Left ventricular mass in the elderly. The Cardiovascular Health Study

Ambulatory blood pressure is associated with left ventricular geometry after 10 years in hypertensive patients with continuous antihypertensive treatment

Both aging and high blood pressure (BP) are associated with a risk of left ventricular concentricity and hypertrophy. We hypothesized that optimal BP management improves left ventricular remodeling beyond aging. Among 558 hypertensive patients on continuous antihypertensive treatment and without concurrent heart disease who were referred to a cardiology clinic with echocardiography and ambulatory BP monitoring data, 142 patients' echocardiographic data was available after 10 years. Baseline BP and changes in left ventricular geometry were evaluated. Mean age at baseline was 71.0 years old. Baseline daytime BP was 129.9/72.4 ± 17.1/10.2 mmHg and nighttime BP was 122.5/67.1 ± 16.9/9.1 mmHg. After 10 years, left ventricular mass index (LVMI) and relative wall thickness (RWT) significantly decreased from 104.5 ± 26.3 to 97.9 ± 26.4 g/m2, p = 0.003 and 0.51 ± 0.09 to 0.47 ± 0.09, p < 0.001, consecutively. Among patients with hypertrophic geometry at baseline, 17.2% reverted to normal geometry at follow-up. Daytime systolic BP (136.9 ± 18.5 mmHg vs 126.2 ± 16.5 mmHg, p = 0.03), nighttime systolic BP (126.2 ± 17.7 mmHg vs 116.3 ± 16.0 mmHg, p = 0.038) and daytime pulse pressure (63.5 ± 17.3 mmHg vs 53.1 ± 14.9 mmHg, p = 0.022) at baseline were higher in patients who remained hypertrophic than those without hypertrophy at follow-up. On logistic regression analysis, daytime, nighttime systolic BP, and daytime pulse pressure were significantly related to the regression of hypertrophy adjusted for age, sex, eGFR, BMI, LVMI, and RWT at baseline. For conclusion, antihypertensive treatment for 10 years improved LV geometry despite aging. Ambulatory BP and pulse pressure at baseline predicted the change of LV geometry after 10 years.

Estimated pulse wave velocity can predict the incidence of new-onset atrial fibrillation: A 11-year prospective study in a Chinese population

BACKGROUND

Arterial stiffness, a risk factor for atrial fibrillation (AF), is rarely applied in clinical practice because of the difficulty and high cost of its measurement. Estimated pulse wave velocity (ePWV) is a simple, reproducible, and non-invasive index of arterial stiffness. This study was to assess the predictive value of ePWV for the risk of new-onset AF.

METHODS

Subjects were selected from the Kailuan cohort study population who underwent initial physical examination between 2006 and 2008. A total of 96,561 subjects were ultimately included in the final analysis. ePWV was divided into four groups according to quartiles. The Kaplan-Meier method was used to calculate the cumulative incidence of AF. A Cox regression model was used to assess the predictive value of estimated arterial stiffness for new-onset AF.

RESULTS

Mean age of subjects was 51.47 ± 9.68 years, while 76,968 (79.65%) were male and 19,663 (20.35%) were female. During mean follow-up period of 11.77 years, 1,215 AF events occurred. Results of the Kaplan-Meier analysis showed that the incidence of new-onset AF increased with increase in ePWV. Cox regression analysis showed that in the total population, the incidence of new-onset AF was 1.64, 1.90, and 2.64 times higher in the medium, medium-high, and high ePWV groups, respectively, compared with the low ePWV group. When stratified according to sex, ePWV had higher predictive value in the female population.

CONCLUSIONS

Increased ePWV increases the incidence of new-onset AF, and may promote application of more aggressive primary prevention.

TRIAL REGISTRY NAME

Risk factors and intervention for cardiology, cerebrovascular and related disease (Kailuan Study); URL: http://www.chictr.org.cn/showproj.aspx?proj=8050; Registration number: ChiCTR-TNRC-11001489.

The impact of age and 24-h blood pressure on arterial health in acute ischemic stroke patients: The Norwegian stroke in the young study

The impact of age and 24‐h ambulatory blood pressure (ABPM) on arterial stiffness and carotid intima‐media thickness (cIMT) in ischemic stroke patients younger than 60 years of age is poorly explored. A total of 385 acute ischemic stroke patients (aged 49.6±9.7 years, 68% men) were prospectively included and grouped in younger (15–44 years, n = 93) and middle‐aged (45–60 years, n = 292). Arterial stiffness was measured by carotid‐femoral pulse wave velocity (PWV), and cIMT by carotid ultrasound. 24‐h ABPM was recorded. The middle‐aged stroke patients had higher prevalence of smoking, hypertension, diabetes mellitus, metabolic syndrome and hypercholesterolemia, and had higher PWV and cIMT (all p < .05). In multivariable linear regression analyses adjusted for sex, BMI, smoking, diabetes mellitus, total cholesterol, high‐density lipoprotein cholesterol, triglycerides, eGFR, systolic BP and concomitant antihypertensive treatment, 1SD (4.4 years) higher age was associated with higher PWV (β = 0.44,R² = 0.46, p < .001) in the younger group, and with higher mean cIMT (β = 0.16, R² = 0.21, p = .01) in the middle‐aged group. In the middle‐aged group, 24‐h pulse pressure had a significant association with PWV (β = 0.18, R² = 0.19, p = .009), while the association with cIMT was attenuated (β = 0.13, R² = 0.16, p = .065). 24‐h diastolic BP was associated with higher cIMT in the middle‐aged group (β = 0.24, p < .001, R² = 0.23), but not with PWV in either age groups. Among ischemic stroke patients < 60 years, higher age was associated with increased arterial stiffness for patients up to age 44 years, and with cIMT in middle‐aged patients. 24‐h pulse pressure was associated with arterial stiffness, and 24‐h diastolic BP was associated with cIMT only in middle‐aged patients.

Association of smoking with indicators of the structure and function of left ventricle of the heart in middle-aged men

Aim. Evaluation of the association of smoking (status, intensity and duration) with indicators of the structure and function of the left ventricle of the heart in a sample of middle-aged men.

Material and methods. This study is part of a 32-year prospective cohort observation of men from childhood (11-12 years). 301 (30.0%) representatives of the original population sample aged 41-44 years were included in the study. The examination included a survey on intensity of smoking, anthropometry, measuring blood pressure, pulse rate, echocardiography, and blood lipid analysis.

Results. 301 men aged 41-44 included 92 (30.6%) men who had never smoked, 73 (24.3%) men smoked in the past and 136 (45.2%) men currently smoke. 75% of current smokers started smoking before age 19, of which 32.3% started smoking before age 15. The duration of smoking cessation among former smokers was 14.4 (12.5; 16.2) years. The average duration of smoking [average (95% confidence interval)] among former smokers was 14.4 (12.5; 16.2), for current smokers – 25.3 (24.6; 26.0) years. Current smoking was statistically significantly associated with higher mean values of the left ventricular myocardium mass (LVMM), the left ventricular myocardial mass index (LVMMI), the end-systolic and end-diastolic interventricular septum thickness (IVSTs/IVSTd), the end-systolic left ventricular posterior wall thickness (LVPWs), and the intensity and duration of current smoking were associated with higher values of the relative wall thickness of the left ventricle, the end-diastolic interventricular septum thickness, the end-systolic interventricular septum thickness, and with low values of the left ventricular stroke volume index (LV SVI). Multiple regression analysis showed that current smoking has an independent effect on the left ventricular myocardium mass, the left ventricular myocardial mass index and the end-diastolic interventricular septum thickness, and the duration and intensity of smoking has an effect on the index of the left ventricular stroke volume index.

Conclusion. Current smoking, duration and intensity in middle-aged men is associated with unfavorable changes in indicators of the structure and function of the left ventricle of the heart. Efforts for primary prevention of smoking should begin as early as childhood and continue into adolescence and young adulthood.

Smoking Status, Intensity of Smoking, and Their Relation to Left Ventricular Hypertrophy in Working Aged Korean Men

INTRODUCTION

Smoking is an established risk factor for atherosclerotic cardiovascular disease. However, the effect of smoking on left ventricular (LV) structure has been less studied. This study was designed to assess the association of smoking status and smoking intensity with left ventricular hypertrophy (LVH).

METHODS

Study subjects were 53,666 working aged Korean men who received echocardiography as an item of health check up. They were grouped by smoking status (never, former, and current smokers), pack-year of smoking (never, <10, 10-19.9, and ≥20 pack-year), and urine cotinine excretion (<100, 100-999, ≥1000 ng/mL). Multivariate logistic regression analysis was used in calculating adjusted odds ratios (ORs) and 95% confidence interval for LVH (adjusted odds ratios [95% confidence interval]). The proportions of abnormal LV geometry patterns were compared among groups.

RESULTS

Former and current smokers had the higher levels in LV mass index, relative wall thickness, and the prevalence of LVH than never smoker. The association with LVH increased in order of never (reference), former (1.44 [1.01-2.04]), and current smokers (2.10 [1.44-3.05]). LVH showed the proportional relationship with pack-year of smoking (never smoker: reference, <10: 1.45 [1.01-2.08], 10-19.9: 1.73 [1.17-2.57], ≥20: 2.43 [1.58-3.74]) and urine cotinine excretion (never smoker: reference, 100-999: 1.70 [1.21-2.37], >1000: 1.97 [1.43-2.72]). The proportions of abnormal LV geometry patterns were higher in smoking groups than never smoking group.

CONCLUSION

Exposure to tobacco use and intensity of smoking was associated with LVH in working aged population.

IMPLICATIONS

In working aged Koreans with mean age of 39.9 ± 7.0 years, former and current smokers are more likely to have LVH than never smoker. Dose-dependent relationship was found between the smoking status (never, former, and current smokers), pack-year of smoking, urine cotinine excretion, and LVH. These findings indicate that smoking has an adverse influence on LV structure even in relatively young age group.

Arterial hypertension and morphologic abnormalities of cardiac chambers: results from the Copenhagen General Population Study

OBJECTIVES

In patients with arterial hypertension (AH), hypertension-mediated organ damage may be manifested by cardiac chamber enlargement and/or remodeling. Cardiac computed tomography imaging has emerged as an important method for morphological assessment of cardiac chambers. We tested the hypothesis that prevalence of cardiac chamber abnormalities is specifically related to clinical categories of AH in the general population.

METHODS

We studied 4747 individuals, mean age was 60 years (range: 40-93), 46% were men, undergoing 320-detector computed tomography in the Copenhagen General Population Study. Clinical categories of AH were: normotensive (n = 2484), untreated hypertensive (n = 1301), treated controlled hypertensive (n = 412) and treated uncontrolled hypertensive (n = 550). Chamber abnormalities in the form of left ventricular (LV) concentric remodeling, LV eccentric hypertrophy, LV concentric hypertrophy or left atrial enlargement were assessed, in addition to LV or right ventricular enlargement.

RESULTS

Chamber abnormalities were present in 23% of all individuals. Combined LV and left atrial abnormalities were rare (<2%). LV concentric remodeling (10%) was the most prevalent abnormality, and most commonly found in individuals with treated hypertension. LV and right ventricular enlargements were unrelated to hypertension. The highest frequencies of chamber abnormalities were found in individuals of elevated blood pressure (BP) with (40%) or without (32%) treatment, as opposed to individuals of normal BP with (27%) or without (14%) treatment, P less than 0.0001.

CONCLUSION

In a general population cohort, untreated or inadequately treated AH was associated with the highest prevalence of cardiac chamber enlargement and remodeling. These observations suggest a strong link between elevated BPs and development of hypertension-mediated organ damage.

Proteomic identification of the proteins related to cigarette smoke-induced cardiac hypertrophy in spontaneously hypertensive rats

Smoking increases the risk of cardiovascular diseases. The present study was designed to determine the effects of 2-month exposure to cigarette smoke (CS) on proteins in the left ventricles of spontaneously hypertensive rats (SHR) and to identify the molecular targets associated with the pathogenesis/progression of CS-induced cardiac hypertrophy. SHR and Wistar Kyoto rats (WKY) were exposed to CS at low (2 puffs/min for 40 min) or high dose (2 puffs/min for 120 min), 5 days a week for 2 months. Using the two-dimensional fluorescence difference gel electrophoresis combined with MALDI-TOF/TOF tandem mass spectrometry, we compared differences in the expression levels of proteins in the whole left ventricles induced by long-term smoking. High-dose CS mainly caused cardiac hypertrophy in SHR, but not WKY, but no change in blood pressure. Proteomic analysis identified 30 protein spots with significant alterations, with 14 up-regulated and 16 down-regulated proteins in the left ventricles of CS-exposed SHR, compared with control SHR. Among these proteins, two members of the heat shock proteins (HSP70 and HSP20) showed significant up-regulation in the left ventricles of CS high-dose SHR, and the results were confirmed by western blot analysis. Our findings suggested that HSPs play an important role in regulation of CS-induced cardiac hypertrophy.

Assessment of Arterial Stiffness in Patients With Resistant Hypertension: Additional Insights Into the Pathophysiology of This Condition?

BACKGROUND

Good understanding of the pathophysiological mechanism(s) of resistant hypertension (RH) and the relationship to vascular dysfunction is important for optimal blood pressure control.

METHODS AND RESULTS

The aim of this review article is to summarize the available data on the methods of arterial stiffness assessment, and their usefulness in RH. Several studies that provide information on the noninvasive methods of evaluation of arterial stiffness have been discussed; specifically, pulse wave velocity (PWV) and augmentation index (AIx) tests. Increased arterial stiffness, elevated AIx, and impaired endothelial function all act as indicators and predictors of cardiovascular events in patients with hypertension (HTN).

CONCLUSION

Our review suggests that PWV and AIx are impaired in patients with severe HTN. Early assessment of these characteristics can potentially be of value in patients with RH.

Normal reference ranges for the left ventricular mass and left ventricular mass index in preterm infants

Objective:

The objective of this study is to establish normal reference ranges for the left ventricular mass (LVM) and LVM index (LVMI) in preterm infants according to the body surface area (BSA) and assess their correlation with body weight and gestational age.

Subjects and Methods:

In a prospective study, 268 preterm babies who fulfilled the criteria for inclusion were examined. Echocardiograms were performed to measure the LVM and LVMI on 0–6 day (s) of life and at weekly intervals until the babies reached 36 weeks. The preterm infants were divided into six groups according to their BSA: 0.07–0.08 m2, 0.09–0.10 m2, 0.11–0.12 m2, 0.13–0.14 m2, 0.15–0.16 m2, and 0.17–0.19 m2.

Results:

The mean gestational age was 29.8 (±2.38 standard deviation [SD]) weeks, ranging from 24 to 35 weeks. The mean body weight was 1479 (±413 SD) g, ranging from 588 to 3380 g, and the mean BSA was 0.13 m2, ranging from 0.07 to 0.19 m2. The LVM correlated well with the gestational age, body weight, and BSA. The LVMI correlated well with body weight and BSA. Reference ranges with the mean ± SD, range, and interquartile range were calculated for the LVM and LVMI according to the BSA. A significant gradual increase was observed in a LVM with increasing BSA. Overall, a progressive and significant increase in the LVM was observed during the first 9 weeks of life.

Conclusion:

The LVM and LVMI exhibited a significant correlation with the BSA and body weight. This study provides reference data that can be used as a normal reference tool for the LVM and LVMI for preterm infants based on the BSA.

Hypertension and Heart Failure

Hypertensive heart disease represents a spectrum of illnesses from uncontrolled hypertension to heart failure. The authors discuss the natural history and pathogenesis of heart failure owing to hypertensive heart disease, reviewing the important role of left ventricular hypertrophy as the inciting process leading to diastolic dysfunction and heart failure with preserved ejection fraction. They describe the various mechanisms by which a subset of patients ultimately develops systolic heart failure. They discuss management strategies for hypertensive heart disease at all stages of the disease process. Treatment in the initial stages before onset of heart failure may result in regression of disease.

Comparison of Cardiac and Vascular Parameters in Powerlifters and Long-Distance Runners: Comparative Cross-Sectional Study

BACKGROUND

Cardiac remodeling is a specific response to exercise training and time exposure. We hypothesized that athletes engaging for long periods in high-intensity strength training show heart and/or vascular damage.

OBJECTIVE

To compare cardiac characteristics (structure and function) and vascular function (flow-mediated dilation [FMD] and peripheral vascular resistance [PVR]) in powerlifters and long-distance runners.

METHODS

We evaluated 40 high-performance athletes (powerlifters [PG], n = 16; runners [RG], n = 24) and assessed heart structure and function (echocardiography), systolic and diastolic blood pressure (SBP/DBP), FMD, PVR, maximum force (squat, bench press, and deadlift), and maximal oxygen uptake (spirometry). A Student's t Test for independent samples and Pearson's linear correlation were used (p < 0.05).

RESULTS

PG showed higher SBP/DBP (p < 0.001); greater interventricular septum thickness (p < 0.001), posterior wall thickness (p < 0.001) and LV mass (p < 0.001). After adjusting LV mass by body surface area (BSA), no difference was observed. As for diastolic function, LV diastolic volume, wave E, wave e', and E/e' ratio were similar for both groups. However, LA volume (p = 0.016) and BSA-adjusted LA volume were lower in PG (p < 0.001). Systolic function (end-systolic volume and ejection fraction), and FMD were similar in both groups. However, higher PVR in PG was observed (p = 0.014). We found a correlation between the main cardiovascular changes and total weight lifted in PG.

CONCLUSIONS

Cardiovascular adaptations are dependent on training modality and the borderline structural cardiac changes are not accompanied by impaired function in powerlifters. However, a mild increase in blood pressure seems to be related to PVR rather than endothelial function.

Ultrasound cardiography examinations detect victims' long-term realized and potential consequences after major disasters: a case-control study

Background

An increase in cardiovascular diseases has been reported following major disasters. Previous work has shown that ultrasonographic findings from ultrasound cardiography examination (UCG) increased until the 44th month after the tsunami caused by the Great East Japan Earthquake. The present study conducted UCG among victims in the tsunami disaster area and investigated the frequency of disaster-related cardiovascular diseases and changes over time until the 55th month after the disaster.

Methods

The subjects were residents of temporary housing complexes and neighboring housing in Watari-gun, Miyagi Prefecture, Japan. There were 207 subjects in the 18th month, 125 in the 30th month, 121 in the 44th month, and 106 in the 55th month after the disaster. Data were collected through UCG and self-report questionnaire.

Results

Significant changes were observed among subjects with clinical findings from the UCG, which increased over the study period—from 42.0 to 60.8, 72.7, and 73.6% beginning in the 18th month after the disaster (p < 0.0001).

Conclusions

It is possible that the UCG can become a useful examination to visualize the potential impact of a major disaster on the cardiac function of victims. Victims with clinical findings continued increasing not only during the acute phase after a disaster but also in the long term. We therefore need to keep this in mind, and note that it is important to establish a support system to control cardiovascular diseases from the early stage of disaster.

Trial registration

UMIN; ID000029802. R000034050. 2 November 2017.

Smoking and Cardiac Structure and Function in the Elderly: The ARIC Study (Atherosclerosis Risk in Communities)

BACKGROUND

Cigarette smoking has been associated with higher risk of incident heart failure independent of coronary artery disease, but the impact of tobacco use on cardiac structure and function in the general population is uncertain. This study evaluated the relationship between smoking and echocardiographic measures in a large elderly cohort.

METHODS AND RESULTS

We studied 4580 participants free of overt coronary artery disease, heart failure, and significant valvular disease from the fifth visit of the ARIC study (Atherosclerosis Risk in Communities) who underwent transthoracic echocardiography. Participants were classified into 3 categories based on self-reported smoking habits: never (43.2%), former (50.5%), and current smokers (6.3%). Pack-years and years of smoking were also estimated. Compared with never smokers, current smokers had greater left ventricular (LV) mass index (80.4±1.1 versus 76.7±0.4 g/m(2); P<0.001), LV mass/volume ratio (1.93±0.03 versus 1.83±0.03 g/mL; P<0.001), higher prevalence of LV hypertrophy (15% versus 9%; P=0.008), and worse diastolic function, as reflected by higher E/E' ratio (11.7±0.2 versus 10.9±0.1; P<0.001), after adjusting for potential confounding factors. In contrast, former smokers showed similar echocardiographic features when compared with never smokers. Furthermore, estimated pack-years and years of smoking, measures of cumulative cigarette exposure, were associated with greater LV mass index, LV mass/volume ratio, and worse diastolic function (higher E/E' ratio) in current smokers after multivariable analysis (all P<0.01).

CONCLUSIONS

Active smoking and cumulative cigarette exposure were associated with subtle alterations in LV structure and function in an elderly, community-based population free of overt coronary artery disease and heart failure.

Cardiac Imaging in Heart Failure with Comorbidities

Imaging modalities stand at the frontiers for progress in congestive heart failure (CHF) screening, risk stratification and monitoring. Advancements in echocardiography (ECHO) and Magnetic Resonance Imaging (MRI) have allowed for improved tissue characterizations, cardiac motion analysis, and cardiac performance analysis under stress. Common cardiac comorbidities such as hypertension, metabolic syndromes and chronic renal failure contribute to cardiac remodeling, sharing similar pathophysiological mechanisms starting with interstitial changes, structural changes and finally clinical CHF. These imaging techniques can potentially detect changes earlier. Such information could have clinical benefits for screening, planning preventive therapies and risk stratifying patients. Imaging reports have often focused on traditional measures without factoring these novel parameters. This review is aimed at providing a synopsis on how we can use this information to assess and monitor improvements for CHF with comorbidities.

Gender, race, age, and regional differences in the association of pulse pressure with atrial fibrillation: the Reasons for Geographic and Racial Differences in Stroke study

Pulse pressure (PP) has been associated with atrial fibrillation (AF) independent of other measures of arterial pressure and other AF risk factors. However, the impact of gender, race, age, and geographic region on the association between PP and AF is unclear. A cross-sectional study of data from 25,109 participants (65 ± 9 years, 54% women, 40% black) from the Reasons for Geographic and Racial Differences in Stroke study recruited between 2003 and 2007 were analyzed. AF was defined as a self-reported history of a previous physician diagnosis or presence of AF on ECG. Multivariable logistic regression models were used to calculate the odds ratio for AF. Interactions for age (<75 years and ≥75 years), gender, race, and region were examined in the multivariable adjusted model. The prevalence of AF increased with widening PP (7.9%, 7.9%, 8.4%, and 11.6%, for PP < 45, 45-54.9, 55-64.9, and ≥65 mm Hg, respectively, [P for trend <.001]) but attenuated with adjustment. No differences by gender, race, and region were observed. However, there was evidence of significant effect modification by age (interaction P = .0002). For those <75 years, PP ≥ 65 mm Hg compared to PP < 45 mm Hg was significantly associated with higher risk of AF in both the unadjusted and multivariable adjusted models (odds ratio = 1.66 [95% CI = 1.42-1.94] and 1.32 [95% CI = 1.03-1.70], respectively). In contrast, higher PP (55-64.9 mm Hg) among those ≥75 years was significantly associated with a lower risk of AF. The relationship between PP and AF may differ for older versus younger individuals.

Carotid Intima-Media Thickness and Arterial Stiffness and the Risk of Atrial Fibrillation: The Atherosclerosis Risk in Communities (ARIC) Study, Multi-Ethnic Study of Atherosclerosis (MESA), and the Rotterdam Study

BACKGROUND

We evaluated the association of carotid intima-media thickness (cIMT), carotid plaque, carotid distensibility coefficient (DC), and aortic pulse wave velocity (PWV) with incident atrial fibrillation (AF) and their role in improving AF risk prediction beyond the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE)-AF risk score.

METHODS AND RESULTS

We analyzed data from 3 population-based cohort studies: Atherosclerosis Risk in Communities (ARIC) Study (n=13 907); Multi-Ethnic Study of Atherosclerosis (MESA; n=6640), and the Rotterdam Study (RS; n=5220). We evaluated the association of arterial indices with incident AF and computed the C-statistic, category-based net reclassification improvement (NRI), and relative integrated discrimination improvement (IDI) of incorporating arterial indices into the CHARGE-AF risk score (age, race, height weight, systolic and diastolic blood pressure, antihypertensive medication use, smoking, diabetes, previous myocardial infarction, and previous heart failure). Higher cIMT (meta-analyzed hazard ratio [95% CI] per 1-SD increment, 1.12 [1.08-1.16]) and presence of carotid plaque (1.30 [1.19-1.42]) were associated with higher AF incidence after adjustment for CHARGE-AF risk-score variables. Lower DC and higher PWV were associated with higher AF incidence only after adjustment for the CHARGE-AF risk-score variables excepting height, weight, and systolic and diastolic blood pressure. Addition of cIMT or carotid plaque marginally improved CHARGE-AF score prediction as assessed by the relative IDI (estimates, 0.025-0.051), but not when assessed with the C-statistic and NRI.

CONCLUSIONS

Higher cIMT, presence of carotid plaque, and greater arterial stiffness are associated with higher AF incidence, indicating that atherosclerosis and arterial stiffness play a role in AF etiopathogenesis. However, arterial indices only modestly improve AF risk prediction.

Is Pulse Pressure an Independent Risk Factor for Incident Stroke, REasons for Geographic And Racial Differences in Stroke

BACKGROUND

Pulse pressure (PP) is a potential risk factor of stroke. The relationship of incident stroke with systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and PP was examined.

METHODS

Data were from the REasons for Geographic And Racial Differences in Stroke national cohort study of 30,239 black and white participants aged ≥45 years, enrolled between 2003 and 2007. PP (SBP-DBP) and MAP (MAP = DBP + 1/3*PP) were calculated. Telephone follow-up occurred every six months for self or proxy-reported suspected stroke events, confirmed using expert adjudication. Cox-proportional hazards models examined the association of incident stroke for the different BP measurements with multivariable adjustment for sociodemographic and clinical risk factors including gender and race.

RESULTS

Men and women without prevalent stroke at baseline were analyzed (n = 25,462). During follow-up (mean 6.3±2.3 years, maximum 10 years), 916 strokes occurred. Unadjusted PP (hazard ratio [HR] = 1.30; 95% confidence interval [CI] 1.24-1.35), SBP (HR = 1.22; 95% CI 1.18-1.32), MAP (HR = 1.24; 95% CI 1.16-1.32), and DBP (HR = 1.09; 95% CI 1.01-1.17) were associated with stroke risk; however, after adjustment for SBP and other risk factors, the association with PP was attenuated (HR = 0.98; 95% CI 0.90-1.07), whereas SBP persisted as a predictor (HR = 1.14; 95% CI 1.06-1.23). These associations were consistent across age (younger vs. older >70 years) and race (black vs. white).

CONCLUSIONS

PP is positively associated with incident stroke, but not independently from SBP; and, there were no significant gender, racial, or regional differences in that association.

Left ventricle size quantification using non-contrast-enhanced cardiac computed tomography--association with cardiovascular risk factors and coronary artery calcium score in the general population: The Heinz Nixdorf Recall Study

BACKGROUND

Increased left ventricular (LV) size is associated with cardiovascular mortality and morbidity. Once non-contrast cardiac computed tomography (CT) is performed for other purposes, information of LV size is readily available.

PURPOSE

To determine the association of gated CT-derived LV size with cardiovascular risk factors and coronary artery calcification (CAC) and to describe age- and gender-specific normative values in a general population cohort.

MATERIAL AND METHODS

LV area was quantified from non-contrast-enhanced CT in axial, end-diastolic images at a mid-ventricular slice in participants of the population-based Heinz Nixdorf Recall Study, free of known cardiovascular disease. LV index (LVI) was calculated by the quotient of LV area and body surface area (BSA). Crude and adjusted regression analyses were used to determine the association of LVI with risk factors and CAC.

RESULTS

Overall, 3926 subjects (age 59 ± 8 years, 53% women) were included in this analysis. From quantification in end-diastolic phase, men had larger LV index (2232 ± 296 mm(2)/m(2) vs. 2088 ± 251 mm(2)/m(2), both P < 0.0001). LVI was strongly correlated systolic blood pressure (men, PE [95% CI]: 22.8 [15.5-30.2] mm(2)/10 mmHg; women, 23.4 [18.1-28.6]), and antihypertensive medication (men, 45.2 [14.7-75.8] mm(2); women: 46.5 [22.7-70.2], all P < 0.005). Cholesterol levels were associated with LVI in univariate analysis, however, correlations were low (R(2) ≤ 0.04). In multivariable regression, blood pressure, antihypertensive medication and cholesterol levels, remained associated with LVI (P < 0.05). LVI was linked with CAC in unadjusted (men, increase of CAC + 1 by 13.0% [1.4-25.8] with increased LVI by 1 standard deviation of LVI, P = 0.03; women, 20.7% [10.0-32.3], P < 0.0001) and risk factor adjusted models (men, 14.6% [3.7-26.6], P = 0.007); women, 17.4% [7.8-27.8], P = 0.0002).

CONCLUSION

Non-contrast cardiac CT derived LV index is associated with body size and hypertension. LVI is weakly linked with CAC-score. Further studies need to evaluate whether assessment of LV dimensions from cardiac CT helps identifying subjects with increased cardiovascular risk.

Is pulse pressure an independent risk factor for incident acute coronary heart disease events? The REGARDS study

BACKGROUND

Increased attention has been given to pulse pressure (PP) as a potential independent risk factor for cardiovascular disease (CVD). We examined the relationship between the three indices of blood pressure consisting of systolic blood pressure (SBP), diastolic blood pressure (DBP), and PP (= SBP - DBP), respectively, and incident acute coronary heart disease (CHD).

METHODS

Participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study, a national cohort study of 30,239 black and white participants > 45 years of age, were enrolled between 2003 and 2007. The participants' SBP, DBP, and PP values were separated into the four groups of < 45mm Hg, 45-54.9mm Hg, 55-64.9mm Hg, and ≥ 65mm Hg, and were analyzed on a groupwise basis. Reported CHD events were confirmed by expert adjudication. Cox proportional hazards models were used to examine the association of incident CHD (first acute CHD event) for the four groups of BP measurements with multivariate-adjusted sociodemographic and clinical risk factors.

RESULTS

Analyses were done for 22,909 men and women (40.4% black, 44.6% male) ≥ 45 years of age (mean age = 64.7±9.4 years) without prevalent CHD at baseline. Associations were found for 681 CHD events, over a mean 3.4 years of follow-up (maximum 6 years), with each unadjusted PP group (hazard ratio [HR] with 95% confidence limits for PP of 45-54.9mm Hg, 55-64.9mm Hg, and ≥ 65mm Hg, respectively, of 3.82, 3.08, and 4.73 as compared with PP < 45mm Hg; P < 0.0001 for linear trend), and this persisted after full adjustment, including that for SBP (1.50, 1.08, 2.09; P trend < 0.01). Subgroup analyses showed no statistically significant differences across age, race, or region of the country, but did suggest the possibility that men were more sensitive to PP than were women.

CONCLUSIONS

Pulse pressure is positively and independently (particularly so with regard to independence from SBP) associated with incident CHD, and there were no significant racial or regional differences in this association.

Myocardial extracellular volume expansion and the risk of recurrent atrial fibrillation after pulmonary vein isolation

OBJECTIVES

This study tested whether myocardial extracellular volume (ECV) is increased in patients with hypertension and atrial fibrillation (AF) undergoing pulmonary vein isolation and whether there is an association between ECV and post-procedural recurrence of AF.

BACKGROUND

Hypertension is associated with myocardial fibrosis, an increase in ECV, and AF. Data linking these findings are limited. T1 measurements pre-contrast and post-contrast in a cardiac magnetic resonance (CMR) study provide a method for quantification of ECV.

METHODS

Consecutive patients with hypertension and recurrent AF referred for pulmonary vein isolation underwent a contrast CMR study with measurement of ECV and were followed up prospectively for a median of 18 months. The endpoint of interest was late recurrence of AF.

RESULTS

Patients had elevated left ventricular (LV) volumes, LV mass, left atrial volumes, and increased ECV (patients with AF, 0.34 ± 0.03; healthy control patients, 0.29 ± 0.03; p < 0.001). There were positive associations between ECV and left atrial volume (r = 0.46, p < 0.01) and LV mass and a negative association between ECV and diastolic function (early mitral annular relaxation [E'], r = -0.55, p < 0.001). In the best overall multivariable model, ECV was the strongest predictor of the primary outcome of recurrent AF (hazard ratio: 1.29; 95% confidence interval: 1.15 to 1.44; p < 0.0001) and the secondary composite outcome of recurrent AF, heart failure admission, and death (hazard ratio: 1.35; 95% confidence interval: 1.21 to 1.51; p < 0.0001). Each 10% increase in ECV was associated with a 29% increased risk of recurrent AF.

CONCLUSIONS

In patients with AF and hypertension, expansion of ECV is associated with diastolic function and left atrial remodeling and is a strong independent predictor of recurrent AF post-pulmonary vein isolation.

Effects of smoking on arterial distensibility, central aortic pressures and left ventricular mass

BACKGROUND

The effects of smoking on central aortic pressures and the age-related increase in left ventricular mass (LVM) are largely unknown. We studied the relationship between smoking, arterial distensibility, central aortic pressures and left ventricular mass in two population-based studies.

METHODS

Data was obtained from two German population-based studies (KORA and SHIP, participants' ages 25-84 years). We identified 114 normotensive current smokers and 185 normotensive all-time non-smokers in KORA as well as 400 and 588 such individuals in SHIP. Echocardiographic LVM was obtained at baseline (T0) and follow-up after ten years (T1) in KORA and at follow-up (T1) in SHIP. Additionally, pulse-wave analysis-based central aortic pressure and augmentation index (AIx) were measured at T1 in KORA.

RESULTS

Cross-sectional analysis, using KORA T0 and SHIP T1, revealed in both studies a higher covariate-adjusted LVM and left ventricular mass index (LVMI) in smokers as compared with non-smokers. Moreover, in the KORA T1 examination, the smokers demonstrated a more pronounced increase, relative to baseline, of LVM (+13.5%) and LVMI (+13.4%) compared to non-smokers (+8.59% and +8.65%; p=0.036 and 0.042, respectively). Additionally, at KORA T1 smokers had a higher central systolic blood pressure and higher AIx than non-smokers (p=0.012 and p=0.001, respectively).

CONCLUSIONS

The difference in central aortic pressure due to enhanced and more prolonged wave reflection may explain our finding of a further pronounced increase in left ventricular wall thickness and mass over time in smokers.

Relation of pulse pressure to long-distance gait speed in community-dwelling older adults: findings from the LIFE-P study

Background

Reduced gait speed is associated with falls, late-life disability, hospitalization/institutionalization and cardiovascular morbidity and mortality. Aging is also accompanied by a widening of pulse pressure (PP) that contributes to ventricular-vascular uncoupling. The purpose of this study was to test the hypothesis that PP is associated with long-distance gait speed in community-dwelling older adults in the Lifestyle Interventions and Independence for Elders Pilot (LIFE-P) study.

Methods

Brachial blood pressure and 400-meter gait speed (average speed maintained over a 400-meter walk at “usual” pace) were assessed in 424 older adults between the ages of 70–89 yrs at risk for mobility disability (mean age = 77 yrs; 31% male). PP was calculated as systolic blood pressure (BP) – diastolic BP.

Results

Patients with a history of heart failure and stroke (n = 42) were excluded leaving 382 participants for final analysis. When categorized into tertiles of PP, participants within the highest PP tertile had significantly slower gait speed than those within the lowest PP tertile (p<0.05). Following stepwise multiple regression, PP was significantly and inversely associated with 400-meter gait speed (p<0.05). Other significant predictors of gait speed included: handgrip strength, body weight, age and history of diabetes mellitus (p<0.05). Mean arterial pressure, systolic BP and diastolic BP were not predictors of gait speed.

Conclusions

Pulse pressure is associated long-distance gait speed in community-dwelling older adults. Vascular senescence and altered ventricular-vascular coupling may be associated with the deterioration of mobility and physical function in older adults.

Left atrial volume index predictive of mortality independent of left ventricular geometry in a large clinical cohort with preserved ejection fraction

OBJECTIVE

To determine the effect on mortality of the left atrial volume index (LAVI) and left ventricular (LV) geometry (normal, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy).

PATIENTS AND METHODS

From January 1, 2004, through December 31, 2006, we evaluated 36,561 patients with preserved ejection fraction with an average follow-up of 1.7±1.0 years. The LAVI was categorized as normal (≤28 mL/m(2)) or increased (mild, 29-33 mL/m(2); moderate, 34-39 mL/m(2); severe, ≥40 mL/m(2)).

RESULTS

Progressive increases in LAVI and mortality were noted with abnormal LV geometry. Similarly, abnormal LV geometry and mortality were significantly higher in patients with increased LAVI. In patients who died vs surviving patients, the LAVI ± SD was significantly higher (33.0±14.8 vs 28.1±10.8 mL/m(2); P<.001) and abnormal LV geometry was significantly more prevalent (62% vs 44%; P<.001). Compared with those with a normal LAVI, patients with a severe LAVI had a 42% increased risk of mortality. In patients with normal LV geometry or concentric remodeling, a severe LAVI was a significant independent predictor of mortality, with an increased risk of 28% and 46%, respectively. Similarly, in patients with eccentric hypertrophy and concentric hypertrophy, the mortality risk in patients with a severe LAVI was twice that of patients with a normal LAVI. Comparison of area under the curve (0.565 [without LAVI] vs 0.596 [with LAVI]; P<.001] and predictive models with and without LAVI for mortality prediction were significant, indicating increased mortality prediction by the addition of LAVI to other independent predictors.

CONCLUSION

The LAVI significantly predicts mortality risk, independent of LV geometry, and adds to the overall mortality prediction in a large cohort of patients with preserved systolic function.

Surrogate markers of cardiovascular disease in CKD: what's under the hood?

Although clinical cardiovascular outcomes, such as heart attack, stroke, and sudden cardiac death, have a dramatic onset, they result from prolonged exposure to an ever-growing array of risk factors. Several noninvasive procedures are available to assess the cumulative effect of these exposures with the goal of more precisely estimating a person's cardiovascular risk. These include ankle-brachial index, which provides an estimation of obstruction in major-vessel lumen caliber; carotid ultrasound, which evaluates carotid intima-media thickness and plaque, visibly quantifying atherosclerotic burden; aortic pulse wave velocity, which provides a measure of large-artery stiffness; and echocardiography, which measures left ventricular mass, providing a measure of subclinical hypertensive heart disease. In this narrative review, we discuss the role of each of these measures, with a particular emphasis on patients with chronic kidney disease.

Implications of prevalent and incident diabetes mellitus on left ventricular geometry and function in the ageing heart: the MONICA/KORA Augsburg cohort study

BACKGROUND AND AIM

It is unclear to what extent diabetes modulates the ageing-related adaptations of cardiac geometry and function.

METHODS AND RESULTS

We examined 1005 adults, aged 25-74 years, from a population-based survey at baseline in 1994/5 and at follow-up in 2004/5. We compared persistently non-diabetic individuals (ND; no diabetes at baseline and at follow-up, n=833) with incident (ID; non-diabetic at baseline and diabetic at follow-up, n=36) and with prevalent diabetics (PD; diabetes at baseline and follow-up examination, n=21). Left ventricular (LV) geometry and function were evaluated by echocardiography. Statistical analyses were performed with multivariate linear regression models. Over ten years the PD group displayed a significantly stronger relative increase of LV mass (+9.34% vs. +23.7%) that was mediated by a more pronounced increase of LV end-diastolic diameter (+0% vs. +6.95%) compared to the ND group. In parallel, LA diameter increased (+4.50% vs. +12.7%), whereas ejection fraction decreased (+3.02% vs. -4.92%) more significantly in the PD group. Moreover, at the follow-up examination the PD and ID groups showed a significantly worse diastolic function, indicated by a higher E/EM ratio compared with the ND group (11.6 and 11.8 vs. 9.79, respectively).

CONCLUSIONS

Long-standing diabetes was associated with an acceleration of age-related changes of left ventricular geometry accumulating in an eccentric remodelling of the left ventricle. Likewise, echocardiographic measures of systolic and diastolic ventricular function deteriorated more rapidly in individuals with diabetes.

Relation of pulse pressure to blood pressure response to exercise in patients with hypertrophic cardiomyopathy

Almost one third of patients with hypertrophic cardiomyopathy (HC) will have an abnormal blood pressure response (ABPR) to exercise, and this has been associated with a greater risk of sudden cardiac death. In the present study, we examined the association between the steady (mean arterial pressure) and pulsatile (pulse pressure) blood pressure components as they relate to ABPR in patients with HC (n = 70). All patients completed a standard Bruce protocol during symptom-limited stress testing with concurrent hemodynamic measurements. Pulse pressure (PP) was significantly greater in patients with HC with an ABPR (n = 19) than in the patients with HC without an ABPR to exercise (p <0.05). According to binary logistic regression analysis, PP at rest was a significant predictor of ABPR in patients with HC (p <0.05). Mean arterial pressure was not significantly different between the 2 groups, nor was it a predictor of an ABPR in the presence of HC. Those within the greatest tertile of PP at rest were 4.8 times more likely to have an ABPR than those within the lowest PP tertile (95% confidence interval 1.24 to 18.2, p <0.05). In conclusion, elevations in PP at rest might identify patients with HC at a greater risk of having an ABPR during exercise.

The aging heart, myocardial fibrosis, and its relationship to circulating C-type natriuretic Peptide

Myocardial aging is characterized by left ventricular (LV) fibrosis leading to diastolic and systolic dysfunction. Studies have established the potent antifibrotic and antiproliferative properties of C-type natriuretic peptide (CNP); however, the relationship between circulating CNP, LV fibrosis, and associated changes in LV function with natural aging are undefined. Accordingly, we characterized the relationship of plasma CNP with LV fibrosis and function in 2-, 11-, and 20-month-old male Fischer rats. Further in vitro, we established the antiproliferative actions of CNP and the participation of the clearance receptor using adult human cardiac fibroblasts. Here we establish for the first time that a progressive decline in circulating CNP characterizes natural aging and is strongly associated with a reciprocal increase in LV fibrosis that precedes impairment of diastolic and systolic function. Additionally, we demonstrate in cultured adult human cardiac fibroblasts that the direct antiproliferative actions of high-dose CNP may involve a non-cGMP pathway via the clearance receptor. Together, these studies provide new insights into myocardial aging and the relationship to the antifibrotic and antiproliferative peptide CNP.

Prospective population studies of incident heart failure without data on baseline left ventricular ejection fraction

INTRODUCTION

Left ventricular ejection fraction (LVEF) is a predictor of incident heart failure (HF). However, baseline LVEF is often unavailable in population studies of HF. METERIAL AND METHODS: Of the 5324 Cardiovascular Health Study (CHS) participants free of baseline HF, 143 (3%) had LVEF < 45% and 1091 (21%) developed HF during 13 years of follow-up. Using public-use copies of the CHS data, we compared two predictor models of incident HF, with and without adjustment for baseline LVEF.

RESULTS

Baseline impaired LVEF was a strong independent predictor of incident HF (adjusted hazard ratio, 2.78; P < 0.001) but had no impact on the direction, magnitude or significance of independent associations of the other predictors of incident HF such as age, sex, race, coronary artery disease, hypertension and diabetes.

CONCLUSION

Baseline LVEF is an important predictor for incident HF but is not essential in population studies of risk factors for incident HF.

Multicenter epidemiological studies of atherosclerosis imaging

Cardiovascular disease is the leading course of death and disability. Conventional cardiac risk factors do not fully explain the level of cardiovascular risk, incidence of coronary artery disease, and coronary events. Risk stratification and therapy based solely on these conventional risk factors may overlook a population who would benefit from lifestyle and risk factor modification. Thus, research has recently focused on improving risk assessment with new tools in an effort to better identify subjects at highest risk and in need of aggressive management. Cardiovascular imaging, both in coronary and extracoronary arterial beds, has proven to be very helpful in this regard. In this article, we review the current literature from multicenter epidemiology studies on the utility of noninvasive imaging modalities for risk stratification in the context of conventional risk factor evaluation.

Left ventricular mass: allometric scaling, normative values, effect of obesity, and prognostic performance

The need for left ventricular mass (LVM) normalization to body size is well recognized. Currently used allometric exponents to normalize LVM may not account for the confounding effect of sex. Because sex is a strong determinant of body size and LVM, we hypothesized that these are subject to potential bias. We analyzed data from 7528 subjects enrolled in the Asklepios Study (n=2524) and the Multiethnic Study of Atherosclerosis (limited access data set; n=5,004) to assess metric relationships between LVM and body size, generate normative data for indexed LVM, and compare the ability of normalization methods to predict cardiovascular events. The allometric exponent that adequately described the LVM-body height relationship was 1.7 in both studies and significantly different from both the unity and 2.7, whereas the LVM-body surface area relationship was approximately linear. LVM/height(2.7) consistently demonstrated important residual relationships with body height and systematically misclassified subjects regarding the presence of LVH. LVH defined by LVM/height(1.7) was more sensitive than LVM/body surface area to identify obesity-related LVH and was most consistently associated with cardiovascular events and all-cause death. In contrast to current assumptions, LVM/height(2.7) is not an adequate method to normalize LVM for body size. We provide more appropriate normalization methods, normative data by 2D echocardiography and gradient-echo cardiac MRI, and cutoffs for defining LVH, along with prognostic validation data.

Is pulse pressure a predictor of new-onset diabetes in high-risk hypertensive patients?: a subanalysis of the Candesartan Antihypertensive Survival Evaluation in Japan (CASE-J) trial

OBJECTIVE

Hypertensive patients have an increased risk of developing diabetes. Accumulating evidence suggests a close relation between metabolic disturbance and increased arterial stiffness. Here, we examined the association between pulse pressure and the risk of new-onset diabetes in high-risk Japanese hypertensive patients.

RESEARCH DESIGN AND METHODS

The Candesartan Antihypertensive Survival Evaluation in Japan (CASE-J) trial examined the effects of candesartan and amlodipine on the incidence of cardiovascular events in 4,728 high-risk Japanese hypertensive patients. In the present study, we analyzed the relationship between pulse pressure at baseline and new-onset diabetes in 2,685 patients without diabetes at baseline (male 1,471; mean age 63.7 years; mean BMI 24.8 kg/m(2)) as a subanalysis of the CASE-J trial.

RESULTS

During 3.3 +/- 0.8 years of follow-up, 97 patients (3.6%) developed diabetes. In multiple Cox regression analysis, pulse pressure was an independent predictor for new-onset diabetes (hazard ratio [HR] per 1 SD increase 1.44 [95% CI 1.15-1.79]) as were male sex, BMI, and additional use of diuretics, whereas age and heart rate were not. Plots of HRs for new-onset diabetes considering both systolic and diastolic blood pressure (DBP) revealed that a higher pulse pressure with a lower DBP, indicating that the increased pulse pressure was largely due to increased arterial stiffness, was strongly associated with the risk of new-onset diabetes.

CONCLUSIONS

Pulse pressure is an independent predictor of new-onset diabetes in high-risk Japanese hypertensive patients. Increased arterial stiffness may be involved in the development of diabetes.

Hypertension and diastolic heart failure

In patients with hypertension, pressure overload leads to left ventricular hypertrophy (LVH), myocardial fibrosis, and impaired diastolic filling without systolic dysfunction. Presently, diastolic heart failure accounts for about 50% of the heart failure population. Fatigue, dyspnea, reduced exercise tolerance, and peripheral edema are common presenting complaints. As a group, patients with diastolic heart failure are older and predominantly female. Diuretics are effective for treating congestive symptoms. beta Blockers and heart rate-lowering calcium blockers show benefit in smaller studies but have not been evaluated in definitive clinical trials. Renin-angiotensin-aldosterone system blockers reduce blood pressure, LVH, and myocardial fibrosis; however, long-term studies with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers demonstrate little effect on symptoms or survival, and inconsistent effects on heart failure hospitalization. At present, evidence-based treatment includes antihypertensive therapy to reduce progression from hypertension to heart failure. In patients with established heart failure, diuretics and other empiric treatments are used to control symptoms.

Body size adjustments for left ventricular mass by cardiovascular magnetic resonance and their impact on left ventricular hypertrophy classification

Methods to index left ventricular (LV) mass, measured by cardiovascular magnetic resonance (CMR), for body size have not been investigated. The purposes of this study were to develop allometric indices for LV mass measured by CMR and compare estimates of the prevalence and predictive value of LV hypertrophy defined by a new allometric height-weight index, LV mass/body surface area (BSA), height indices (a new allometric height index; and previously derived indices from echocardiographic measurements: LV mass/height(2), LV mass/height(2.7)), and non-indexed LV mass. 5,004 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) with CMR measurements of LV mass and no clinical cardiovascular disease at baseline were followed for a median of 4.1 years. The new indices and limits for hypertrophy (95th percentile) were derived from 822 normal-weight, normotensive, non-diabetic MESA participants. 107 events (coronary heart disease or stroke) were observed. The estimated prevalence of hypertrophy at baseline and hazard ratio for event associated with hypertrophy were 8% and 2.4 with the new allometric height-weight index, 11% and 2.2 with LV mass/BSA, 23-24% and 2.0-2.1 with height indices, and 20% and 1.7 with non-indexed LV mass. A statistically significant difference was detected between the hazard ratios based on the new height-weight index and non-indexed LV mass. The prevalence of hypertrophy is higher for indices that do not account for weight. The predictive value of hypertrophy is significantly better with the new allometric height-weight index than with non-indexed LV mass and may be better than indices without weight.

Arterial pulsatile hemodynamic load induced by isometric exercise strongly predicts left ventricular mass in hypertension

Although resting hemodynamic load has been extensively investigated as a determinant of left ventricular (LV) hypertrophy, little is known about the relationship between provoked hemodynamic load and the risk of LV hypertrophy. We studied central pressure-flow relations among 40 hypertensive and 19 normotensive adults using carotid applanation tonometry and Doppler echocardiography at rest and during a 40% maximal voluntary forearm contraction (handgrip) maneuver. Carotid-femoral pulse wave velocity (CF-PWV) was measured at rest. Hypertensive subjects demonstrated various abnormalities in resting and induced pulsatile load. Isometric exercise significantly increased systemic vascular resistance, aortic characteristic impedance (Zc), induced earlier wave reflections, increased augmentation index, and decreased total arterial compliance (TAC; all P < or = 0.01). In hypertensive subjects, CF-PWV was the strongest resting predictor of LV mass index (LVMI) and remained an independent predictor after adjustment for age, gender, systemic vascular resistance, reflection magnitude, aortic Zc, and TAC (beta = 2.52 m/s; P < 0.0001). Age, sex, CF-PWV, and resting hemodynamic indexes explained 48% of the interindividual variability in LVMI. In stepwise regression, TAC (beta = -17.85; P < 0.0001) during handgrip, Zc during handgrip (beta = -150; P < 0.0001), and the change in the timing of wave reflections during handgrip (beta = -0.63; P = 0.03) were independent predictors of LVMI. A model that included indexes of provoked hemodynamic load explained 68% of the interindividual variability in LVMI. Hemodynamic load provoked by isometric exercise strongly predicts LVMI in hypertension. The magnitude of this association is far greater than for resting hemodynamic load, suggesting that provoked testing captures important arterial properties that are not apparent at rest and is advantageous to assess dynamic arterial load in hypertension.

Pulse pressure, prehypertension, and mortality: the San Antonio heart study

BACKGROUND

Prehypertension increases mortality risk. Pulse pressure is also associated with increased mortality. Nevertheless, the impact of pulse pressure on the relationship between prehypertension and mortality is not known in individuals who are free of diabetes and cardiovascular disease.

METHODS

Cox regression analysis was used to examine mortality risk among 3,632 (97.0%) participants in the San Antonio Heart Study (age range, 25-64 years; mean follow-up, 15.2 years). Results were adjusted for age, sex, ethnicity, education, body mass index (BMI), smoking, and total cholesterol concentration. The Seventh Report of the Joint Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) categories were used for blood pressure staging: normal, <120/80 mm Hg; prehypertension, 120-139/80-89 mm Hg.

RESULTS

Prehypertension prevalence was 31.6% at baseline. There were 218 deaths during the follow-up period. Prehypertension-predicted mortality (all-cause, hazard ratio (HR) 1.49 (1.12-1.99); cardiovascular, HR 1.79 (1.07-3.02)). Relative to normal blood pressure plus pulse pressure in the lower tertile, prehypertension plus pulse pressure in the upper tertile was associated with increased mortality (all-cause, HR 2.14 (1.38-3.32); cardiovascular, HR 2.47 (1.13-5.39)); however, prehypertension plus pulse pressure in the lower tertile was not significantly associated with mortality (all-cause, HR 1.19 (0.52-2.67); cardiovascular, HR 0.43 (0.05-3.40)).

CONCLUSIONS

Prehypertension increases mortality risk (all-cause and cardiovascular) in individuals who are free of diabetes and cardiovascular disease. Nevertheless, this relationship is not evident in individuals with narrow pulse pressure. Therefore, pulse pressure may be a relevant measure of blood pressure for the definition of normal blood pressure.

Effects of body size and body fatness on left ventricular mass in children and adolescents: Project HeartBeat!

BACKGROUND

Left ventricular mass (LVM) is a strong predictor of cardiovascular disease in adults. Available study findings on effects of body fatness on LVM in children are inconsistent. Understanding the impact of body fat on LVM in children may help prevent excessive LVM through measures to reduce overweight and obesity.

METHODS

Healthy children (n=678) aged 8, 11, and 14 years at baseline were examined at 4-month intervals for up to 4 years (1991-1995); 4608 valid measurements of LVM were obtained with M-mode echocardiography. A multilevel linear model was used for analysis. The impact of body size was examined by adding separately nine body-size indicators to a basic LVM-gender-age model. The impact of body fatness was tested by introducing four body-fatness indicators into the nine models, yielding 36 models.

RESULTS

All body-size indicators showed strong, positive effects on LVM. In models containing weight or body surface area (measuring both fat-free and fat contributions to body size), additional effects of body fatness were negative; in models containing fat-free mass (FFM) or height (both measuring body size independent of body fat), increased body fatness was related to a significant increase in LVM. For example, in models with FFM as a body-size indicator, a 1-SD increase in percent body fat or fat mass was related to a 5.4- or 7.2-g increase in LVM, respectively.

CONCLUSIONS

Effects of body size on LVM attributable to fat-free body mass can be distinguished from those attributable to fat body mass; both are independent, positive predictors, but the former is the stronger determinant. When a body-size indicator not independent of body fat is used as a predictor, effects of fat-free body mass and fat body mass are forced to relate to the same indicator; because their magnitudes are estimated to be equal, the effect of fat body mass is overestimated. Thus, when an additional body-fatness indicator is included in the prediction of LVM, the additional estimated effect related to the indicator appears to be negative.

Longitudinal tracking of left ventricular mass over the adult life course: clinical correlates of short- and long-term change in the framingham offspring study

BACKGROUND

Information is limited on the longitudinal tracking of left ventricular (LV) mass over the adult life course and the determinants of such change.

METHODS AND RESULTS

We used multilevel modeling to evaluate the correlates of LV mass prospectively over a 16-year period in 4217 Framingham study participants (mean age 45 years, 53% women) using up to 4 serial routine echocardiographic observations on each individual (11 762 observations). Age, sex, body mass index, systolic blood pressure, antihypertensive treatment, smoking, and diabetes mellitus were related to longitudinal measures of LV mass. Women and participants with diabetes mellitus experienced a steeper increase in LV mass with advancing age (compared with men and those without diabetes mellitus; P for interactions <0.0001 and 0.0003, respectively). Women also displayed greater increments in LV mass with increasing body mass index (compared with men, P=0.04 for interaction). Participants with optimal values of these risk factors experienced lesser increases in LV mass over time. Analyses evaluating short-term (4-year) changes in LV mass (2605 unique individuals providing 4494 observations) identified the same key determinants that influenced its long-term trajectory (ie, body mass index, sex, systolic blood pressure, antihypertensive treatment, and smoking).

CONCLUSIONS

Our longitudinal observations on a large community-based sample identified higher blood pressure, excess adiposity, smoking, and diabetes mellitus as fundamental determinants of LV mass tracking over the adult life course. These observations are consistent with the notion that maintenance of optimal levels of these risk factors in midlife will reduce the burden of LV hypertrophy, and possibly heart failure, in older age.

Differences in determinants of left ventricular mass assessed by cardiac magnetic resonance imaging across subjects with and without previous symptomatic atherosclerotic disease

BACKGROUND

Most previous studies on determinants of left ventricular (LV) mass have used echocardiography, which is less accurate than cardiac MRI (CMR). Furthermore, studies that used CMR to study the determinants of LV mass were performed in the general population. However, determinants may differ between those with and without previous symptomatic events. We studied the relation between atherosclerotic risk factors and LV mass in subjects free from cardiac disease, yet with and without atherosclerotic disease elsewhere.

METHODS

A CMR was performed in 531 hypertensive subjects with clinically manifest extra-cardiac atherosclerotic disease or marked risk factors for atherosclerosis. In all subjects information on atherosclerotic risk factors was collected. Multivariable linear regression was used to study the relation of risk factors with LV mass. Interaction was evaluated with multiplicative interaction terms.

RESULTS

Overall, male gender, weight, height, systolic blood pressure, albuminuria, current smoking, and a history of abdominal aortic aneurysm (AAA) were related to an increased LV mass. In subjects without a history of symptomatic atherosclerotic disease, gender, weight, height and systolic blood pressure were related to LV mass. In addition to these risk factors, albuminuria, current smoking and a history of AAA were related to LV mass in subjects with a history of symptomatic atherosclerotic disease.

CONCLUSION

Our study points towards differences in risk factor relations across populations with and without symptomatic atherosclerotic disease. The observed relationship between cardiovascular risk factors and LV mass re-emphasizes the importance of adequate treatment of modifiable risk factors in the prevention of cardiovascular disease.

Change in pulse pressure/stroke index in response to sustained blood pressure reduction and its impact on left ventricular mass and geometry changes: the life study

BACKGROUND

In cross-sectional data in hypertensive subjects, brachial pulse pressure (PP)/Doppler stroke index (SVi), (PP/SVi) correlates weakly but significantly with left ventricular (LV) mass and relative wall thickness (RWT).

METHODS

In the Losartan Intervention For End-point reduction in hypertension (LIFE) study, we evaluated the impact of antihypertensive treatment on change of PP/SVi as raw indicator of systemic arterial stiffness, and further explored the impact of the change in PP/SVi on the change in LV mass and RWT.

RESULTS

Compared to baseline, mean PP/SVi reduction was -13% at year 1, -15% at year 2, and -16% at year 3 follow-up, and was sustained through year 4 and year 5 follow-ups; change in PP/SVi was related to increased SVi and decreased PP during the annual follow-ups, but not to LV mass change. Restricting analyses to the first two follow-ups to ensure highest statistical power, age >65 and diabetes were associated with higher PP/SVi at baseline and throughout follow-ups; black participants and women had baseline PP/SVi mean values comparable with those of their counterparts, showed blunted PP/SVi reduction after 1 year, but differences became smaller and not statistically significant at year 2 follow-up. Losartan- or atenolol-based treatments were associated with comparable reduction of PP/SVi. At year 2 follow-up, reduced PP/SVi was associated with greater reductions in mean blood pressure (BP) and heart rate and greater increase in SVi, but not with lower LV mass; RWT was lower with lower PP/SVi at year 2 follow-up.

CONCLUSIONS

Reduction in PP/SVi by long-term antihypertensive treatment did not have significant impact on change in LV mass index, but correlated with LV remodeling toward eccentric geometry.

Left ventricular mass predicts heart failure not related to previous myocardial infarction: the Cardiovascular Health Study

AIMS

The relationship of left ventricular hypertrophy (LVH) to incident heart failure (HF) not attributable to myocardial infarction (MI) has not been defined. We assessed whether LVH is an independent predictor of MI-independent HF.

METHODS AND RESULTS

LVH was assessed by echocardiographic LV mass index (in g/m2.7) and excess of LV mass (eLVM, in % of the observed value) relative to the amount predicted by sex, stroke work, and height, using a prognostically validated equation in 2078 participants of Cardiovascular Health Study without prevalent MI and normal systolic function. Increasing eLVM was associated with progressively increasing left atrial dimension and concentric geometry, decreasing systolic (P < 0.0001), and diastolic function (P < 0.04). After adjustment for age, sex, obesity, diabetes, hypertension, and antihypertensive therapy, and accounting for by incident MI, hazard of HF increased by 1% for each 1% increase in eLVM and by 3% for each g/m2.7 increase in LV mass index (both P < 0.0001). The results were confirmed when also C-reactive protein and measures of systolic (endocardial shortening) and diastolic function (categories of E/A ratio) were added to the Cox models.

CONCLUSION

In an elderly population, LVH, measured as LV mass index or eLVM is an independent predictor of incident HF not related to prevalent or incident MI.

Age-specific impact of self-monitored pulse pressure on hypertensive target organ damage in treated hypertensive patients

The authors examined the relationship of clinic and self-measured pulse pressure with target organ damage in 597 treated hypertensive patients without clinical evidence of renal dysfunction or a history of heart failure. The cross-sectional relationships of plasma brain natriuretic peptide (BNP) and urinary albumin/creatinine ratio with clinic and self-monitored pulse pressures were estimated in age tertile groups: younger than 67 years (n=193), 67 to 75 years (n=216), and older than 75 years (n=188), controlling for various confounding factors. In multivariable analyses, both clinic and self-monitored higher pulse pressures were associated with increased urinary albumin/creatinine ratio in all 3 age groups. Self-monitored higher pulse pressure, but not clinic pulse pressure, was consistently associated with increased BNP in the younger and middle-aged patients. In the very old (older than 75 years), however, there were no consistent associations between pulse pressure measures and BNP. More studies are needed in the evaluation of cardiac risk with hemodynamic measures in the very old.