

Obesity and Cardiac Function - The Role of Caloric Excess and its Reversal

Obesity is recognized as an independent and increasingly prevalent risk factor for cardiovascular morbidity and mortality. This stems in part from the contribution of obesity towards insulin resistance and diabetes, which associate with premature atherosclerosis, enhanced thrombogenicity and activation of systemic inflammatory programs with resultant cardiovascular dysfunction. This review will focus on the more direct mechanisms underpinning obesity-associated cardiac pathophysiology including the metabolic consequences of lipid accumulation in the myocardium and the consequences of direct systemic effects of lipid toxicity. Furthermore, there is growing recognition that metabolic intermediates, which may be perturbed with caloric excess, may play an important role in intracellular signal transduction and on the post-translational control of metabolic functioning within the heart. As strategies to reverse obesity appear to have ameliorative cardiac effects, surgical and therapeutic approaches to facilitate weight reduction this will also be discussed.

Effects of antihypertensive therapy on glucose, insulin metabolism, left ventricular diastolic dysfunction and renin system in overweight and obese hypertensives

BACKGROUND

We attempted to test the hypothesis that the direct renin inhibitor aliskiren can improve diastolic dysfunction, glucose, and insulin metabolism (GIM) in overweight and obese hypertensive patients.

METHODS AND RESULTS

Seventy-eight hypertensive patients were divided into two groups: 38 treated with aliskiren for six months, and 40 treated without aliskiren but with only traditional anti-hypertensive therapy, as controls. Doppler mitral flow velocity patterns were assessed before and after aliskiren during a six-month period. GIM (three-hour intravenous glucose tolerance test) was measured after four to six weeks of washout and six months of treatment. The mitral E/A ratio increased from 0.65 ± 0.11 to 0.75 ± 0.19. None of the indexes changed in the control group. In the control group, GIM parameters, fasting glucose levels (5.3 ± 0.9 to 6.0 ± 1.5 mmol/l; p = 0.003), fasting insulin levels (121 ± 121 to 189 ± 228 pmol/l; p = 0.03), and most other relevant metabolic measures (p < 0.05 for all) significantly worsened. Aliskiren did not affect GIM. In the control group LVM/height was not affected (119 ± 12 to 120 ± 17 g/m; p = 0.8), whereas aliskiren significantly reduced LVM/height (120 ± 13 to 111 ± 19 g/m; p = 0.04).

CONCLUSIONS

Optimal target BP was achieved in the group as a whole and in both obese patient groups, while benefits to cardiac structure were of a smaller magnitude. In high-risk, overweight/obese patients with hypertension, traditional therapy provides significantly greater BP- versus aliskiren-lowering throughout the 24-hour dosing interval. Therefore in obese, hypertensive individuals, adequate and similar blood pressure control was achieved with aliskiren; however, the aliskiren group and not the control group was associated with a more favorable GIM profile and led to a significant regression of LVM; overall aliskiren-based treatment offers sustained control of PRA.

The influence of body composition, fat distribution, and sustained weight loss on left ventricular mass and geometry in obesity

Alterations in left ventricular mass and geometry vary along with the degree of obesity, but mechanisms underlying such covariation are not clear. In a case-control study, we examined how body composition and fat distribution relate to left ventricular structure and examine how sustained weight loss affects left ventricular mass and geometry. At the 10-year follow-up of the Swedish obese subjects (SOS) study cohort, we identified 44 patients with sustained weight losses after bariatric surgery (surgery group) and 44 matched obese control patients who remained weight stable (obese group). We also recruited 44 matched normal weight subjects (lean group). Dual-energy X-ray absorptiometry, computed tomography, and echocardiography were performed to evaluate body composition, fat distribution, and left ventricular structure. BMI was 42.5 kg/m(2), 31.5 kg/m(2), and 24.4 kg/m(2) for the obese, surgery, and lean groups, respectively. Corresponding values for left ventricular mass were 201.4 g, 157.7 g, and 133.9 g (P < 0.001). In multivariate analyses, left ventricular diastolic dimension was predicted by lean body mass (β = 0.03, P < 0.001); left ventricular wall thickness by visceral adipose tissue (β = 0.11, P < 0.001) and systolic blood pressure (β = 0.02, P = 0.019); left ventricular mass by lean body mass (β = 1.23, P < 0.001), total body fat (β = 1.15, P < 0.001) and systolic blood pressure (β = 2.72, P = 0.047); and relative wall thickness by visceral adipose tissue (β = 0.02, P < 0.001). Left ventricular adjustment to body size is dependent on body composition and fat distribution, regardless of blood pressure levels. Obesity is associated with concentric left ventricular remodeling and sustained 10-year weight loss results in lower cavity size, wall thickness and mass.

Non-alcoholic fatty liver disease is independently associated with left ventricular hypertrophy in hypertensive Type 2 diabetic individuals

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) and left ventricular hypertrophy (LVH) are highly prevalent in Type 2 diabetes and both conditions are associated with an increased risk of incident cardiovascular disease. The aim of this study is to evaluate whether there is an association between NAFLD and echocardiographically detected LVH in Type 2 diabetes.

METHODS

We studied 116 consecutive patients with hypertension and Type 2 diabetes after excluding those with pre-existing history of cardiovascular disease, advanced kidney disease, excessive alcohol consumption and other known causes of chronic liver disease (e.g., virus, medications, autoimmunity, iron overload). NAFLD was diagnosed by means of ultrasonography, whereas LVH was diagnosed by means of conventional trans-thoracic echocardiography in all patients.

RESULTS

The prevalence of LVH was markedly higher among diabetic patients with NAFLD than among those without this disease (82% vs 18%; p=0.01). Multivariate logistic regression analysis revealed that NAFLD was associated with LVH independently of age, sex, body mass index, systolic blood pressure, glycated hemoglobin, duration of diabetes, and parameters of kidney function.

CONCLUSIONS

Our findings suggest that hypertensive Type 2 diabetic patients with NAFLD have a remarkably higher frequency of LVH than do hypertensive diabetic patients without steatosis, and that NAFLD is associated with LVH independently of classical cardiovascular risk factors and other potential confounders.

Sex differences in obesity-related changes in left ventricular morphology: the Strong Heart Study

OBJECTIVES

It is unclear whether there are sex differences in the relations of left ventricular mass to body composition and fat distribution in nonobese or obese hypertensive and nonhypertensive individuals and whether the obesity-related increase in left ventricular mass is similar in men and women.

METHODS

We examined sex differences in the relations between left ventricular mass and both body composition and fat distribution, in the presence or absence of obesity in 1068 men and 1851 women (65%) of the Strong Heart Study cohort, without prevalent cardiovascular disease or severe chronic kidney disease. Fat-free mass (FFM) and adipose mass were estimated by bioelectric impedance analysis and fat distribution by waist-to-hip ratio (WHR).

RESULTS

Adipose mass was significantly higher in women than in men for any weight category (P < 0.0001). After adjusting for age, hypertension, systolic blood pressure (BP) and diabetes, both left ventricular mass/height (LVMi) and left ventricular mass (LVM)/FFM were greater in obese women than obese men (P < 0.0001). Relative wall thickness was also greater in women than in men (P < 0.0001). LVM was independently related to Doppler-stroke volume, FFM and systolic BP in both sexes, with WHR and adipose mass contributing to variance of LVM in women but not in men (both P < 0.03).

CONCLUSION

Obesity influences left ventricular geometry substantially more in women than in men, possibly due to biological factors specifically associated with female adiposity.

Diabetes and the risk of heart failure

Prevalence of diabetes and heart failure are increasing exponentially worldwide. Diabetes is well-known to increase the risk of heart failure independent of other traditional risk factors and ischemia. Current evidence indicates the presence of several biochemical and molecular changes associated with diabetes that lead to diastolic dysfunction or American Heart Association stage B heart failure. Some, if not all, changes may also predate the development of frank diabetes. In this review, the authors present some of the epidemiologic evidence and a brief description of major mechanistic pathways that favor the development of heart failure in prediabetic and diabetic states.

Impact of 6-year body weight change on cardiac geometry and function in ageing adults: the SUpplémentation en Vitamines et Minéraux AntioXydants -2 (SU.VI.MAX-2) cardiovascular ultrasound substudy

BACKGROUND AND OBJECTIVE

Although the relationships between BMI and cardiac geometry and function have been established, information remains limited on the impact of BMI, waist circumference and body composition variations over time on echocardiographic changes in ageing adults.

METHODS AND RESULTS

Multiple linear regressions were used to correlate cardiac echographic parameters and baseline anthropometric data and their changes over 6 years in 280 participants of the SU.VI.MAX 2 cohort study. During the follow-up, BMI increased by 0.6 (95% confidence interval: 0.3-0.8) kg/m, waist circumference by 2.3 (1.6-3.0) cm and percentage body fat mass (%BFM) by 4.0 (3.4-4.6) %. A 6-year change (2001-2007) by 1 kg/m in BMI or 1 cm in waist circumference was associated with an increase in indexed left ventricular mass by 2.3 g/m (1.3-3.3, P < 0.001) and 0.4 g/m (0.06-0.6, P < 0.017), respectively, and an increase in left atrial area by 0.3 cm (0.1-0.5, P < 0.001) and 0.05 cm (0.003-0.10, P < 0.037), respectively. Follow-up left ventricular mass and left atrial area were not impacted by changes in percentage body fat mass. A significant correlation was observed between E-wave transmitral flow deceleration time and baseline BMI and waist circumference, but not with their changes over time.

CONCLUSION

Changes in anthropometric markers over time are associated with increased left ventricular mass and left atrial size. These findings reinforce the potential benefit of a healthy diet and lifestyle to maintain body weight and, in turn, cardiac geometry and function in ageing adults.

Systemic hemodynamics in young adults with the metabolic syndrome: the Cardiovascular Risk in Young Finns Study

OBJECTIVE

We conducted the present study to examine associations of three different metabolic syndrome (MetS) definitions and their components to arterial stiffness, systemic vascular resistance, and left ventricular function at population level. In addition, the objective of the study was to examine associations of spontaneous recovery from MetS over 6 years' follow-up to systemic hemodynamics.

METHODS

The study population consisted of 1,741 Finnish young adults (aged 30-45 years) who had complete MetS risk factor and hemodynamic data available at 2007. Associations of spontaneous recovery from MetS to systemic hemodynamics was studied on a subpopulation of 1,391 subjects who had also complete MetS risk factor data available at 2001. Hemodynamic measurements were performed using a whole-body impedance cardiography device.

RESULTS

MetS and increasing number of MetS components were associated with lower stroke index (P < 0.001) and higher systemic vascular resistance index (P < 0.005) and arterial pulse wave velocity (P < 0.005). In MetS persistent group, stroke index was lower (P = 0.024), and pulse wave velocity was higher (P = 0.003) compared to MetS recovery group.

CONCLUSION

All current MetS definitions identify young adults with altered systemic hemodynamics, and recovery from MetS is associated with a favorable hemodynamic profile.

Early echocardiography abnormalities in obese children and adolescent and reversibility of these abnormalities after significant weight reduction

BACKGROUND

Obesity is becoming an epidemic threat for the individual and society. The increasing prevalence of overweight children and adolescents is likely to have a great impact on the future cardiovascular health of these subjects. Obesity is a strong risk factor for cardiovascular morbidity and mortality. Cardiac abnormalities of obese children and adolescents include the echocardiographically revealed early and preclinical LV or septal hypertrophy, and left or right ventricular dysfunction. Most of these abnormalities, which are usually more pronounced in patients with morbid obesity, can be partially reversed after weight reduction.

AIM OF THE STUDY

Evaluate early echocardiography changes in obese children and whether these cardiac abnormalities reverse with significant weight reduction in children and adolescents or not.

METHODS

We started this study by 50 obese children and adolescents and 30 non obese controls matched for age and sex. BMI was calculated. Complete echocardiographic study was performed on each patient and control subject. Hematological and biochemical variables were determined in the obese subjects from fasting blood samples and included glucose, total cholesterol, triglycerides (TG), HDL cholesterol and LDL cholesterol. All our patients' strict dietetic regime with exercises for 6 months. After 6 months full examination, including all measurements and echocardiography and laboratory investigations were done again.

RESULTS

Obese children has abnormalities of left ventricle structure and function (consisting of increased left ventricular wall dimensions and mass and alteration of diastolic function) that can be detected by echocardiography. Furthermore, (parameters of lipid metabolism) were found to be independent predictors of adverse LV remodeling and of diastolic dysfunction. As well as this study provides evidence that abnormalities of left ventricular wall dimension and mass in obese children and adolescents can improve with significant weight reduction.

CONCLUSION

This study has demonstrated that young, obese children and adolescents have early significant changes in left ventricular wall dimensions and early diastolic filling compared with non obese and this changes are reversible with weight reduction.

Symmetric and asymmetric left ventricular hypertrophy in patients with end-stage renal failure on long-term hemodialysis

BACKGROUND

Patients with end-stage renal disease on regular hemodialysis have an increased prevalence of left ventricular (LV) hypertrophy that is associated with morbidity and mortality. Asymmetric septal hypertrophy and impairment of LV outflow can occur in these patients and may contribute to adverse outcomes. More insight into the prevalence, extent, geometry, and promoting factors of LV hypertrophy is important.

METHODS

An unselected group of 62 patients (31 women), aged 55 +/- 14 years, on maintenance hemodialysis was investigated by Doppler echocardiography. Eight patients with valvular heart disease were excluded from further analysis. We assessed prevalence of LV hypertrophy and asymmetric septal hypertrophy, as well as parameters of LV geometry and LV filling and outflow dynamics.

RESULTS

Prevalence of LV hypertrophy was 65%. Patients were analyzed according to LV mass and geometry. Mean LV mass index was normal (105 +/- 17 g/m2) in Group 1 without LV hypertrophy (n = 19); it was markedly elevated in Group 2 (symmetric hypertrophy, n = 22) and Group 3 (asymmetric hypertrophy with systolic anterior movement of mitral valve, n = 7), and highest (191 +/- 54 g/m2) in Group 4 (asymmetric hypertrophy without systolic anterior movement of mitral valve, n = 6, p < 0.001). Age, body mass index, and duration of hypertension were associated with LV hypertrophy and asymmetric septal hypertrophy (p = 0.01). Group 3 with systolic anterior motion of mitral valve had the smallest end-diastolic LV diameters (p = 0.02); increased heart rates, and increased ejection velocities in the LV outflow tract (p = 0.03, and p = 0.005, respectively, vs. Groups 1, 2, and 4) which pointed to an impairment of LV outflow.

CONCLUSIONS

Symmetric LV hypertrophy and asymmetric septal hypertrophy are frequent in patients on maintenance hemodialysis. Predictors for LV hypertrophy were age and body mass index, and, particularly for asymmetric septal hypertrophy, age and hypertension duration. Volume withdrawal during hemodialysis may lead to symptomatic hypotension due to dynamic obstruction in some patients with severe asymmetric septal hypertrophy.

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

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

Prolonged caloric restriction in obese patients with type 2 diabetes mellitus decreases myocardial triglyceride content and improves myocardial function

OBJECTIVES

This study sought to assess the effects of prolonged caloric restriction in obese patients with type 2 diabetes mellitus (T2DM) on myocardial triglyceride (TG) content and myocardial function.

BACKGROUND

Myocardial TG content is increased in patients with T2DM and may reflect altered myocardial function. It is unknown whether myocardial TG content is influenced during a therapeutic intervention.

METHODS

Myocardial TG content (magnetic resonance [MR] spectroscopy), myocardial function (MR imaging), plasma hemoglobin A1c, and body mass index (BMI) were measured in 12 obese, insulin-treated T2DM patients before and after a 16-week very-low-calorie diet (VLCD) (450 kcal/day) to achieve substantial weight loss. Insulin was stopped during the VLCD.

RESULTS

The BMI decreased from 35.6 +/- 1.2 kg/m(2) (baseline, mean +/- SEM) to 27.5 +/- 1.3 kg/m(2) (after the VLCD, p < 0.001) and was associated with an improvement in hemoglobin A1c from 7.9 +/- 0.4% (baseline) to 6.3 +/- 0.3% (after the VLCD, p = 0.006). Myocardial TG content decreased from 0.88 +/- 0.12% to 0.64 +/- 0.14%, respectively (p = 0.019), and was associated with improved diastolic function (reflected by the ratio between the early and atrial filling phase) from 1.02 +/- 0.08 to 1.18 +/- 0.06, respectively (p = 0.019).

CONCLUSIONS

Prolonged caloric restriction in obese T2DM patients decreases BMI and improves glucoregulation associated with decreased myocardial TG content and improved diastolic heart function. Therefore, myocardial TG stores in obese patients with T2DM are flexible and amendable to therapeutic intervention by caloric restriction.

Early cardiac abnormalities in obese children: importance of obesity per se versus associated cardiovascular risk factors

We investigated whether obese children and adolescents have early echocardiographic signs of subclinical cardiac dysfunction and evaluated the respective influence of obesity per se versus parameters of carbohydrate and lipid metabolism that are frequently abnormal in obese subjects. The role of tissue Doppler imaging as a screening tool for these abnormalities was explored. Blood pressure and echocardiographic parameters, including tissue Doppler measurements of the septal mitral annulus were evaluated in 49 obese children and adolescents and 45 age and sex matched controls. The respective influence of obesity versus parameters of carbohydrate and lipid metabolism was examined with linear regression analysis. Obese subjects showed significantly larger left ventricular wall dimensions (posterior wall, septum, and left ventricular mass index) and signs of early diastolic filling abnormalities on conventional and tissue Doppler echocardiography compared with nonobese subjects. Multiple regression analysis showed that mainly BMI-SD scores and/or body surface area explained significant proportions of the variance of the early cardiac abnormalities. In conclusion, young, obese children and adolescents have significant changes in left ventricular wall dimensions and early diastolic filling compared with nonobese subjects. Obesity per se and not the parameters of carbohydrate and lipid metabolism predicted the early cardiac abnormalities.

Relation of childhood risk factors to left ventricular hypertrophy (eccentric or concentric) in relatively young adulthood (from the Bogalusa Heart Study)

Left ventricular (LV) structural alterations were associated with increased cardiovascular morbidity and mortality in a middle-aged and older population. The aim of this study was to determine childhood and adulthood cardiovascular risk predictors of LV geometric remodeling in a biracial (black-white) population of young adults. As part of the Bogalusa Heart Study, echocardiographic examinations of the heart were performed in 824 adults (age range 24 to 44 years, average 36; 41% men, 69% white) who had risk-factor variables in their childhood. Eccentric LV hypertrophy and concentric remodeling were the most commonly encountered LV geometric changes in this young adult population (4.7% vs 1.8% for concentric LV hypertrophy). In adulthood, subjects with eccentric and/or concentric LV hypertrophy compared with normal geometry were more likely to be obese and/or diabetic and had significantly increased body mass index, waist circumference, systolic and diastolic blood pressures, glucose, insulin, hemoglobin A1c, total/high-density lipoprotein cholesterol ratio, triglycerides, and urinary albumin-creatinine ratios. In multinomial logistic regression analyses, both adulthood and childhood body mass index were significant determinants of eccentric LV hypertrophy (odds ratios [ORs] 1.15 and 1.19). The presence of diabetes mellitus in adulthood (OR 8.25) and diastolic blood pressure in childhood (OR 1.14) were significant predictors of concentric LV hypertrophy. In adults, blacks had higher ORs for concentric LV hypertrophy and related to diabetes and systolic blood pressure. In conclusion, in this community-based study of young adults, eccentric LV hypertrophy was more frequent and obesity since childhood was the only consistent and significant determinant of this type of adverse cardiac remodeling.

Sex-specific determinants of left ventricular mass in pre-diabetic and type 2 diabetic subjects: the Augsburg Diabetes Family Study

OBJECTIVE

Obesity and hypertension are regarded as the most important determinants of left ventricular mass in the community. Little is known about sex-specific influences of obesity, hypertension, and other risk factors on left ventricular mass in pre-diabetic or diabetic subjects.

RESEARCH DESIGN AND METHODS

We examined how body composition, blood pressure, and other factors are related to left ventricular structure in elderly subjects (mean age 62 years, 88% of women postmenopausal) with pre-diabetes (impaired fasting glucose or impaired glucose tolerance; n = 112) and diabetes with (n = 181) and without (n = 213) overt cardiovascular disease (CVD).

RESULTS

Neither microalbuminuria nor physical activity was significantly associated with left ventricular mass. In pre-diabetic as well as diabetic subjects with CVD, mainly BMI and fat mass, particularly in women, were correlated with left ventricular mass. In the diabetic group without overt CVD, fat mass was only slightly correlated with left ventricular mass. In the latter group waist-to-hip-ratio, and, only in men, systolic blood pressure, glucose, and A1C were moderately correlated with left ventricular mass. Multiregression analysis over all groups again revealed fat mass as the main determinant of left ventricular mass in women. In women but not men obesity was associated with a significantly increased prevalence of concentric left ventricular hypertrophy.

CONCLUSIONS

In pre-diabetic and diabetic elderly subjects fat mass is the major determinant of left ventricular mass in women but not in men. These results may partly explain sex differences in CVD mortality in obese elderly diabetic subjects and underscore the need for activities focused on weight reduction.

Reduced left ventricular mass after treatment of obese patients with sibutramine: An echocardiographic multicentre study

AIM

In obesity, left ventricular hypertrophy is frequently observed, especially in the presence of hypertension. Following body weight reduction, the left ventricular mass (LVM) is reduced. It is not known to which extent this occurs after treatment with sibutramine.

METHODS

In this multicentre trial, 195 male and female patients (18-65 years of age, body mass index 30-40 kg/m2) were treated for 12 weeks with either 15 mg/day sibutramine or placebo. They were advised to follow mildly hypocaloric reducing diets. Exclusion criteria were blood pressure values >180/110 mmHg and tachycardia (heart rate > or =100 beats/min). Echocardiography in M-mode was performed to determine LVM as well as systolic function.

RESULTS

Body weight was reduced by 6.9 +/- 0.3 kg under sibutramine and by 2.1 +/- 0.6 kg under placebo; body fat was reduced by 5.2 +/- 0.4 kg and 1.6 +/- 0.7 kg respectively. In the sibutramine group, LVM was reduced by 10.9 +/- 24.2 g; LVM indexed for body surface area was reduced by 2.3 +/- 11.8 g/m2 and LVM indexed for body height was reduced by 2.5 +/- 6.0 g/m(2.7). In the placebo group, LVM and LVM indices were not significantly changed. Changes in LVM correlated with reductions in body weight and initial LVM but not with changes in blood pressure or heart rate.

CONCLUSIONS

After 3 months of treatment with sibutramine, obese patients lost about three times as much of body weight and LVM than patients treated with placebo. Therefore, sibutramine may be recommended not only to reduce body weight but also to obtain a regression of the LVM in obese patients with and without hypertension.

Obesity and insulin resistance: Effects on cardiac structure, function, and substrate metabolism

It is widely recognized that obesity and insulin resistance can contribute to an increased risk of coronary disease, but it has also become increasingly apparent that they may contribute directly to cardiac dysfunction even in the absence of significant coronary disease. Recently, obesity, which is frequently accompanied by insulin resistance, has been independently related to clinically diagnosed heart failure. Thus, there is renewed interest in the pathophysiology of myocardial disease related to obesity and insulin resistance, as well as in the specific cellular mechanisms by which obesity may cause detrimental cardiac structural and functional changes. Alterations in hemodynamics, plasma volume, neurohormonal status, and myocardial substrate metabolism all appear to contribute to these changes. Improving our understanding of cardiac dysfunction related to obesity and insulin resistance may provide clues for new strategies to prevent and treat this alarmingly prevalent condition.

Cardiac abnormalities as a new manifestation of nonalcoholic fatty liver disease: echocardiographic and tissue Doppler imaging assessment

Nonalcoholic fatty liver disease (NAFLD) is linked to the metabolic syndrome. The aim of the present study is to determine the effect of the metabolic syndrome on left ventricular (LV) geometry and function using as a model patients with NAFLD. Thirty-eight patients with NAFLD, less than 55 years of age and with a normal exercise test, were compared with an age and sex-matched control group. Patients with diabetes mellitus, hypertension, and body mass index>40 were excluded. A complete echocardiographic study including tissue Doppler imaging (TDI) was performed. The following parameters were assessed by echo Doppler: peak velocities of early (E) and late (A) diastolic filling, E/A ratio, flow propagation velocity (Vp). Using TDI early diastolic velocity (E'), and systolic velocity (S') of mitral annulus were obtained. The patients with NAFLD had a significantly higher body mass index (31.4+/-5 vs. 26.4+/-4 kg/m, P=0.01), higher glucose (100.6+/-13 vs. 83.0+/-10 mg/dL, P=0.01), and triglyceride levels (126.5+/-44 vs. 206.5+/-67 mg/dL, P<0.001). Increased thickness of the intraventricular septum, posterior wall (11.03+/-2.2 vs. 8.9+/-2.9 mm, P=0.001; 8.5+/-1.7 vs. 9.7+/-2.3 mm, P=0.04), and larger LV mass and LV mass/height (160.7+/-58.7 vs.115.3+/-35.4 g, P=0.001 and 92.6+/-29.5 vs. 69.2+/-19.8 g/m, P=0.001, respectively) were found in NAFLD group. LV systolic function was similar in both groups. Patients with NAFLD had a lower E (73.6+/-11.0 vs. 86.4+/-20.0 cm/s, P<0.006) and E/A ratio (1.0+/-0.3 vs. 1.76+/-0.8 P<0.0001). Moreover, the Vp and the E' on TDI were significantly lower compared with the control group (49.0+/-9.7 vs. 74.7+/-18.4 cm/s, P<0.0001 and 10.3+/-2.0 vs. 13.8+/-1.7 cm/s, P<0.0001, respectively). On multivariate analysis the E' on TDI was the only independent parameter associated with NAFLD. In conclusion, patients with NAFLD in the absence of morbid obesity, hypertension, and diabetes have mildly altered LV geometry and early features of left ventricular diastolic dysfunction. Early diastolic velocity on TDI was found to be the only index that could identify the patients with NAFLD and metabolic syndrome.

Regression of cardiac hypertrophy in type 2 diabetes with hypertension by candesartan

This study was designed to compare the effect of candesartan on cardiac left ventricular mass in Japanese patients with that of amlodipine. A total of 40 type 2 diabetic patients with hypertension and left ventricular hypertrophy (LVH) were randomly assigned to receive candesartan (n=20) or amlodipine (n=20). The two treatments when administered for 6 months significantly reduced systolic and diastolic blood pressures (BPs) to a comparable extent. Notably, candesartan significantly reduced left ventricular mass index (LVMI: from 131.5+/-4.5 to 112.1+/-5.9g/m(2), P=0.0009, M+/-S.E.M.), LV posterior wall thickness (PWTd: from 10.3+/-0.3 to 9.1+/-0.3mm, P=0.0052) and interventricular septal thickness (IVSTd: from 10.7+/-0.4 to 9.3+/-0.4mm, P=0.0019) as determined by echocardiography in diastole, but amlodipine treatment did not. LVMI, PWTd and IVSTd were decreased more significantly by the treatment with candesartan than by that with amlodipine (P=0.020, 0.031 and 0.043). The present study thus revealed that candesartan effectively induced regression of LVH in type 2 diabetic patients with hypertension due to effects beyond reduction in BP.

The effect of obesity on echocardiographic and metabolic parameters in childhood

BACKGROUND

Obese children are predisposed to left ventricular (LV) hypertrophy and cardiac dysfunction. We evaluated ventricular function of obese children with conventional echocardiography and tissue Doppler imaging (TDI) and correlated these with fasting serum glucose, lipid and insulin levels.

METHODS

Thirty obese children were examined by conventional echocardiography and TDI and compared with an age-matched control group. In the obese children, fasting serum glucose, lipid, and insulin levels were obtained.

RESULTS

Systolic and diastolic function of the LV was normal in obese children. LVM/ht2.7 (LVM normalized for height), relative wall thickness (RWT), and LV end-diastolic diameter were significantly greater in obese children. The early to late relaxation velocity ratio (E/A) determined by TDI for the right ventricle and interventricular septum (IVS) were significantly lower in the obese group, LVM/ht2.7 and RWT correlated with body mass index (BMI). In the obese group, IVS and LV posterior wall thickness correlated with insulin, very low density lipoprotein, and triglyceride levels. However, we failed to show this correlation when these measurements were indexed to height.

CONCLUSION

Left ventricular hypertrophy, as evidenced by increased LV mass, was present in obese children. Higher BMI, insulin, very low density lipoprotein, and triglyceride levels were associated with LV hypertrophy. TDI revealed subclinical changes in diastolic function of the right ventricle and IVS.

Glucose metabolism in patients with essential hypertension

PURPOSE

Arterial hypertension is an insulin-resistant condition that has been associated with an increased incidence of diabetes. We assessed the prevalence of glucose abnormalities in a population of patients with essential hypertension.

METHODS

In this cross-sectional study, 420 consecutively referred essential hypertensive patients were studied at 16 hypertension clinics in university and community hospitals of Spain. Fasting and 2-hour plasma glucose and insulin levels were determined in nondiabetic patients.

RESULTS

An abnormal glucose metabolism was diagnosed in 68.5% (95% confidence interval [CI], 63.7%-72.9%) of the patients. Isolated insulin resistance, defined by a homeostasis model assessment-estimated insulin resistance (HOMA-IR) equal to or above 3.8, was shown in 9.3% (95% CI, 6.7%-12.5%); impaired fasting glucose in 11.2% (95% CI, 8.6%-14.7%); impaired glucose tolerance in 22.5% (95% CI, 18.5%-26.9%); silent undiagnosed type 2 diabetes in 11.5% (95% CI, 8.6%-14.5%); and known diabetes mellitus in 13.9% (95% CI, 10.4%-17.2%) of the patients. According to the European Group for the Study of Insulin Resistance and the Adult Treatment Program III criteria, the metabolic syndrome was diagnosed in 41.5% (95% CI, 35.9%-47.3%) and 47.9% (95% CI, 43.1%-52.8%) of the patients, respectively. The prevalence of left ventricular hypertrophy (defined by a left ventricular mass index [LVMI] >125 g/m2 was 44.2%. The relation between HOMA-IR and LVMI was statistically nonsignificant, and the LVMI values in the HOMA-IR quartiles were similar. Only 27 patients (6.4%) showed good control of cardiovascular risk factors. In most patients (273, 65%; 95% CI, 60.3%-69.4%) 2 or more cardiovascular risk factors were identified as not being under control.

CONCLUSIONS

Two thirds of the patients attending hypertension clinics with essential hypertension show an abnormal glucose metabolism. The metabolic syndrome can be identified in a substantial number of these patients, and 2 or more cardiovascular risk factors are not controlled in the majority of patients.

Myocardial collagen turnover in normotensive obese patients: relation to insulin resistance

OBJECTIVES

The present study was undertaken to assess the differential impact of insulin resistance, leptin and body composition on myocardial mass and serum markers of cardiac fibrosis in obese subjects, within a small range of elevated BMI (30-40 kg/m(2)), without pulmonary disease, cardiovascular disease, hypertension, cardiac hypertrophy or other cardiovascular disease.

BACKGROUND

Obesity is an independent predictor of left ventricular mass (LVM) and is associated with disturbances in cardiac structure. The extent of the interstitial fibrosis in obese patients is not known, especially in the absence of cardiac hypertrophy.

METHODS AND RESULTS

We included 160 obese subjects. The LVM was obtained using the Devereux formula. Body composition was estimated from a total body scan. Insulin sensitivity was assessed by homeostasis model assessment (HOMA), and cardiac collagen turnover by measurement of procollagen type III aminopeptide (PIIINP). PIIINP was correlated to the E/A ratio (r=0.24; P=0.012), a marker of ventricular function. PIIINP was independently correlated with glucose concentration (r=0.27; P=0.004), indexes of insulin resistance (HOMA (r=0.27; P=0.003), insulin (r=0.24; P=0.008)), and parameters associated with the insulin-resistance syndrome (HDL-cholesterol r=-0.27; P=0.004) and fat trunk/fat leg ratio (r=0.24; P=0.053)). The variable most correlated with PIIINP was HDL-cholesterol, followed by HOMA (r (2)=0.13). When HOMA was substituted for blood glucose concentration and insulinemia (Model 2), HDL-cholesterol was strongly related to lower PIIINP levels, followed by higher glucose concentration (r (2)=0.21). Regression analyses showed that LVM had the strongest independent positive correlation with fat-free mass (FFM) (r=0.39; P=0.0002), followed by systolic blood pressure (r=0.19; P=0.034). Neither adipose mass nor height independently added information to multivariate models. The ratio leptin/fat mass was correlated with LVM (r=-0.27; P=0.004), but not independently of the FFM. Markers for fibrosis were not significantly correlated with LVM. As a result, FFM was the most predictive factor of LVM in obese subjects.

CONCLUSION

We found that serum levels of markers of cardiac collagen synthesis were significantly associated with insulin resistance in normotensive, nondiabetic obese subjects, and not related to the LVM. As a result, PIIINP could be a very early marker of ventricular dysfunction in these patients. Furthermore, we suggest that, for better detection of left ventricle hypertrophy in obese subjects, LVM should be indexed to FFM rather than to body surface area, or height.

Obesidade visceral, hipertensão arterial e risco cárdio-renal: uma revisão

A maior parte da adversidade atribuída à obesidade é dada pelo risco cardiovascular/coronariano imputado à mesma, particularmente presente nos obesos com distribuição visceral de gordura corporal. O acúmulo de gordura visceral está sabidamente associado à maior prevalência de desarranjos metabólicos, hormonais, inflamatórios e hemodinâmicos, que no conjunto implicarão em maior acometimento da microvasculatura e impacto negativo sobre os órgãos-alvo, particularmente sobre o eixo cárdio-renal. Neste sentido, além da associação clássica com a doença coronariana, têm-se verificado uma associação maior da obesidade visceral com a hipertrofia ventricular esquerda e microalbuminúria, ambos fatores de risco cardiovascular e nefrológico reconhecidos. Assim, a abordagem terapêutica dos pacientes obesos, particularmente dos hipertensos, deve levar em conta a estratificação de risco baseada na distribuição de gordura corporal, o que permitirá uma terapêutica mais adequada, visando-se não só o controle dos fatores de risco como a monitorização do acometimento de órgãos-alvo nestas populações.

Metabolic syndrome and target organ damage in untreated essential hypertensives

BACKGROUND

The prevalence and the relationship between metabolic syndrome, and target organ damage (TOD) in essential hypertensive patients has not been fully explored to date.

OBJECTIVE

To investigate the association between metabolic syndrome, as defined by the ATP III report, and cardiac and extracardiac TOD, as defined by the 2003 ESH-ESC guidelines for management of hypertension, in a large population of never-treated essential hypertensives.

METHODS

A total of 447 grade 1 and 2 hypertensive patients (mean age 46 +/- 12 years) who were attending a hypertension hospital outpatient clinic for the first time underwent the following procedures: (i) physical examination and repeated clinic blood pressure measurements; (ii) routine examinations; (iii) 24-h urine collection for microalbuminuria; (iv) 24-h ambulatory blood pressure monitoring; (v) echocardiography; and (vi) carotid ultrasonography. Metabolic syndrome was defined as involving at least three of the following alterations: increased waist circumference, increased triglycerides, decreased high-density lipoprotein cholesterol, increased blood pressure, or high fasting glucose. Left ventricular hypertrophy (LVH) was defined according to two different criteria: (i) 125 g/m in men and 110 g/m in women; (ii) 51 g/h in men and 47 g/h in women.

RESULTS

The 135 patients with metabolic syndrome (group I) were similar for age, sex distribution, known duration of hypertension and average 24-h, daytime and night-time ambulatory blood pressure to the 312 patients without it (group II). The prevalence of altered left ventricular patterns (LVH and left ventricular concentric remodelling) was significantly higher in group I (criterion a = 30%, criterion b = 42%) than in group II (criterion a = 23%, criterion b = 30%, P < 0.05 and P < 0.01, respectively). A greater urinary albumin excretion (17 +/- 35 versus 11 +/- 23 mg/24 h, P = 0.04) was also found in group I compared to group II. There were no significant differences between the two groups in the prevalence of carotid intima-media thickening and plaques.

CONCLUSIONS

These results from a representative sample of untreated middle-aged hypertensives show that: (i) the metabolic syndrome is highly prevalent in this setting and (ii) despite similar ambulatory blood pressure values, patients with metabolic syndrome have a more pronounced cardiac and extracardiac involvement than those without it.

Nutritional modulation of parathyroid hormone secretion may influence risk for left ventricular hypertrophy

Recent studies demonstrate low serum levels of 25-hydroxyvitamin D in patients with congestive heart failure (CHF). Although this may in part reflect reduced capacity for outdoor exercise, the possibility that poor vitamin D status increases risk for left ventricular hypertrophy (LVH), and its common sequel CHF, merits consideration. In cardiomyocytes, hormones which activate protein kinase C (PKC) -- including norepinephrine, angiotensin II, and endostatin, implicated in the pathogenesis of LVH -- induce a hypertrophic response analogous to that seen in LVH. Transgenic mice overexpressing PKC-beta2 or its upstream activator Galphaq in cardiac myofibers develop a syndrome similar to LVH. Parathyroid hormone (PTH) also activates Galphaq and PKC in cardiomyocytes, and provokes the expected hypertrophic response. Both primary and secondary hyperparathyroidism are associated with high risk for LVH. Moreover, in uncomplicated essential hypertension, left ventricular mass index has been shown to correlate very tightly with serum PTH levels, independent of blood pressure. This latter finding suggests that variations of PTH within the normal range can influence induction of LVH in at-risk subjects. If so, nutritional and lifestyle measures which modulate PTH secretion may have an impact on LVH risk. PTH secretion should be down-regulated by good vitamin D status -- achieved through supplementation or regular uv exposure -- and by vegan diets moderately low in bioavailable phosphate. Although high calcium intakes can likewise suppress PTH, they also boost renin secretion, which could have a countervailing effect on risk for LVH. Whether these nutritional measures do indeed influence LVH risk could be examined in prospective studies targeting patients at high risk, such as hypertensives.