Left ventricular mass and geometry and the risk of ischemic stroke

Left ventricular hypertrophy and left atrial size are associated with ischemic strokes among non-vitamin K antagonist oral anticoagulant users

BACKGROUND

Ischemic strokes (IS) occurring in patients taking non-vitamin K antagonist oral anticoagulants (NOACs) are becoming increasingly more frequent. We aimed to determine the clinical, echocardiographic, and neuroimaging markers associated with developing IS in patients taking NOACs for atrial fibrillation.

METHODS

From a quaternary care center, clinical/radiologic data were collected from consecutive NOAC users with IS and age-matched controls without IS. Brain MRIs were reviewed for markers of cerebral small vessel disease. Variables with significant differences between groups were entered into a multivariable regression model to determine predictors of IS. Among IS patients, a Cox regression analysis was constructed to determine predictors of IS recurrence during follow-up.

RESULTS

112 patients with IS and 94 controls were included in the study. Variables significantly different between groups included apixaban use, dabigatran use, prior cerebrovascular events, hemoglobin A1c (HbA1c), left ventricular hypertrophy, left atrial volume index, and severe white matter hyperintensities. After multivariable adjustment, prior cerebrovascular events (aOR 23.86, 95% CI [6.02-94.48]), HbA1c levels (aOR 2.36, 95% CI [1.39-3.99]), left ventricular hypertrophy (aOR 2.73, 95% CI [1.11-6.71]) and left atrial volume index (aOR 1.05, 95% CI [1.01-1.08]) increased the risk of stroke, whereas apixaban use appeared to decrease the risk (aOR 0.38, 95% CI [0.16-0.92]). Malignancy was associated with IS recurrence (aHR 4.90, 95% CI [1.35-18.42]) after adjustment for age and chronic renal failure.

CONCLUSIONS

Prior cerebrovascular events, diabetes, left ventricular hypertrophy, and increased left atrial size are risk factors for developing an IS among NOAC users.

Subclinical left ventricular systolic dysfunction and incident stroke in the elderly: long-term findings from Cardiovascular Abnormalities and Brain Lesions

AIMS

Heart disease is associated with an increased risk for ischaemic stroke. However, the predictive value of reduced left ventricular ejection fraction (LVEF) for stroke is controversial and only observed in patients with severe reduction. LV global longitudinal strain (LV GLS) can detect subclinical LV systolic impairment when LVEF is normal. We investigated the prognostic role of LV GLS for incident stroke in a predominantly elderly cohort.

METHODS AND RESULTS

Two-dimensional echocardiography with speckle tracking was performed in the Cardiac Abnormalities and Brain Lesions (CABL) study. Among 708 stroke-free participants (mean age 71.4 ± 9.4 years, 60.9% women), abnormal LV GLS (>-14.7%: 95% percentile of the subgroup without risk factors) was detected in 133 (18.8%). During a mean follow-up of 10.8 ± 3.9 years, 47 participants (6.6%) experienced an ischaemic stroke (26 cardioembolic or cryptogenic, 21 other subtypes). The cumulative incidence of ischaemic stroke was significantly higher in participants with abnormal LV GLS than with normal LV GLS (P < 0.001). In multivariate stepwise logistic regression analysis, abnormal LV GLS was associated with ischaemic stroke independently of cardiovascular risk factors including LVEF, LV mass, left atrial volume, subclinical cerebrovascular disease at baseline, and incident atrial fibrillation [hazard ratio (HR): 2.69, 95% confidence interval (CI): 1.47-4.92; P = 0.001]. Abnormal LV GLS independently predicted cardioembolic or cryptogenic stroke (adjusted HR: 3.57, 95% CI: 1.51-8.43; P = 0.004) but not other subtypes.

CONCLUSION

LV GLS was a strong independent predictor of ischaemic stroke in a predominantly elderly stroke-free cohort. Our findings provide insights into the brain-heart interaction and may help improve stroke primary prevention strategies.

Association between basal septal hypertrophy and left ventricular geometry in a community population

BACKGROUND

Left ventricular (LV) geometry is closely associated with cardiovascular disease; however, few studies have evaluated the relationship between basal septal hypertrophy (BSH) and LV geometry. In this study, we examined the relationship between BSH and LV geometry in a Beijing community population.

METHODS

The clinical and echocardiographic data of 1032 participants from a community in Beijing were analyzed. BSH was defined as a basal interventricular septal thickness ≥ 14 mm and a basal septal thickness/mid-septal thickness ≥ 1.3. On the basis of their echocardiographic characteristics, patients were described as having a normal geometry, concentric remodeling, concentric hypertrophy, or eccentric hypertrophy. Multivariable logistic regression was used to analyze the relationship between BSH, LV mass index (LVMI), and relative wall thickness (RWT).

RESULTS

The prevalence of BSH was 7.4% (95% confidence interval [CI] 5.8-9.0%). Basal and middle interventricular septal thickness, LV posterior wall thickness, and RWT were greater, while LVMI and LV end-diastolic dimension were lower in the BSH group than in the non-BSH group (p < 0.05). The BSH group accounted for the highest proportion of patients with concentric remodeling. A multivariable regression analysis showed that BSH increased by 3.99-times (odds ratio [OR] 3.99, 95% CI 2.05-7.78, p < 0.01) when RWT was > 0.42, but not when LVMI increased (OR 0.16, 95% CI 0.02-1.19, p = 0.07). There were no interactions between BSH and age, body mass index, sex, diabetes mellitus, coronary heart disease, stroke, and smoking in relation to an RWT > 0.42.

CONCLUSION

BSH was independently associated with an RWT > 0.42.

Deep learning-based whole-heart segmentation in 4D contrast-enhanced cardiac CT

Automatic cardiac chamber and left ventricular (LV) myocardium segmentation over the cardiac cycle significantly extends the utilization of contrast-enhanced cardiac CT, potentially enabling in-depth assessment of cardiac function. Therefore, we evaluate an automatic method for cardiac chamber and LV myocardium segmentation in 4D cardiac CT. In this study, 4D contrast-enhanced cardiac CT scans of 1509 patients selected for transcatheter aortic valve implantation with 21,605 3D images, were divided into development (N = 12) and test set (N = 1497). 3D convolutional neural networks were trained with end-systolic (ES) and end-diastolic (ED) images. Dice similarity coefficient (DSC) and average symmetric surface distance (ASSD) were computed for 3D segmentations at ES and ED in the development set via cross-validation, and for 2D segmentations in four cardiac phases for 81 test set patients. Segmentation quality in the full test set of 1497 patients was assessed visually on a three-point scale per structure based on estimated overlap with the ground truth. Automatic segmentation resulted in a mean DSC of 0.89 ± 0.10 and ASSD of 1.43 ± 1.45 mm in 12 patients in 3D, and a DSC of 0.89 ± 0.08 and ASSD of 1.86 ± 1.20 mm in 81 patients in 2D. The qualitative evaluation in the whole test set of 1497 patients showed that automatic segmentations were assigned grade 1 (clinically useful) in 98.5%, 92.2%, 83.1%, 96.3%, and 91.6% of cases for LV cavity and myocardium, right ventricle, left atrium, and right atrium. Our automatic method using convolutional neural networks performed clinically useful segmentation across the cardiac cycle in a large set of 4D cardiac CT images, potentially enabling in-depth assessment of cardiac function.

The remodelling index risk stratifies patients with hypertensive left ventricular hypertrophy

Aims 

Hypertensive left ventricular hypertrophy (LVH) is associated with increased cardiovascular events. We previously developed the remodelling index (RI) that incorporated left ventricular (LV) volume and wall-thickness in a single measure of advanced hypertrophy in hypertensive patients. This study examined the prognostic potential of the RI in reference to contemporary LVH classifications.

Methods and results 

Cardiovascular magnetic resonance was performed in 400 asymptomatic hypertensive patients. The newly derived RI (EDV3t, where EDV is LV end-diastolic volume and t is the maximal wall thickness across 16 myocardial segments) stratified hypertensive patients: no LVH, LVH with normal RI (LVH_Normal-RI), and LVH with low RI (LVH_Low-RI). The primary outcome was a composite of all-cause mortality, acute coronary syndromes, strokes, and decompensated heart failure. LVH_Low-RI was associated with increased LV mass index, fibrosis burden, impaired myocardial function and elevated biochemical markers of myocardial injury (high-sensitive cardiac troponin I), and wall stress. Over 18.3 ± 7.0 months (601.3 patient-years), 14 adverse events occurred (2.2 events/100 patient-years). Patients with LVH_Low-RI had more than a five-fold increase in adverse events compared to those with LVH_Normal-RI (11.6 events/100 patient-years vs. 2.0 events/100 patient-years, respectively; log-rank P < 0.001). The RI provided incremental prognostic value over and above a model consisting of clinical variables, LVH and concentricity; and predicted adverse events independent of clinical variables, LVH, and other prognostic markers. Concentric and eccentric LVH were associated with adverse prognosis (log-rank P = 0.62) that was similar to the natural history of hypertensive LVH (5.1 events/100 patient-years).

Conclusion 

The RI provides prognostic value that improves risk stratification of hypertensive LVH.

Prognostic power of left atrial strain in patients with acute heart failure

AIMS

Left atrial (LA) dysfunction can be associated with left ventricular (LV) disorders; however, its clinical significance has not been well-studied in patients with acute heart failure (AHF). We evaluated prognostic power of peak atrial longitudinal strain (PALS) of the left atrium according to heart failure (HF) phenotypes and atrial fibrillation (AF).

METHODS AND RESULTS

From an AHF registry with 4312 patients, we analysed PALS in 3818 patients. Patients were categorized into PALS tertiles. We also divided the patients according to HF phenotypes [HF with reduced ejection fraction (HFrEF), HF with mid-range ejection fraction (HFmrEF), or HF with preserved ejection fraction (HFpEF)] and presence of AF. The primary outcomes were all-cause mortality and HF hospitalization. PALS was weakly but significantly correlated with LA volume index (r = -0.310, P < 0.001), E/e' (r = -0.245, P < 0.001), and LV ejection fraction (r = 0.371, P < 0.001). A total of 2016 patients (52.8%) experienced adverse clinical events during median follow-up duration of 30.6 months (interquartile ranges 11.6-54.4 months). In the multivariate analysis, PALS was a significant predictor of events [hazard ratio (HR) 0.984, 95% confidence interval (CI) 0.971-0.996; P = 0.012]. Patients with the lowest tertile (HR 1.576, 95% CI 1.219-2.038; P < 0.001) had a higher number of events than those with the highest tertile in the multivariate analysis. In the subgroup analysis, however, PALS was not a prognosticator (HR 0.987, 95% CI 0.974-1.000; P = 0.056) in AF patients. The prognostic power of PALS was not different between HFrEF (HR 0.977, 95% CI 0.969-0.974; P < 0.001), HFmrEF (HR 0.984, 95% CI 0.972-0.996; P = 0.008), and HFpEF (HR 0.980, 95% CI 0.973-0.987; P < 0.001, P for interaction = 0.433).

CONCLUSION

PALS was a significant prognostic marker in AHF patients. The prognostic power was similar regardless of HF phenotypes, but PALS was not associated with clinical events in AF patients.

Association of relative wall thickness of left ventricle with incidence of thromboembolism in patients with non-valvular atrial fibrillation: The Fushimi AF Registry

AIMS

Atrial fibrillation (AF) increases the risk of thromboembolism, such as ischaemic stroke or systemic embolism (SE). The aim of this study was to investigate the relationship between left ventricular relative wall thickness (RWT) and the risk of thromboembolism in patients with non-valvular AF.

METHODS AND RESULTS

The Fushimi AF Registry is a community-based prospective survey of the patients with AF in Japan. Analyses were performed on 3067 non-valvular AF patients, in which RWT values determined by transthoracic echocardiography were available at the baseline. The high-RWT group (RWT above the median) was more often female, older, and had higher systolic blood pressure, CHADS2 and CHA2DS2-VASc scores, as compared with low-RWT group. During the median follow-up period of 1309 days, there was a higher incidence of ischaemic stroke/SE in the high-RWT group [unadjusted hazard ratio (HR), 1.91; 95% confidence interval (CI), 1.42-2.59]. On multivariate Cox regression analysis, including the components of CHA2DS2-VASc score, left atrial diameter, oral anticoagulant prescription at baseline, and type of AF, high RWT was independently associated with ischaemic stroke/SE (adjusted HR, 1.81; 95% CI, 1.34-2.47). Stratified analysis demonstrated no significant interaction for any subgroups. In Kaplan-Meier analysis, ordinal RWT quartiles stratified the incidence of ischaemic stroke/SE. Finally, addition of RWT to CHA2DS2-VASc score increased the performance of risk stratification for the incidence of stroke/SE.

CONCLUSION

Relative wall thickness was independently associated with ischaemic stroke/SE among Japanese patients with non-valvular AF, suggesting the importance of left ventricular morphology in contributing to adverse outcomes, particularly thromboembolism.

Left atrial enlargement and its association with left atrial strain in university athletes participated in 2015 Gwangju Summer Universiade

AIMS

Intensive and repetitive athletic training may result in cardiac geometric changes, but the determinants of left atrial (LA) enlargement (LAE) has been poorly studied. We investigated incidence and determinants of LAE and its association with LA strains in highly trained university athletes.

METHODS AND RESULTS

A total of 1073 athletes (451 females, 22.4 ± 2.4 years old) who were able to measure LA size, volume, and strains during 2015 Gwangju Summer Universiade were enrolled. LAE was defined as the increased LA volume index > 42 mL/m2. LA strains, reservoir, conduit, and contractile were measured by 2D speckle tracking method, and LA reservoir strain < 27.6% was considered as abnormal. LAE was developed in 205 athletes (19.1%). In univariate analysis, male [odds ratio (OR) = 1.679], Caucasian (OR = 1.746), non-African descent (OR = 1.804), body muscle mass (OR = 1.056), body fat mass (OR = 0.962), systolic blood pressure (OR = 1.012), heart rate (OR = 0.980), sports type with cardiovascular (CV) demand (OR = 1.474), training time (OR = 1.011), left ventricular (LV) global longitudinal strain (LVGLS, OR = 0.906), and LV stroke volume (LVSV, OR = 1.044) were significantly associated with LAE. In multivariate logistic regression analysis, heart rate (OR = 0.961) and sports type with CV demand (OR = 1.299), LVGLS (OR = 0.865) and LVSV (OR = 1.013) were independent determinants of LAE. Abnormal LA reservoir strain was noted in 56 athletes (5.2%), and the incidence of abnormal value was not different between two groups; 42 athletes (4.8%) in LAE vs. 14 (6.8%) in no LAE group (P = 0.293).

CONCLUSION

LAE was common in university athletes (19.1%) and associated with heart rate, sports type with CV demand, LVGLS, and LVSV. Although LAE was significantly associated with the lower LA reservoir strain, the incidence of abnormal value was very low (5.2%) and indifferent between LAE and no LAE group.

Blood pressure variability and night-time dipping assessed by 24-hour ambulatory monitoring: Cross-sectional association with cardiac structure in adolescents

Greater blood pressure (BP) is associated with greater left ventricular mass indexed to height2.7 (LVMi2.7) in adolescents. This study examined whether greater BP variability and reduced night-time dipping are associated with cardiac remodeling in a general population of adolescents. A cross-sectional analysis was undertaken in 587 UK adolescents (mean age 17.7 years; 43.1% male). BP was measured in a research clinic and using 24-hour ambulatory monitoring. We examined associations (for both systolic and diastolic BP) of: 1) clinic and 24-hour mean BP; 2) measures of 24-hour BP variability: standard deviation weighted for day/night (SDdn), variability independent of the mean (VIM) and average real variability (ARV); and 3) night-time dipping with cardiac structures. Cardiac structures were assessed by echocardiography: 1) LVMi2.7; 2) relative wall thickness (RWT); 3) left atrial diameter indexed to height (LADi) and 4) left ventricular internal diameter in diastole (LVIDD). Higher systolic BP was associated with greater LVMi2.7. Systolic and diastolic BP were associated with greater RWT. Associations were inconsistent for LADi and LVIDD. There was evidence for associations between both greater SDdn and ARV and higher RWT (per 1 SD higher diastolic ARV, mean difference in RWT was 0.13 SDs, 95% CI 0.045 to 0.21); these associations with RWT remained after adjustment for mean BP. There was no consistent evidence of associations between night-time dipping and cardiac structure. Measurement of BP variability, even in adolescents with blood pressure in the physiologic range, might benefit risk of cardiovascular remodeling assessment.

Prevalence of and risk factors for abnormal left ventricular geometrical patterns in hypertensive subjects administered irbesartan

Background

Distinct populations differ in LVH prevalence and impaired LV geometry. Currently, the prevalence of and risk factors for LV geometric patterns in Chinese hypertensives administered irbesartan have not been specifically addressed in large studies.

Methods

Totally 10,883 patients (6623 men and 4260 women) completed the survey, including 1181 hypertensives administered irbesartan (488 males and 693 females) that were finally enrolled. Based on LVMI and RWT derived from comprehensive echocardiography, the LV geometric patterns of irbesartan‐treated hypertensive individuals were classified into four types, including the normal, concentric remodeling, and concentric and eccentric hypertrophy groups. Logistic regression analysis was applied in males and females, respectively, for determining odds ratios (ORs) and 95% confidence intervals (CIs) for various potential risk factors for abnormal LV geometrical patterns in irbesartan‐treated hypertensives.

Results

The clinical and echocardiographic data differed significantly between males and females. The prevalence rates of concentric remodeling, concentric hypertrophy, and eccentric hypertrophy were 36.3%, 15.4%, and 6.1% in males, respectively, and 23.5%, 20.3%, and 23.8% in females, accordingly. Gender, daily dose of irbesartan, BMI, SBP, WtHR, and neck‐circumference were significantly associated with LV geometric patterns. After adjustment for confounding factors, risk factors for LVH and impaired LV geometry included SBP, WtHR in males, and MAU‐Cr and WtHR in females.

Conclusions

LVH and impaired LV geometric patterns are more prevalent in females (67.7%) compared with that in males (57.8%) among hypertensives upon irbesartan administration. For such population, risk factors beyond elevated blood pressure may be involved in the progression of LVH and impaired LV geometric patterns in both genders.

Fibroblast growth factor 23 and cognitive impairment: The health, aging, and body composition study

BACKGROUND

Concentrations of fibroblast growth factor 23 (FGF-23), a hormone that regulates phosphorus and vitamin D metabolism, increase as kidney function declines. Excess fibroblast growth factor 23 may impact brain function through promotion of vascular disease or through direct effects on neuronal tissue.

METHODS

In the Healthy Aging and Body Composition Study, a longitudinal observational cohort of well-functioning older adults, intact serum FGF-23 was assayed in 2,738 individuals. Cognitive function was assessed at baseline and longitudinally at years 3, 5, and 8 by administration of the Modified Mini Mental State Examination (3MSE), a test of global cognitive function, and the Digit Symbol Substitution Test (DSST), a test primarily of executive function. The associations between FGF-23 and baseline cognitive function and incident cognitive impairment were evaluated using logistic and Poisson regression respectively, and were adjusted for demographics, baseline estimated glomerular filtration rate (eGFR), urine albumin/creatinine ratio, comorbidity, and other measures of mineral metabolism including soluble klotho.

RESULTS

The mean (SD) age was 74(3) years, with 51% female, and 39% black. The median (25th, 75th) FGF-23 concentration was 47 pg/mL (37, 60). Three hundred ninety-two individuals had prevalent cognitive impairment by the 3MSE and 461 by the DSST. There was no observed association between FGF-23 and baseline cognitive function for either cognitive test. There were 277 persons with incident cognitive impairment by 3MSE, and 333 persons with incident cognitive impairment by DSST. In fully adjusted models, each two-fold higher concentration of baseline FGF-23 was not associated with incident cognitive impairment by the 3MSE (IRR = 1.02[0.88, 1.19] fully adjusted model) or by the DSST (IRR = 0.98 [0.84, 1.15]. We saw no difference when analyses were stratified by eGFR greater than or less than 60 ml/min/1.73m2.

CONCLUSION

Intact FGF-23 was not associated with baseline cognitive function or incident cognitive impairment in this cohort well-functioning older adults.

Hemoglobin concentration and the incidence of stroke in the general Japanese population: the Jichi Medical School Cohort Study

BACKGROUND

Several studies have described an association between hemoglobin concentration and stroke; however, the influence of hemoglobin on stroke incidence has not been fully revealed. Our objective was to elucidate the association between hemoglobin concentration and stroke incidence in Japanese community residents.

METHODS

In the present study, we collected the data of 12,490 subjects who were enrolled between April 1992 and July 1995 in the Jichi Medical School (JMS) Cohort Study. We excluded the subjects with a history of stroke. Hemoglobin concentrations were grouped in quartiles, and quartile 2 (Q2) was used as the reference category. A Cox proportional-hazards model was used to examine hazard ratios (HRs) and the stroke incidence rates with 95% confidence intervals (CIs).

RESULTS

During 10.8 years of follow-up, 409 participants (212 men and 197 women) experienced a new stroke, including 97 intracerebral hemorrhages, 259 cerebral infarctions, and 52 subarachnoid hemorrhages (SAH). In sex-specific hemoglobin quartiles, the multivariate-adjusted HR was statistically significantly higher in Q1 than in Q2, and a relationship similar to a J shape was observed between all strokes (HR in Q2 vs. Q1, 1.36; 95% CI, 1.02-1.83; Q3, 1.20; 95% CI, 0.87-1.64; and Q4, 1.16; 95% CI, 0.84-1.60). Furthermore, the analysis of stroke subtypes showed a statistically significantly higher multivariate-adjusted HR in Q1 than in Q2 for SAH (HR, 2.61; 95% CI, 1.08-6.27).

CONCLUSIONS

A low hemoglobin concentration was associated with an increased risk of stroke, which was strongly influenced by the incidence of SAH.

Left Ventricular Hypertrophy and Cerebral Small Vessel Disease: A Systematic Review and Meta-Analysis

Background and Purpose

Left ventricular hypertrophy (LVH) is associated with the risk of stroke and dementia independently of other vascular risk factors, but its association with cerebral small vessel disease (CSVD) remains unknown. Here, we employed a systematic review and meta-analysis to address this gap.

Methods

Following the MOOSE guidelines (PROSPERO protocol: CRD42018110305), we systematically searched the literature for studies exploring the association between LVH or left ventricular (LV) mass, with neuroimaging markers of CSVD (lacunes, white matter hyperintensities [WMHs], cerebral microbleeds [CMBs]). We evaluated risk of bias and pooled association estimates with random-effects meta-analyses.

Results

We identified 31 studies (n=25,562) meeting our eligibility criteria. In meta-analysis, LVH was associated with lacunes and extensive WMHs in studies of the general population (odds ratio [OR]_lacunes, 1.49; 95% confidence interval [CI], 1.12 to 2.00) (OR_WMH, 1.73; 95% CI, 1.38 to 2.17) and studies in high-risk populations (OR_lacunes: 2.39; 95% CI, 1.32 to 4.32) (OR_WMH, 2.01; 95% CI, 1.45 to 2.80). The results remained stable in general population studies adjusting for hypertension and other vascular risk factors, as well as in sub-analyses by LVH assessment method (echocardiography/electrocardiogram), study design (cross-sectional/cohort), and study quality. Across LV morphology patterns, we found gradually increasing ORs for concentric remodelling, eccentric hypertrophy, and concentric hypertrophy, as compared to normal LV geometry. LVH was further associated with CMBs in high-risk population studies.

Conclusions

LVH is associated with neuroimaging markers of CSVD independently of hypertension and other vascular risk factors. Our findings suggest LVH as a novel risk factor for CSVD and highlight the link between subclinical heart and brain damage.

Additional prognostic value of electrocardiographic left ventricular hypertrophy in traditional cardiovascular risk assessments in chronic kidney disease

BACKGROUND

Left ventricular hypertrophy (LVH) is a common predictor of the cardiovascular prognosis in chronic kidney disease (CKD). However, whether or not electrocardiography-derived LVH (ECG-LVH) has prognostic value in patients with various degrees of CKD and improves the cardiovascular risk stratification based on traditional risk factors remains unclear.

METHODS

A total of 7206 participants at least 40 years of age who were free from cardiovascular events in a general population were followed for the incidence of cardiovascular events. CKD was confirmed by either the presence of a reduced estimated glomerular filtration rate (eGFR) (<60 ml/min per 1.73 m) or albuminuria, defined as a urinary albumin-to-creatinine ratio (UACR) of at least 30 mg/g Cr.

RESULTS

A total of 1886 (26.2%) had CKD, of which 1471 (78.0%) had a preserved eGFR (CKD stage 1-2). After an average 11.3 years of follow-up, the adjusted hazard ratio for the incidence of cardiovascular events significantly increased for ECG-LVH according to the Sokolow--Lyon voltage, Cornell voltage, or Cornell voltage product among participants with CKD (hazard ratio 1.47, P = 0.002), in contrast to those without CKD (hazard ratio 1.15, P = 0.210). The inclusion of any ECG-LVH parameters improved the accuracy of reclassification in any risk prediction model based on the eGFR, UACR, or Framingham 10-year risk score in the CKD participants (net reclassification improvement = 0.13-0.32, all P values <0.040).

CONCLUSION

In patients with CKD stage 1-5, ECG-LVH is useful for predicting the risk of future cardiovascular events and adds prognostic information to traditional cardiovascular risk assessments.

Ischemic stroke risk during post-discharge phases of heart failure: association of left ventricular concentric geometry

Despite a higher risk of ischemic stroke in hospitalized patients with acute heart failure (HF), little is known about the risk of ischemic stroke during the post-discharge phases of HF. Here we investigated (1) the ischemic stroke incidence rate during the post-discharge phases among HF patients receiving standard treatments; (2) the association between ischemic stroke incidence and clinical background, including cardiac structure and function. Among 950 patients who required hospitalization for HF (median duration: 19 days) at our institution, where they received standard treatments, we investigated stroke occurrences during the 2-year period following their discharge and retrospectively evaluated their clinical data. Relative wall thickness (RWT) and left ventricular (LV) mass were determined based on echocardiographic measurements and then used to determine LV geometric patterns. During the follow-up period, ischemic stroke occurred in 25 patients (2.6%) after hospital discharge (1.4 per 100 patient-years). The incidence rate of IS tended to be higher in patients with AF than those without AF (1.8 vs. 1.0 per 100 patient-years, respectively). Notably, multivariate analysis revealed a significant association between RWT and ischemic stroke risk (p < 0.05). RWT was associated with ischemic stroke risk in patients with AF or left atrial enlargement, but not in patients without them. These findings suggest that even with standard HF treatments, the risk of ischemic stroke is high in patients with HF. Moreover, LV concentric geometry is a significant risk factor for ischemic stroke in patients with HF, especially in those with left atrial remodeling and/or AF.

Left Ventricular Mass at MRI and Long-term Risk of Cardiovascular Events: The Multi-Ethnic Study of Atherosclerosis (MESA)

Background Few data exist on the long-term risk prediction of elevated left ventricular (LV) mass quantified by MRI for cardiovascular (CV) events in a contemporary, ethnically diverse cohort. Purpose To assess the long-term impact of elevated LV mass on CV events in a prospective cohort study of a multiethnic population in relationship to risk factors and coronary artery calcium (CAC) score. Materials and Methods The Multi-Ethnic Study of Atherosclerosis, or MESA (ClinicalTrials.gov: NCT00005487), is an ongoing prospective multicenter population-based study in the United States. A total of 6814 participants (age range, 45-84 years) free of clinical CV disease at baseline were enrolled between 2000 and 2002. In 4988 participants (2613 [52.4%] women; mean age, 62 years ± 10.1 [standard deviation]) followed over 15 years for CV events, LV mass was derived from cardiac MRI at baseline enrollment by using semiautomated software at a central core laboratory. Cox proportional hazard models, Kaplan-Meier curves, and z scores were applied to assess the impact of LV hypertrophy. Results A total of 290 participants had hard coronary heart disease (CHD) events (207 myocardial infarctions [MIs], 95 CHD deaths), 57 had other CV disease-related deaths, and 215 had heart failure (HF). LV hypertrophy was an independent predictor of hard CHD events (hazard ratio [HR]: 2.7; 95% confidence interval [CI]: 1.9, 3.8), MI (HR: 2.8; 95% CI: 1.8, 4.0), CHD death (HR: 4.3; 95% CI: 2.5, 7.3), other CV death (HR: 7.5; 95% CI: 4.2, 13.5), and HF (HR: 5.4; 95% CI: 3.8, 7.5) (P < .001 for all end points). LV hypertrophy was a stronger predictor than CAC for CHD death, other CV death, and HF (z scores: 5.4 vs 3.4, 6.8 vs 2.4, and 9.7 vs 3.2 for LV hypertrophy vs CAC, respectively). Kaplan-Meier analysis demonstrated an increased risk of CV events in participants with LV hypertrophy, particularly after 5 years. Conclusion Elevated left ventricular mass was strongly associated with hard coronary heart disease events, other cardiovascular death, and heart failure over 15 years of follow-up, independent of traditional risk factors and coronary artery calcium score. © RSNA, 2019 See also the editorial by Hanneman in this issue.

Impact of obstructive sleep apnea on cardiac organ damage in patients with acute ischemic stroke

BACKGROUND AND PURPOSE

Both obstructive sleep apnea (OSA) and cardiac organ damage have a crucial role in acute ischemic stroke. Our aim is to explore the relationship between OSA and cardiac organ damage in acute stroke patients.

METHODS

A total of 130 consecutive patients with acute ischemic stroke were enrolled. Patients underwent full multichannel 24-h polysomnography for evaluation of OSA and echocardiography to evaluate left ventricle (LV) mass index (LV mass/BSA, LV mass/height), thickness of interventricular septum (IVS) and posterior wall (LVPW), LV ejection fraction and left atrium enlargement. Information on occurrence of arterial hypertension and its treatment before stroke was obtained from patients' history.

RESULTS

61.9% (70) of patients, mostly men (67.1%), with acute stroke had OSA (AHI > 10). Patients with acute stroke and OSA showed a significant increase (P < 0.05) of LV mass index, IVS and LVPW thickness and a significant left atrial enlargement as compared with patients without OSA. LV ejection fraction was not significantly different in stroke patients with and without OSA and was within normal limits. No relationship was found among cardiac alterations, occurrence of OSA and history of hypertension.

CONCLUSION

Acute stroke patients with OSA had higher LV mass and showed greater left atrial enlargement than patients without OSA. This study confirms the high prevalence of OSA in stroke patients, suggesting also an association between OSA and cardiac target organ damage. Our finding of structural LV abnormalities in acute stroke patients with OSA suggests a potential role of OSA as contributing factor in determining both cerebrovascular and cardiac damage, even in absence of clear link with a history of blood pressure elevation.

Changes in Left Ventricular Mass and Geometry in the Older Adults: Role of Body Mass and Central Obesity

BACKGROUND

Left ventricular (LV) hypertrophy is an independent risk factor for cardiovascular outcomes. There are limited data about modifiable factors associated with progression of LV hypertrophy in older adults. Our objective is to describe the changes in LV mass and geometry over time in a predominantly older multiethnic cohort and to identify possible predictors of changes over time.

METHODS

We analyzed data from participants in the Northern Manhattan Study who underwent serial echocardiographic studies, comparing the baseline and the most recent echocardiograms. We recorded changes in LV mass and geometry and correlated them with baseline characteristics using linear regression models.

RESULTS

There were 826 participants (mean age, 64.2 ± 8.0 years) included in the analysis (time between measurements, 8.5 ± 2.7 years). Overall, LV mass index increased from 45.0 ± 12.7 to 50.3 ± 14.6 g/m^2.7 (P < .001). There were 548 participants (66.3%) with LV mass increase; 258 individuals (31.2%) showed worsening LV geometry. Multivariable analysis showed that change in LV mass index was independently associated with baseline LV mass index (β estimate, -17.000 [standard error, 1.508]; P < .001), hypertension (2.094 [0.816], P = .011), body mass index (0.503 [0.088], P < .001), and waist-to-hip ratio (1.031 [0.385], P = .008). Both waist-to-hip ratio and waist-to-height ratio remained significantly associated with LV mass increase even after adjusting for body mass index (P = .008 and P = .036, respectively).

CONCLUSIONS

Regardless of race/ethnicity, LV mass progressed over time in older adults. We also observed that worsening geometry was frequent. Assessment of central obesity in the older population is important because indicators of central obesity add prognostic value over body mass index for the risk of LV mass increase.

Echocardiographic Abnormalities and Determinants of 1-Month Outcome of Stroke Among West Africans in the SIREN Study

Background

Little is known about the relationship between echocardiographic abnormalities and outcome among patients with acute stroke. We investigated the pattern and association of baseline echocardiographic variables with 1‐month disability and mortality among patients with stroke in the SIREN (Stroke Investigative Research and Education Network) study.

Methods and Results

We enrolled and followed up consecutive 1020 adult patients with acute stroke with baseline transthoracic echocardiography from west Africa. To explore the relationship between echocardiographic variables and 1‐month disability (using modified Rankin scale >3) and fatality, regression models were fitted. Relative risks were computed with 95% CIs. The participants comprised 60% men with a mean age of 59.2±14.6 years. Ischemic stroke was associated with smaller aortic root diameter (30.2 versus 32.5, P=0.018) and septal (16.8 versus 19.1, P<0.001) and posterior wall thickness at systole (18.9 versus 21.5, P=0.004). Over 90% of patients with stroke had abnormal left ventricular (LV) geometry with eccentric hypertrophy predominating (56.1%). Of 13 candidate variables investigated, only baseline abnormal LV geometry (concentric hypertrophy) was weakly associated with 1‐month disability (unadjusted relative risk, 1.80; 95% CI, 0.97–5.73). Severe LV systolic dysfunction was significantly associated with increased 1‐month mortality (unadjusted relative risk, 3.05; 95% CI, 1.36–6.83).

Conclusions

Nine of 10 patients with acute stroke had abnormal LV geometry and a third had systolic dysfunction. Severe LV systolic dysfunction was significantly associated with 1 month mortality. Larger studies are required to establish the independent effect and unravel predictive accuracy of this association.

Differential impact of local and regional aortic stiffness on left ventricular remodeling: a cardiovascular magnetic resonance study

BACKGROUND

Left ventricular (LV) remodeling and aortic stiffness have independent predictive value for all causes and cardiovascular mortality. Because elastic properties of the arterial wall vary along the aortic pathway, we hypothesized that local and regional aortic stiffness could differently impact on LV remodeling.

METHODS AND RESULTS

Regional aortic stiffness was determined from carotid-femoral pulse wave velocity (cfPWV) measured by aplanation tonometry. Aortic arch pulse wave velocity was measured by phase contrast cardiovascular magnetic resonance (CMR). Local stiffness was calculated in the ascending aorta pulse wave velocity (aaPWV) and descending aorta pulse wave velocity using central pulse pressure measurement, cine CMR acquisition, and surface change estimation. CMR LV remodeling was expressed as LV mass to end-diastolic volume ratio.We evaluated 146 study participants (41 ± 15 years) free of overt cardiovascular disease. In stepwise multivariate regression analysis, cfPWV and aaPWV were significantly and independently correlated to mass to end-diastolic volume ratio (partial R = 0.07 and R = 0.10, respectively, all P < 0.005) after adjustment for age, sex, BMI, brachial mean blood pressure, and central pulse pressure. Descending aorta pulse wave velocity was correlated with mass to end-diastolic volume ratio to a lower extent (R = 0.04, P = 0.0115) and aortic arch pulse wave velocity was not independently associated with mass to end-diastolic volume ratio. CfPWV and aaPWV were both independently associated with mass to end-diastolic volume ratio, explaining 5 and 8% of mass to end-diastolic volume ratio variance, respectively.

CONCLUSION

In study participants free of overt cardiovascular disease, stiffness of the ascending aorta representing the local proximal aortic function face to the LV and of the downstream aortic pathway assessed by cfPWV reflecting more advanced alterations of material properties involving the entire aorta, are independent determinants of LV remodeling after adjustment to age, BMI, mean blood pressure, and sex.

Prognostic value of global left atrial peak strain in patients with acute ischemic stroke and no evidence of atrial fibrillation

Prognostic stratification of acute ischemic stroke (AIS) patients without atrial fibrillation (AF) remains a challenge. Two-dimensional speckle tracking echocardiography (2D-STE) has recently been introduced for dynamic evaluation of left atrial function. However only few data are actually available regarding the application of 2D-STE in AIS patients. The aim of our study was to assess the prognostic role of global left atrial peak strain (GLAPS), measured by 2D-STE, in AIS patients without AF history. Eighty-five AIS patients (mean age 74.1 ± 12.1 years, 49 males) with normal sinus rhythm on ECG and without AF history were enrolled in the prospective study. All patients underwent a complete echocardiographic study with 2D-STE. At 1 year follow-up, we evaluated the occurrence of a composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations. GLAPS was markedly reduced in AIS patients (15.71 ± 4.70%), without any statistically significant difference between the stroke subtypes. At 1-year follow-up, 14 deaths and 17 hospital readmissions were detected in AIS subjects. On a multivariate Cox model, variables independently associated with the occurrence of the composite endpoint were the "Rankin in" Scale (HR 1.69, p = 0.001), GFR (HR 0.98, p = 0.03) and the GLAPS value (HR 0.78, p < 0.0001). A GLAPS value ≤ 15.5% predicted the composite endpoint with sensitivity of 100% and specificity of 80%. A GLAPS value ≤ 15.5% reflects a more advanced atrial cardiomyopathy and might provide a reliable and useful prognostic risk stratification of AIS patients without AF history.

Left ventricular geometry and periodontitis in patients with the metabolic syndrome

OBJECTIVE

The presence of periodontal disease (PD) in subjects affected by the metabolic syndrome (MetS) may affect their risk of developing cardiovascular disease. The aim of this cross-sectional study was to investigate the systemic impact of PD in MetS, by assessing measures of sub-clinical atherosclerosis and left ventricular mass and geometry.

MATERIALS AND METHODS

A total of 103 patients undergoing treatment for MetS were examined for confirmation of diagnosis, blood sampling, and measures of pulse wave velocity (PWV), carotid intima-media thickness (c-IMT), left ventricular mass index (LVM), and relative wall thickness (RWT). All subjects underwent a detailed dental assessment, including measurements of DMFT (decayed-missing-filled teeth) and periodontal parameters.

RESULTS

Ten patients (10%) were diagnosed with healthy-mild periodontitis, 38 patients (37%) were diagnosed in the moderate periodontitis group, and 55 (53%) had severe periodontitis. A total of 37% of subjects were affected by dental caries. Linear regression analysis revealed that patients with severe PD had increased average ventricular RWT (adjusted p = 0.032). Average full mouth probing pocket depth (PPD) was also associated with RWT (adjusted p = 0.006). No associations between PD and c-IMT, PWV, and LVM were detected after adjusted analyses.

CONCLUSION

This study suggests that periodontitis may be associated with concentric left ventricular remodeling, a predictive index of cardiovascular events.

CLINICAL RELEVANCE

The presence of periodontitis in patients with MetS might have an effect on left ventricular geometry. These findings stress the importance of prevention, diagnosis, and management of periodontitis in patients with MetS.

TRAIL REGISTRATION

NCT03297749.

Estimate of ischemic stroke prevalence according to a novel 4-tiered classification of left ventricular hypertrophy: insights from the general Chinese population

BACKGROUND

Recently, a novel 4-tiered classification of left ventricular hypertrophy (LVH) based on ventricular dilatation (indexed LV end-diastolic volume [EDV]) and concentricity (mass/EDV^0.67) has improved all-cause and cardiovascular mortality risk stratification. However, their possible association with ischemic stroke has not been extensively evaluated in the general population.

METHODS

We evaluated a cross-sectional study of 11,037 subjects from the general population of China in whom echocardiographic and ischemic stroke data were available to subdivide patients with LVH into four geometric patterns: indeterminate, dilated, thick and both thick and dilated hypertrophy.

RESULTS

Compared with normal LV geometry, indeterminate and thick hypertrophy showed a higher prevalence of ischemic stroke (p < .05). Ischemic stroke was significantly greater in participants with indeterminate (adjusted odd ratio [OR]:1.635, 95% confidence interval [CI]: 1.115-2.398) and thick (2.143 [1.329-3.456]) hypertrophy but not significantly in those with dilated (1.251 [0.803-1.950]) and both thick and dilated hypertrophy (0.926 [0.435-1.971]) compared with normal geometry in multivariable analysis.

CONCLUSIONS

Indeterminate and thick hypertrophy were significantly associated with the presence of ischemic stroke in the general Chinese population. The new 4-tiered categorization of LVH can permit a better understanding of which subjects are at high enough risk for ischemic stroke to warrant early targeted therapy. Key messages This was the first study to investigate whether a 4-tiered classification of LVH defines subgroups in the general population that are at variable risks of ischemic stroke. We identified that thick hypertrophy carried the greatest odd for ischemic stroke, independently of traditional risk factors, followed by indeterminate hypertrophy. The new 4-tiered categorization of LVH emerged as a valuable operational approach, a potential alternative to LVM, to refine ischemic stroke stratification in general population.

Subclinical Compromise in Cardiac Strain Relates to Lower Cognitive Performances in Older Adults

BACKGROUND

Global longitudinal strain (GLS), reflecting total shortening of the myocardium during the cardiac cycle, has emerged as a more precise myocardial function measure than left ventricular ejection fraction (LVEF). Longitudinal strain may be selectively affected in subclinical heart disease, even in the presence of normal LVEF. This study examines subclinical cardiac dysfunction, assessed by GLS and LVEF, and cognition among older adults.

METHODS AND RESULTS

Vanderbilt Memory and Aging Project participants who were free of clinical dementia, stroke, and heart failure (n=318, 73±7 years, 58% male) completed neuropsychological assessment and cardiac magnetic resonance to quantify GLS and LVEF. Linear regression models related GLS and LVEF to neuropsychological performances, adjusting for age, sex, race/ethnicity, education, Framingham Stroke Risk Profile, cognitive diagnosis, and APOE*ε4 status. Models were repeated with a cardiac×cognitive diagnosis interaction term. Compromised GLS (reflected by higher values) related to worse naming (β=-0.07, P=0.04), visuospatial immediate recall (β=-0.83, P=0.03), visuospatial delayed recall (β=-0.22, P=0.03), and verbal delayed recall (β=-0.11, P=0.007). LVEF did not relate to worse performance on any measure (P>0.18). No diagnostic interactions were observed.

CONCLUSIONS

Our study results are among the first to suggest that compromised GLS relates to worse episodic memory and language performance among older adults who are free of clinical dementia, stroke, and heart failure. Subclinical cardiac dysfunction may correlate with cognitive health in late life, even when LVEF remains normal. The results add to growing evidence that GLS may be a more sensitive and preferred method for quantifying subclinical changes in cardiac function.

Sequencing of Linkage Region on Chromosome 12p11 Identifies PKP2 as a Candidate Gene for Left Ventricular Mass in Dominican Families

Increased left ventricular mass (LVM) is an intermediate phenotype for cardiovascular disease (CVD) and a predictor of stroke. Using families from the Dominican Republic, we have previously shown LVM to be heritable and found evidence for linkage to chromosome 12p11. Our current study aimed to further characterize the QTL by sequencing the 1 LOD unit down region in 10 families from the Dominican Republic with evidence for linkage to LVM. Within this region, we tested 5477 common variants [CVs; minor allele frequency (MAF) ≥5%] using the Quantitative Transmission-Disequilibrium Test (QTDT). Gene-based analyses were performed to test rare variants (RVs; MAF < 5%) in 181 genes using the family-based sequence kernel association test. A sample of 618 unrelated Dominicans from the Northern Manhattan Study (NOMAS) and 12 Dominican families with Exome Array data were used for replication analyses. The most strongly associated CV with evidence for replication was rs1046116 (Discovery families P = 9.0 × 10-4; NOMAS P = 0.03; replication families P = 0.46), a missense variant in PKP2 In nonsynonymous RV analyses, PKP2 was one of the most strongly associated genes (P = 0.05) with suggestive evidence for replication in NOMAS (P = 0.05). PKP2 encodes the plakophilin 2 protein and is a desmosomal gene implicated in arrythmogenic right ventricular cardiomyopathy and recently in arrhythmogenic left ventricular cardiomyopathy, which makes PKP2 an excellent candidate gene for LVM. In conclusion, sequencing of our previously reported QTL identified common and rare variants within PKP2 to be associated with LVM. Future studies are necessary to elucidate the role these variants play in influencing LVM.

Similarities and Differences in Epidemiology and Risk Factors of Cerebral and Myocardial Ischemic Disease

Ischemic heart disease and cerebral ischemia represent the leading causes of mortality worldwide. Both entities share risk factors, pathophisiology and etiologic aspects by means of a main common mechanism, atherosclerosis. The autors aimed to investigate differences and similarities in epidemiology and risk factors that could be found between both entities. In a retrospective sudy 403 patients were included and divided into two groups: group of 289 patients with history of myocardial infarction (AMI), and group of 114 patients with history of ischemic stroke (IS). All patients were evaluated for nonmodifiable risk faktors, which included age and sex, and modifiable, such as hypertension, dyslipidemia, diabetes, obesity, physical activity and smoking. Diff erences in some epidemiological aspects were also considered: occupation, marital status, alcohol consumption, exposure to stress. Patients with history of IS were significantly older then AMI patients (64.0 ± 9.9 vs 64.0 ± 9.9, p=0,028), with higher diastolic blood pressure (87,1 ± 10,2 vs 83,6 ± 10,4, p=0,003) and higher Sokolow-Lyon index in ECG, an also index of left ventricular hypertrophy (19,2 ± 9,1 vs 14,7 ± 6,5). Th ere were no significant differences between groups in the estimated body mass index and waist circumference. Differences between groups in stress exposure, occupation, alcohol consumption or physical activity were no significant. Patients in AMI group were more frequently male (199 (69%) vs 59 (52%), p=0,001), married (252 (87%) vs 88 (77%), p=0,037), smokers (162 (56%) vs 50 (44%), p=0,018) and with higher incidence od dyslipidemia (217 (75%) vs 73 (64%), p=0,019) compared with IS group. Incidence of arterial hypertension and diabetes was similar in both groups. Both entities share similar pathophysiological mechanisms and, consequently, main traditional risk factors. However, incidence of myocardial infarction increases with male sex, dyslipidemia, smoking and marital status, while incidense of ischemic stroke increases with age, higher diastolic blood pressure and also with ECG signs of left ventricular hypertrophy.

Novel Index of Maladaptive Myocardial Remodeling in Hypertension

BACKGROUND

Hypertensive left ventricular hypertrophy (HTN-LVH) is a leading cause of heart failure. Conventional patterns of cardiac geometry do not adequately risk-stratify patients with HTN-LVH. Using cardiovascular magnetic resonance, we developed a novel Remodeling Index (RI) that was designed to detect an exaggerated hypertrophic response to hypertension and tested its potential to risk-stratify hypertensive patients.

METHODS AND RESULTS

The RI was derived using LaPlace's Law (), and normal RI ranges were established in 180 healthy volunteers. The utility of the RI was examined in 256 asymptomatic hypertensive patients and 10 patients with heart failure with preserved ejection fraction. Hypertensive patients underwent multimodal cardiac assessment: contrast-enhanced cardiovascular magnetic resonance, echocardiograms, 24-hour blood pressure monitoring, and cardiac biomarkers (high-sensitivity cardiac troponins, NT-proBNP [N-terminal pro-B-type natriuretic peptide], and galectin-3). Blood pressure accounted for only 20% of the variance observed in LV mass. Although there was no association between blood pressure and myocardial fibrosis, LV mass was independently associated with fibrosis. Compared with hypertensive patients without LVH (n=191; 74.6%) and those with HTN-LVH and normal RI (n=50; 19.5%), patients with HTN-LVH and low RI (HTN-LVH/low RI; n=15, 5.9%) had an amplified myocardial response: elevated indexed LV masses (83±24 g/m2), more fibrosis (73%), and higher biomarkers of myocardial injury and dysfunction (P<0.05 for all). RI was similar in HTN-LVH/low RI and heart failure with preserved ejection fraction (4.1 [3.4-4.5] versus 3.7 [3.4-4.0], respectively; P=0.15).

CONCLUSIONS

We suggest that RI provides an approach for stratifying hypertensive patients and is suitable for testing in other disease cohorts to assess its clinical utility.

CLINICAL TRIAL REGISTRATION

URL: https://clinicaltrials.gov. Unique identifier: NCT02670031.

Left Ventricular Geometry Determines Prognosis and Reverse J-Shaped Relation Between Blood Pressure and Mortality in Ischemic Stroke Patients

OBJECTIVES

This study sought to investigate the prognostic significance of left ventricular (LV) mass and geometry in ischemic stroke survivors, as well as the LV geometry-specific differences in the blood pressure-mortality relationship.

BACKGROUND

LV mass and geometry are well-known prognostic factors in various populations; however, there are no data on their role in ischemic stroke patients.

METHODS

We prospectively recruited 2,328 consecutive patients admitted with acute ischemic stroke to our institute between 2002 and 2010. Of these, 2,069 patients were analyzed in whom echocardiographic data were available to assess LV mass and geometry.

RESULTS

All-cause mortality was significantly greater in patients with concentric hypertrophy (adjusted hazard ratio [HR]: 1.417; 95% confidence interval [CI]: 1.045 to 1.920) and concentric remodeling (HR: 1.540; 95% CI: 1.115 to 2.127) but nonsignificantly in those with eccentric hypertrophy (HR: 1.388; 95% CI: 0.996 to 1.935) compared with normal geometry in multivariate analyses. Relative wall thickness was a significant predictor of all-cause mortality (HR: 1.149 per 0.1-U increase in relative wall thickness; 95% CI: 1.021 to 1.307), whereas LV mass index was not (HR: 1.003 per 1 g/m² increase in LV mass index; 95% CI: 0.999 to 1.007). Similar results were observed with cardiovascular mortality. In multivariable fractional polynomials, patients with altered LV geometry showed reverse J-curve relationships between acute-phase systolic blood pressure and all-cause or cardiovascular mortality, with the highest risks in the lower extremes, whereas those with normal geometry did not.

CONCLUSIONS

Echocardiographic assessment of LV geometry provided independent and additive prognostic information in ischemic stroke patients. A reverse J-shaped relation of mortality with blood pressure was found in patients with abnormal LV geometry.

Echocardiographic characteristics of hypertensive patients affected by transient ischemic attack: a cross-sectional study

Atrial septal aneurysm (ASA), common finding in normal echocardiographies, has been described in association with transient ischemic attacks (TIAs)/strokes, as well as hypertensive end-organ damage such as left ventricular (LV) hypertrophy. Aim of this study was to assess if a cluster of echocardiographic aspects could characterize TIA hypertensive patients. A cross-sectional study on patients with history of TIA, referring to a Hypertension Center echolab, has been performed. A total of 5223 patients received transthoracic echocardiography. TIA patients were 292 (5.6%). A total of 102 age/sex-matched patients without TIA have been collected as controls. The main characteristic of TIA patients resulted ASA/bulging (B) (TIA 61%, controls 6%, P = .0001). Other aspect was LV concentric remodeling (TIA 32.3%, controls 20.8%, P = .029) and mitral flow aspects of diastolic dysfunction. After adjustment for age and hypertension, ASA/B (odds ratio [OR] = 62.4, 95% confidence interval [CI]: 13.6-73.9, P < .001), followed by LV concentric hypertrophy (OR = 2.1, 95% CI: 1.1-4.3, P = .043), was associated with a positive TIA history. A binary logistic regression performed in ASA/B patients, identified relative wall thickness as the strongest TIA-associated aspect (OR = 53.4, 95% CI: 11.9-74.18, P = .001). ASA/B, common finds in general population, could carry a significant incremental possibility of association with TIA when concentric geometry, frequent hypertensive aspect, is present as well.

Lower Body Weight in Men, an Epidemiological Predictor of Enlarged Left Atrium in Sinus Rhythm Patients with Dilated Heart

BACKGROUND/AIMS

The source of thrombi in patients with dilated cardiomyopathy is not necessarily from the dilated left ventricle. Left atrium (LA) and left atrial appendage (LAA) might be in charge for relatively high rate of systemic embolizations in these patients. The main aim of our study was to identify epidemiological predictors in sinus rhythm patients with dilated heart for LA and LAA dilation and/or dysfunction.

PATIENTS AND METHODS

This was a prospective cross-sectional study conducted from 2009 to 2014 in 101 sinus rhythm patients with dilated heart. We excluded patients with swallowing problems, acute myocardial infarction, atrial fibrillation/flutter, severe systolic dysfunction, mechanical valves, oral anticoagulation therapy, and/or patients with a history of stroke/systemic thromboembolic event.

RESULTS

Mean patient age was 58.13 ± 12.66 years and 69.3% were men. Hypertension was encountered in 51% of our patients, 56% of them had a history of coronary artery disease, 30% had diabetes, 25% had dyslipidemia, 30% were smokers, whereas 10% were alcoholics. Mean LA dimensions resulted higher than reference values, whereas 86% of our patients had LAA dysfunction. Male gender was an independent predictor for LA diameter dilation (95% confidence interval [CI]: 1.765-9.078, P = 0.005), while lower body weight was a predictor for enlargement of LA area (95% CI: 0.044-0.351, P = 0.014) and LA volume (95% CI: 0.160-2.067, P = 0.024).

CONCLUSION

Male patients with dilated cardiomyopathy at sinus rhythm with lower body weight tend to have larger LA and consequently might be at higher risk of developing atrial thrombus and its subsequent consequences.

Left ventricular mass-geometry and silent cerebrovascular disease: The Cardiovascular Abnormalities and Brain Lesions (CABL) study

BACKGROUND

Although abnormal left ventricular geometric patterns have prognostic value for morbidity and mortality, their possible association with silent cerebrovascular disease has not been extensively evaluated.

METHODS

We examined 665 participants in the CABL study who underwent transthoracic echocardiography and brain magnetic resonance imaging. Participants were divided into 4 geometric patterns: normal geometry (n=397), concentric remodeling (n=89), eccentric hypertrophy (n=126), and concentric hypertrophy (n=53). Subclinical cerebrovascular disease was defined as silent brain infarcts (SBIs) and white matter hyperintensity volume (WMHV; expressed as log-transformed percentage of the total cranial volume).

RESULTS

Silent brain infarcts were observed in 94 participants (14%). Mean log-WMHV was -0.97±0.93. Concentric hypertrophy carried the greatest risk for both SBI (adjusted odds ratio [OR] 3.39, P<.001) and upper quartile of log-WMHV (adjusted OR 3.35, P<.001), followed by eccentric hypertrophy (adjusted ORs 2.52 [P=.001 for SBI] and 1.96 [P=.004] for log-WMHV). Concentric remodeling was not associated with subclinical brain disease. In subgroup analyses, concentric and eccentric hypertrophies were significantly associated with SBI and WMHV in both genders and nonobese participants, but differed for SBI by age (all ages for eccentric hypertrophy, only patients ≥70years for concentric hypertrophy) and by race-ethnicity (Hispanics for eccentric hypertrophy, blacks for concentric hypertrophy; no association in whites).

CONCLUSIONS

Left ventricular hypertrophy, with both eccentric and concentric patterns, was significantly associated with subclinical cerebrovascular disease in a multiethnic stroke-free general population. Left ventricular geometric patterns may carry different risks for silent cerebrovascular disease in different sex, age, race-ethnic, and body size subgroups.

Hemoglobin Concentration and Risk of Incident Stroke in Community-Living Adults

BACKGROUND AND PURPOSE

In previous observational studies, hemoglobin concentrations have been associated with an increased risk of stroke. However, these studies were limited by a relatively low number of stroke events, making it difficult to determine whether the association of hemoglobin and stroke differed by demographic or clinical factors.

METHODS

Using Cox proportional hazards analysis and Kaplan-Meier plots, we examined the association of baseline hemoglobin concentrations with incident stroke in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a cohort of black and white adults aged ≥45 years.

RESULTS

A total of 518 participants developed stroke over a mean 7±2 years of follow-up. There was a statistically significant interaction between hemoglobin and sex (P=0.05) on the risk of incident stroke. In Cox regression models adjusted for demographic and clinical variables, there was no association of baseline hemoglobin concentration with incident stroke in men, whereas in women, the lowest (<12.4 g/dL) and highest (>14.0 g/dL) quartiles of hemoglobin were associated with higher risk of stroke when compared with the second quartile (12.4-13.2 g/dL; quartile 1: hazard ratio, 1.59; 95% confidence interval, 1.09-2.31; quartile 2: referent; quartile 3: hazard ratio, 0.91; 95% confidence interval, 0.59-1.38; quartile 4: hazard ratio, 1.59; 95% confidence interval, 1.08-2.35). Similar results were observed in models stratified by hemoglobin and sex and when hemoglobin was modeled as a continuous variable using restricted quadratic spline regression.

CONCLUSIONS

Lower and higher hemoglobin concentrations were associated with a higher risk of incident stroke in women. No such associations were found in men.

Left ventricular geometry and white matter lesions in ischemic stroke patients

Abnormal left ventricular (LV) geometry is associated with extracardiac organ damage in patients with hypertension. The aim of this study was to determine the relationship between LV geometry and white matter lesions (WMLs) in ischemic stroke patients. We retrospectively analyzed data from 155 patients (median age 62; 49.8% male) with mild ischemic stroke (median National Institutes of Health Stroke Scale score 4) who underwent brain magnetic resonance imaging and echocardiography. Patients were categorized into four groups: normal LV geometry, concentric remodeling, eccentric left ventricular hypertrophy (LVH) and concentric LVH. WMLs were graded using the Fazekas scale on fluid-attenuated inversion recovery images. Extensive WMLs were defined as a Fazekas score > 2. Extensive WMLs were more prevalent in patients with concentric LVH, eccentric LVH and concentric remodeling than in those with normal LV geometry. After adjusting for hypertension, age, diabetes mellitus, hypercholesterolemia, glomerular filtration rate and ischemic heart disease, patients with concentric remodeling [odds ratio (OR) 3.94, 95% confidence interval (CI) 1.26-12.31, p = 0.02] and those with concentric LVH (OR 3.69, 95% CI 1.24-10.95, p = 0.02), but not patients with eccentric LVH (OR 2.44, 95% CI 0.72-8.29, p = 0.15), had higher risk of extensive WMLs than patients with normal LV geometry.

Wave Intensity Analysis Can Identify Eccentric Cardiac Hypertrophy in Hypertensive Patients With Varied Left Ventricular Configurations

OBJECTIVES

The primary aim of this study was to determine whether wave intensity can discriminate cases of eccentric hypertrophy in patients with essential hypertension who have varied left ventricular configurations.

METHODS

A total of 155 hypertensive patients with different ventricular configurations (27 normal configuration, 42 concentric remodeling, 62 concentric hypertrophy, and 24 eccentric hypertrophy) were recruited. We performed a noninvasive wave intensity analysis of the common carotid artery and conventional echocardiography. Blood pressure and flow velocity were measured in the right carotid artery of all patients.

RESULTS

The left ventricular ejection fraction (LVEF) in the eccentric hypertrophy group was significantly lower than the values in the other groups (P < .05). The R-W1 interval/W1-W2 interval ratio (where W1 indicates the first positive peak and W2 the second positive peak) in the eccentric hypertrophy group was much higher than the values in the other groups (P < .05). However, there were no significant differences in W1, W2, and negative area among these groups. Pearson correlation analysis showed that R-W1/W1-W2, R-W1, and W1-W2were correlated with the LVEF, whereas there was no correlation between W1, W2, negative area, and the reflection coefficient with the LVEF.

CONCLUSIONS

We propose that by using the R-W1/W1-W2 ratio, wave intensity analysis can identify hypertensive patients with eccentric hypertrophy without the need for echocardiography.

Association of growth differentiation factor 11/8, putative anti-ageing factor, with cardiovascular outcomes and overall mortality in humans: analysis of the Heart and Soul and HUNT3 cohorts

AIMS

Growth differentiation factor 11 and/or its homologue growth differentiation factor 8 (GDF11/8) reverses age-related cardiac hypertrophy and vascular ageing in mice. We investigated whether GDF11/8 associates with cardiovascular outcomes, left ventricular hypertrophy (LVH), or age in humans.

METHODS AND RESULTS

We measured plasma GDF11/8 levels in 928 participants with stable ischaemic heart disease in the Heart and Soul study. We adjudicated heart failure hospitalization, stroke, myocardial infarction, death, and their composite endpoint. Left ventricular hypertrophy was evaluated by echocardiography. We used multivariable Cox proportional hazards models to compare rates of cardiovascular events and death across GDF11/8 quartiles and logistic regression models to evaluate the association between GDF11/8 and LVH. Four hundred and fifty participants (48.5%) experienced a cardiovascular event or death during 8.9 years of follow-up. The adjusted risk of the composite endpoint was lower in the highest compared with the lowest GDF11/8 quartile [hazard ratio (HR), 0.45; 95% confidence interval (CI), 0.33-0.60; P < 0.001]. We replicated this relationship of GDF11/8 to adverse events in 971 participants in the HUNT3 cohort (adjusted HR, 0.34; 95% CI, 0.23-0.51; P < 0.001). Left ventricular hypertrophy was present in 368 participants (39.7%) at baseline. Participants in the highest quartile of GDF11/8 were less likely to have LVH than those in the lowest quartile (adjusted OR, 0.55; 95% CI, 0.35-0.86; P = 0.009). GDF11/8 levels were lower in older individuals (P < 0.001).

CONCLUSION

In patients with stable ischaemic heart disease, higher GDF11/8 levels are associated with lower risk of cardiovascular events and death. Our findings suggest that GDF11/8 has similar cardioprotective properties in humans to those demonstrated in mice.

Left ventricular relative wall thickness versus left ventricular mass index in non-cardioembolic stroke patients

In non-cardioembolic stroke patients, the cardiac manifestations of high blood pressure are of particular interest. Emerging data suggest that echocardiographically determined left ventricular hypertrophy is independently associated with risk of ischemic stroke.The primary objective of this study was to evaluate the frequency of different patterns of left ventricular (LV) remodeling and hypertrophy in a group of consecutive patients admitted with non-cardioembolic stroke or transient ischemic attack (TIA). In particular, we were interested in how often the relative wall thickness (RWT) was abnormal in patients with normal LV mass index (LVMI). As both abnormal RWT and LVMI indicate altered LV remodeling, the secondary objective of this research was to study whether a significant number of patients would be missing the diagnosis of LV remodeling if the RWT is not measured.All patients were referred within 48 hours after a stroke or a TIA for a clinically indicated transthoracic echocardiogram. The echocardiographic findings of consecutive patients with non-cardioembolic stroke or TIA were analyzed.All necessary measurements were performed in 368 patients, who were enrolled in the study. Mean age was 63.7 ± 12.5 years, 64.4% men. Concentric remodeling carried the highest frequency, 49.2%, followed by concentric hypertrophy, 30.7%, normal pattern, 15.5%, and eccentric hypertrophy, 4.1%. The frequency of abnormal left ventricular RWT (80.4%) was significantly higher than that of abnormal LVMI (35.3%), (McNemar P < 0.05).In this group of non-cardioembolic stroke patients, abnormal LV remodeling as assessed by relative wall thickness is very frequent. As RWT was often found without increased LV mass, the abnormal left ventricular geometry may be missed if RWT is not measured or reported.

Prevalence and risk factors of abnormal left ventricular geometrical patterns in untreated hypertensive patients

Background

The various prevalence of LVH and abnormal LV geometry have been reported in different populations. So far, only a few reports are available on the prevalence of LV geometric patterns in a large Chinese untreated hypertensive population.

Methods

A total of 9,286 subjects (5167 men and 4119 women) completed the survey and 1641 untreated hypertensive patients (1044 males and 597 females) enrolled in the present study. The LV geometry was classified into four patterns: normal; abnormal,defined as concentric remodeling;concentric or eccentric hypertrophy based on the values of left ventricular mass index (LVMI) and relative wall thickness (RWT). Logistic regression model was applied to determine the odds ratio (OR) and 95% confidence intervals (CI) of the risk factors of left ventricular hypertrophy.

Results

The prevalence of LVH was 20.2% in untreated hypertensive patients, much higher in women (30.8%) than in men (14.2%) (P < 0.01). The prevalence of LV geometrical patterns was 34.9%, 11.1%, 9.1% for concentric remodeling, concentric and eccentric hypertrophy,respectively. After adjustment by using Logistic regression model, the risk factors for LVH and abnormal LV geometry were age, female, systolic blood pressure, and body mass index. And low high density lipoprotein maybe a positive factor.

Conclusions

The prevalence of LVH and abnormal LV geometric patterns was higher in women than in men and increased with age. It is crucial to improve the awareness rate of hypertension and control the risk factors of CV complications in untreated hypertensive population.

Subclassification of left ventricular hypertrophy based on dilation stratifies coronary artery disease patients with distinct risk

BACKGROUND

A new 4-tired classification of left ventricular hypertrophy (LVH) based on LV concentricity and dilation has been proposed; however, the association between the new categorization of LV geometry and outcomes in patients with coronary artery disease (CAD) is still unknown.

METHODS

All the 2297 patients with CAD included underwent echocardiographic examination prior to discharge. Left ventricular mass (LVM) was calculated, and left ventricular end-diastolic volume (EDV) was indexed by body surface area (BSA). Study cohort was divided into five groups according to LV geometry: (i) eccentric nondilated LVH (normal LVM/EDV((2/3)) and EDV/BSA) (n = 129); (ii) eccentric dilated LVH (normal LVM/EDV((2/3)) with increased EDV/BSA) (n = 222); (iii) concentric nondilated LVH (increased LVM/EDV((2/3)) with normal EDV/BSA) (n = 441); (iv) concentric dilated LVH (increased LVM/EDV((2/3)) and EDV/BSA) (n = 118); and (v) normal LV mass (n = 1387).

RESULTS

Dilated LVH was associated with a higher event rates of all-cause death (eccentric 13·1% vs. 3·1%; concentric 13·6% vs. 8·4%) and composite events (eccentric: 17·6% vs. 5·4%; concentric: 18·6% vs. 12·7%) compared with nondilated LVH. While eccentric nondilated LVH had comparable risk for adverse outcomes compared with normal LV mass (all-cause death: relative risk (RR) 0·68, 95% confidential interval (CI) 0·25-1·85; composite events: RR 0·75, 95% CI 0·36-1·58). Cox regression analyses showed that eccentric dilated LVH had the highest propensity to all-cause death (adjusted hazard ratio [aHR] 2·752 [95% CI 1·749-4·328], P < 0·001) and composite events (aHR 2·462 [95% CI 1·688-3·592], P < 0·001).

CONCLUSION

In patients with CAD, dilated LVH and nondilated LVH provide distinct prognostic information. Eccentric nondilated LVH does not predict adverse outcomes.

Echocardiographic assessment of left ventricular geometric patterns in hypertensive patients in Nigeria

Left ventricular (LV) hypertrophy is an important predictor of morbidity and mortality in hypertensive patients, and its geometric pattern is a useful determinant of severity and prognosis of heart disease. Studies on LV geometric pattern involving large number of Nigerian hypertensive patients are limited. We examined the LV geometric pattern in hypertensive patients seen in our echocardiographic laboratory. A two-dimensional, pulsed, continuous and color flow Doppler echocardiographic evaluation of 1020 consecutive hypertensive patients aged between 18 and 91 years was conducted over an 8-year period. LV geometric patterns were determined using the relationship between the relative wall thickness and LV mass index. Four patterns of LV geometry were found: 237 (23.2%) patients had concentric hypertrophy, 109 (10.7%) had eccentric hypertrophy, 488 (47.8%) had concentric remodeling, and 186 (18.2%) had normal geometry. Patients with concentric hypertrophy were significantly older in age, and had significantly higher systolic blood pressure (BP), diastolic BP, and pulse pressure than those with normal geometry. Systolic function index in patients with eccentric hypertrophy was significantly lower than in other geometric patterns. Doppler echocardiographic parameters showed some diastolic dysfunction in hypertensive patients with abnormal LV geometry. Concentric remodeling was the most common LV geometric pattern observed in our hypertensive patients, followed by concentric hypertrophy and eccentric hypertrophy. Patients with concentric hypertrophy were older than those with other geometric patterns. LV systolic function was significantly lower in patients with eccentric hypertrophy and some degree of diastolic dysfunction were present in patients with abnormal LV geometry.

Elevated Plasma Factor VIII in Patients with Ischemic Stroke: Does it have any Association with Hypertensive Heart Disease?

BACKGROUND

Elevated factor VIII (FVIII) has been linked with higher risk of vascular events. We aimed to determine the relationship between FVIII and hypertension in patients with acute ischemic stroke.

METHODS

FVIII levels and transthoracic echocardiogram reports were reviewed in patients with acute ischemic stroke who presented to our stroke center between July 2008 and September 2011. Presenting systolic and diastolic blood pressure, history of hypertention, left ventricular hypertrophy, diastolic dysfunction, and depressed left ventricular function (ejection fraction <50%) were compared in patients with normal and elevated FVIII levels.

RESULTS

No differences in presenting blood pressure or frequency of hypertension history were found based on FVIII level. Patients with elevated FVIII had demonstrated a statistically significant higher frequency of diastolic dysfunction (64.8 vs. 43.6%, p=0.042) and a trend towards higher frequency of left ventricular hypertrophy (18.5 vs 5.1%, p=0.073). Median FVIII was significantly higher in patients with left ventricular hypertrophy (194.4 vs 152.9%, p=0.042) and diastolic dysfunction (180.5 vs 149.3%, p=0.031) than patients without these findings.

CONCLUSIONS

Among patients with acute ischemic stroke, FVIII levels were higher when there was evidence of hypertensive heart disease. Synthesis of FVIII may be augmented by the ongoing presence of shear stress and could contribute to the higher risk of vaso-occlusive events in patients with elevated FVIII.

Relation between long sleep and left ventricular mass (from a multiethnic elderly cohort)

Short-sleep and long-sleep duration are associated with prevalent hypertension, poor cardiovascular health, and mortality. The relation of sleep hours with increased left ventricular (LV) mass, a strong correlate of elevated blood pressure (BP) values, is not established. We conducted a cross-sectional analysis among the participants of the population-based Cardiovascular Abnormalities and Brain Lesions study. LV mass was estimated by transthoracic echocardiography. Sleep duration was assessed by reported hours of sleep on a diary kept during 24-hour BP monitoring. Multivariate linear regression models were constructed to assess the relation between sleep hours and LV mass index (LV mass divided by body surface area). Analysis of sleep hour categories (short and long sleep) was performed. Among 756 participants (mean age 71 ± 9 years, 60% women, and 71% Hispanics), the mean sleep duration was 8.6 ± 1.8 hours, and LV mass index was 103 ± 26 g/m². A J-shaped relation between sleep hours squared and LV mass index was observed adjusting for demographics and cardiovascular risk factors. Categorical analysis showed an association between long-sleep duration (>11 hours) and LV mass index (β = 7.4; p = 0.013). Long sleepers had higher diurnal systolic BP (p = 0.012) and nocturnal systolic BP (p <0.001) compared with the reference group. A great part of the variance between sleep duration and LV mass was explained by 24-hour systolic BP (β = 0.45; p <0.0001). In conclusion, self-reported long-sleep duration was associated with increased LV mass. Higher systolic BP, especially nocturnal, may account for part of the observed association.

Left ventricular global function index by magnetic resonance imaging--a novel marker for assessment of cardiac performance for the prediction of cardiovascular events: the multi-ethnic study of atherosclerosis

Left ventricular (LV) function is generally assessed independent of structural remodeling and vice versa. The purpose of this study was to evaluate a novel LV global function index (LVGFI) that integrates LV structure with global function and to assess its predictive value for cardiovascular (CV) events throughout adult life in a multiethnic population of men and women without history of CV diseases at baseline. A total of 5004 participants in the Multi-Ethnic Study of Atherosclerosis underwent a cardiac magnetic resonance study and were followed up for a median of 7.2 years. The LVGFI by cardiac magnetic resonance was defined by the ratio of stroke volume divided by LV total volume defined as the sum of mean LV cavity and myocardial volumes. Cox proportional hazard models were constructed to predict the end points of heart failure, hard CV events, and a combined end point of all CV events after adjustment for established risk factors, calcium score, and biomarkers. A total of 579 (11.6%) CV events were observed during the follow-up period. In adjusted models, the end points of heart failure, hard CV events, and all events were all significantly associated with LVGFI (heart failure, hazard ratio=0.64, P<0.0001; hard CV events, hazard ratio=0.79, P=0.007; all events, hazard ratio=0.79, P<0.0001). LVGFI had a significant independent predictive value in the multivariable models for all CV event categories. The LVGFI was a powerful predictor of incident HF, hard CV events, and a composite end point, including all events in this multiethnic cohort.