Nocturnal Blood Pressure Pattern Affects Left Ventricular Remodeling and Late Gadolinium Enhancement in Patients with Hypertension and Left Ventricular Hypertrophy

Twenty-four hour ambulatory blood pressure monitoring in patients with stable heart failure. Prevalence and associated factors

INTRODUCTION AND OBJECTIVES

Hypertension is highly common in heart failure (HF). However, there is limited information on its prevalence, circadian variation, and relationship with the various HF phenotypes. The objective of this study was to describe the prevalence of hypertension and its patterns in HF.

METHODS

This was a cross-sectional observational study of patients with optimized stable chronic HF. The patients underwent blood pressure (BP) measurement in the office and 24-hour ambulatory monitoring. We estimated the prevalence of hypertension, and its diurnal (controlled, uncontrolled, white coat, and masked) and nocturnal (dipper, nondipper, and reverse dipper) patterns. We also analyzed the factors associated with the different patterns and HF phenotypes.

RESULTS

From 2017 to 2021, 266 patients were included in the study (mean age, 72±12 years, 67% male, 46% with reduced ejection fraction). Hypertension was present in 83%: controlled in 68%, uncontrolled in 10%, white coat in 10%, and masked in 11%. Among patients with high office BP, 51% had white coat hypertension. Among those with normal office BP, 14% had masked hypertension. The prevalence of dipper, nondipper, and reverse dipper patterns was 31%, 43%, and 26%, respectively. Systolic BP was lower in HF with reduced ejection fraction than in HF with preserved ejection fraction (P <.001).

CONCLUSIONS

Ambulatory BP monitoring in HF identified white coat hypertension in more than half of patients with high office BP and masked hypertension in a relevant percentage of patients. The distribution of daytime patterns was similar to that of the population without HF in the literature, but most of the study patients had a pathological nocturnal pattern.

The association between frontal QRS-T angle and reverse dipper status in newly diagnosed hypertensive patients

The frontal QRS-T angle (fQRS-T angle) in ECG is a new measure of myocardial repolarization, in which a higher fQRS-T angle is linked with worse cardiac outcomes. Reverse dipper hypertension is also linked to poor cardiac outcomes. The purpose of this study was to investigate the association between the fQRS-T angle and reverse dipper status in individuals newly diagnosed with hypertension who did not have left ventricular hypertrophy (LVH). The investigation recruited 171 hypertensive individuals without LVH who underwent 24-h ambulatory blood pressure monitoring (ABPM). On the basis of the findings of 24-h ABPM, the study population was categorized into the following three groups: patients with dipper hypertension, non-dipper hypertension, and reverse dipper hypertension. LVH was defined by echocardiography. The fQRS-T angle was measured using the 12-lead ECG. The fQRS-T angle in individuals with reverse dipper hypertension was substantially greater than in patients with and without dipper hypertension (51° ± 28° vs. 28° ± 22° vs. 39° ± 25°, respectively, P < 0.001). The fQRS-T angle (odds ratio: 1.040, 95% confidence interval: 1.016-1.066; P = 0.001) was independently associated with reverse dipper hypertension according to multivariate analysis. In receiver operating characteristic curve analysis, the fQRS-T angle to predict reverse dipper hypertension was 33.5° with 76% sensitivity and 71% specificity. This study showed that an increased fQRS-T angle was associated with reverse dipper hypertension in newly diagnosed hypertensive patients without LVH.

Association of continuous positive airway pressure therapy on cardiac hypertrophy in patients with sleep apnea comorbid with type 2 diabetes mellitus

Previous reports indicated the therapeutic effect of chronic continuous positive airway pressure (CPAP) therapy on cardiac hypertrophy due to sleep apnea syndrome. However, little is known for cases involving diabetic complications. This retrospective observational study examined the effects of CPAP therapy on left ventricular hypertrophy (LVH) in patients with obstructive sleep apnea syndrome (OSAS) and type 2 diabetes mellitus (T2DM). For all cases, the observation period was 3 years from the time when the patient was introduced to CPAP therapy. Overall, 123 patients were divided into a good CPAP group (CPAP ≥4 h/day, n = 63) and non-adherence group (CPAP <4 h/day, n = 60). The mean CPAP usage times were 5.58 ± 1.23 and 1.03 ± 1.17 h/day in the good CPAP and non-adherence groups, respectively. Regression tendencies of the thickness of the left ventricular posterior (-0.30 ± 1.19 mm) and interventricular septal walls (-0.48 ± 1.22 mm) were observed in the good CPAP group. Hypertrophic tendencies of the left ventricular posterior wall (+0.59 ± 1.44 mm) and interventricular septal wall thickness (+0.59 ± 1.43) were observed in the non-adherence group. Left ventricular posterior wall thickness (coefficient: -0.254, p = 0.0376) and interventricular septal wall thickness (coefficient: -0.426, p = 0.0006) were more likely to be greater in the non-adherence group than in the good CPAP group. Patients in the non-adherence group with an apnea hypopnea index ≥30 had increased left ventricular posterior wall thickness (coefficient: -0.263, p = 0.0673) and interventricular septal wall thickness (coefficient: -0.450, p = 0.0011). In conclusion, appropriate CPAP therapy is an effective treatment for LVH in patients with T2DM and OSAS, especially for severe cases.

The Circadian Biology of Heart Failure

Driven by autonomous molecular clocks that are synchronized by a master pacemaker in the suprachiasmatic nucleus, cardiac physiology fluctuates in diurnal rhythms that can be partly or entirely circadian. Cardiac contractility, metabolism, and electrophysiology, all have diurnal rhythms, as does the neurohumoral control of cardiac and kidney function. In this review, we discuss the evidence that circadian biology regulates cardiac function, how molecular clocks may relate to the pathogenesis of heart failure, and how chronotherapeutics might be applied in heart failure. Disrupting molecular clocks can lead to heart failure in animal models, and the myocardial response to injury seems to be conditioned by the time of day. Human studies are consistent with these findings, and they implicate the clock and circadian rhythms in the pathogenesis of heart failure. Certain circadian rhythms are maintained in patients with heart failure, a factor that can guide optimal timing of therapy. Pharmacologic and nonpharmacologic manipulation of circadian rhythms and molecular clocks show promise in the prevention and treatment of heart failure.

Cardiac Magnetic Resonance in Hypertensive Heart Disease: Time for a New Chapter

Hypertension is one of the most important cardiovascular risk factors, associated with significant morbidity and mortality. Chronic high blood pressure leads to various structural and functional changes in the myocardium. Different sophisticated imaging methods are developed to properly estimate the severity of the disease and to prevent possible complications. Cardiac magnetic resonance can provide a comprehensive assessment of patients with hypertensive heart disease, including accurate and reproducible measurement of left and right ventricle volumes and function, tissue characterization, and scar quantification. It is important in the proper evaluation of different left ventricle hypertrophy patterns to estimate the presence and severity of myocardial fibrosis, as well as to give more information about the benefits of different therapeutic modalities. Hypertensive heart disease often manifests as a subclinical condition, giving exceptional value to cardiac magnetic resonance as an imaging modality capable to detect subtle changes. In this article, we are giving a comprehensive review of all the possibilities of cardiac magnetic resonance in patients with hypertensive heart disease.

P-Wave Terminal Force V1 Is Associated with Left Ventricular Diastolic Function in Patients with No Significant Perfusion Abnormality

P-wave terminal force in lead V1 (PTFV1) is a marker of increased left atrial (LA) overload. Whether PTFV1 is associated with left ventricular (LV) diastolic function remains undetermined. We tested the hypothesis that PTFV1 is associated with LV diastolic parameters derived from gated myocardial perfusion single-photon emission computed tomography (SPECT) in patients with no significant perfusion abnormalities.The study population included 158 patients with preserved ejection fraction and no significant perfusion abnormalities. The amplitude and duration of the P-wave negative phase in lead V1 were measured using an electrocardiogram, and PTFV1 was calculated. The peak filling rate (PFR) and one-third mean filling rate (1/3 MFR) were obtained as LV diastolic parameters using gated SPECT.PTFV1 showed a weak correlation with the LA volume index (r = 0.31; P < 0.001). Significant associations were observed between PTFV1 and PFR (r = -0.27; P < 0.001) and 1/3 MFR (r = -0.26; P = 0.001). A multivariate linear regression analysis showed that age (β = -0.26; P < 0.001), LV end-diastolic volume index (β = -0.27; P = 0.001), and PTFV1 (β = -0.15; P = 0.036) were significant factors associated with PFR. Moreover, male gender (β = -0.16; P = 0.041), LV mass index (β = -0.17; P = 0.046), and PTFV1 (β = -0.17; P = 0.022) were significant factors associated with the 1/3 MFR.PTFV1 is associated with LV diastolic function, as derived from gated SPECT in patients with no significant perfusion abnormalities.

Nocturnal Hypertension and Heart Failure: Mechanisms, Evidence, and New Treatments

Heart failure (HF) is a common condition with an increasing prevalence. Despite a variety of evidence-based treatments for patients with HF with reduced ejection fraction, morbidity and mortality rates remain high. Furthermore, there are currently no treatments that have yet been shown to reduce complication and death rates in patients who have HF with preserved ejection fraction. Hypertension is a common comorbidity in patients with HF, contributing to disease development and prognosis. For example, hypertension is closely associated with the development of left ventricular hypertrophy, which an important precursor of HF. In particular, nighttime blood pressure (BP) appears to be an important, modifiable risk factor. Both nighttime BP and an abnormal circadian pattern of nighttime BP dipping have been shown to predict development of HF and the occurrence of cardiovascular events, independent of office BP. Key mechanisms for this association include sodium handling/salt sensitivity and increased sympathetic activation. These pathogenic mechanisms are targeted by several new treatment options, including sodium-glucose cotransporter 2 inhibitors, angiotensin receptor neprilysin inhibitors, mineralocorticoid receptor antagonists, and renal denervation. All of these could form part of antihypertensive strategies designed to control nighttime BP and contribute to the goal of achieving perfect 24-hour BP management. Nevertheless, additional research is needed to determine the effects of reducing nighttime BP and improving the circadian BP profile on the rate of HF, other cardiovascular events, and mortality.

Interactions of hypertension, obesity, left ventricular hypertrophy, and heart failure

PURPOSE OF REVIEW

Hypertension (HTN) and obesity are major risk factors for cardiac remodeling and dysfunction, leading to left ventricular hypertrophy (LVH) and heart failure (HF). In this review, we discuss the complex mechanisms and effects of HTN and obesity, and their treatments in LVH, ventricular function, and HF.

RECENT FINDINGS

Obesity and HTN impact the heart through overlapping neurohormonal pathways. However, the relationship between obesity and cardiomyopathy is more complex, and additional metabolic and hemodynamic pathways seem to contribute to cardiac dysfunction in these patients. Weight loss and blood pressure (BP) control help to prevent and reverse at least some of the damage caused by obesity and HTN even beyond what would be expected from solely the hemodynamic changes.

SUMMARY

Obesity and HTN cause maladaptive changes in the heart that can lead to LVH and HF. Weight loss and BP control help to, at least partially, reverse some of these changes and improve clinical outcomes in patients with HF.

Abnormal diurnal blood pressure profile and hypertension-mediated organ damage in nondiabetic chronic kidney disease G1-G3b patients

OBJECTIVE

Chronic kidney disease (CKD) is associated with high cardiovascular risk. Prevalence of hypertension and hypertension-mediated organ damage (HMOD) increases with CKD progression. Nocturnal blood pressure (BP) is a strong predictor of cardiovascular complications. This cross-sectional study investigated the link between the diurnal BP profile and HMOD in nondiabetic CKD G1-G3b patients.

METHODS

We investigated 109 CKD patients and 41 apparently healthy persons as controls. All subjects underwent 24-ambulatory blood pressure monitoring (ABPM), echocardiography with left ventricular mass index (LVMI) calculation and pulse wave velocity (PWV) measurement.

RESULTS

Hypertension was present in 84% of CKD patients. SBP-24 and DBP-24, SBP-day and DBP-day did not differ between CKD and controls. Significant differences were found in SBP-night and DBP-night. The nondipping BP profile (SBP-night/SBP-day ratio ≥0.9) was found in 62% of CKD patients and 32% of controls (P < 0.005). Nocturnal hypertension was found in 56% of CKD patients. LVMI was higher in CKD compared to controls, higher in nondipping than dipping CKD patients, and higher in patients with nocturnal hypertension than without nocturnal hypertension. Abnormal left ventricular geometry was found in 72% nondipping and 43% dipping CKD patients. PWV was higher in CKD than in controls, in patients with nocturnal hypertension than without nocturnal hypertension but did not differ between CKD nondippers and dippers.

CONCLUSION

The nondipping BP profile and nocturnal hypertension are associated with HMOD in G1-G3b CKD patients. Hence, there is a need for more extensive use of ABPM for individual risk assessment and personalization of antihypertensive treatment in CKD patients.

Restoration of nocturnal blood pressure dip and reduction of nocturnal blood pressure with evening anti-hypertensive medication administration in pediatric kidney transplant recipients: A pilot randomized clinical trial

Non-dipping and nocturnal hypertension are commonly found during ABPM in pediatric kidney transplant recipients. These entities are independently associated with increased cardiovascular disease risk in adults. Kidney transplant recipients aged 5-21 years with eGFR > 30 mL/min/1.73 m² and ABPM demonstrating non-dipping status and normal daytime BP were randomized to intervention (short acting BP medication added in the evening) or control (no medication change) in this pilot, randomized, open-label, blinded end-point clinical trial. ABPM, echocardiography, and PWV were performed at baseline, 3 months, and 6 months. The trial included 17 intervention and 16 control participants. Conversion to dipper status occurred in 53.3% vs 7.7% (P = .01) at 6 months for intervention and controls, respectively. Systolic dip was greater in the intervention group compared to controls (10.9 ± 4.5 vs 4.2 ± 4.6, P = .001), and average systolic nighttime BP was significantly lower in the intervention group (106 ± 8.3 vs 114.9 ± 9.5 mm Hg, P = .01) at 6 months. There were no significant differences in LVMI, PWV, or eGFR between groups. Within-group changes in the intervention group demonstrated improvements in non-dippers, dipping, systolic nighttime BP and nighttime BP load. Restoration of nocturnal dip and improvement in nocturnal BP were observed in the population following chronotherapy. Future studies are needed with larger sample sizes over a longer period of time to delineate the long-term effect of improved nocturnal dip on target organ damage.

Fragmented QRS as a Marker of Myocardial Fibrosis in Hypertension: a Systematic Review

PURPOSE OF REVIEW

Hypertension cause damage in cardiac structure and induce pathological myocardial fibrosis that leads to hypertensive cardiomyopathy. A narrow fragmented QRS complex (fQRS) is associated with myocardial fibrosis and scar tissue in various cardiovascular diseases. It is also associated with myocardial fibrosis in hypertensive patients even in the absence of any structural heart diseases. This article aimed to demonstrate importance and usefulness of fQRS in hypertensive patients.

RECENT FINDINGS

Current evidence suggest that the frequency of fQRS is significantly higher in hypertensive patients compared to normotensives. Also, fQRS seems to be a predictor of left ventricular hypertrophy, increased systolic blood pressure, non-dipping, deterioration of the left ventricular geometry, and worse systolic and diastolic functions in hypertensive patients. As a simple and easy detectable electrocardiographic finding, fQRS may indicate myocardial fibrosis, uncontrolled blood pressure, and deteriorated cardiac structure in hypertensive patients even in the absence of other structural heart diseases, and may also be useful to predict high-risk hypertensives.

The effect of circadian blood pressure pattern on presence of fragmented QRS complexes in hypertensive subjects

The association of deteriorated circadian blood pressure (BP) variability with presence of fragmented QRS (fQRS) on electrocardiography (ECG) is not clear. The present study aims to evaluate the relationship of BP patterns with presence of fQRS on ECG. A total of 338 consecutive newly diagnosed and never treated hypertensive patients who are without left ventricular hypertrophy and underwent 24-hour ambulatory BP monitoring were enrolled. Patients were classified as dippers, nondippers, and reverse dippers according to ambulatory BP monitoring results. The groups were compared regarding frequency of fQRS on ECG. The frequency of fQRS was significantly higher in reverse dippers compared with dippers (37.7% vs. 20.6%, P = .013). In multivariate logistic regression analysis, nighttime systolic BP was found to be an independent predictor of fQRS on ECG (P < .001, 95% confidence interval = 0.901-0.955). Other predictors of fQRS were daytime diastolic BP and age. Furthermore, fQRS was found to be an independent predictor of reverse dipping BP pattern in hypertensive patients (P = .004, odds ratio: 2.416, 95% confidence interval = 1.327-4.396). In conclusion, as a marker of fibrosis and higher fibrotic burden within myocardium, fQRS may be useful to determine the high-risk hypertensive patients in the absence of left ventricular hypertrophy.

Riser Pattern: Another Determinant of Heart Failure With Preserved Ejection Fraction

Paradoxical increase in blood pressure (BP) during sleep, exceeding those of awake BP, is called the "riser" BP pattern, and known as an abnormal circadian BP rhythm, has been reported to be associated with adverse cardiovascular prognoses. However, the significance of ambulatory BP in heart failure patients with preserved ejection fraction (HFpEF) has never been reported. Here, we tested our hypothesis that abnormal circadian BP rhythm is associated with HFpEF. The authors enrolled 508 patients with hospitalized HF (age 68±13 years; 315 men, 193 women). There were 232 cases of HFpEF and 276 cases of heart failure with reduced ejection fraction (HFrEF). The riser BP pattern was significantly more frequent in the HFpEF (28.9%) group compared with the HFrEF group (19.9%). In a multivariable logistic regression analysis, the riser BP pattern was associated with HFpEF (odds ratio, 1.73; 95% confidence interval, 1.02-2.91; P=.041) independent of the other covariates. In conclusion, the riser BP pattern was associated with HFpEF.

Ambulatory Blood Pressure Parameters and Heart Failure With Reduced or Preserved Ejection Fraction in Elderly Treated Hypertensive Patients

BACKGROUND

The association between ambulatory blood pressure (BP) and future risk of heart failure (HF) is unclear. We investigated the association between ambulatory BP parameters and risk of HF with reduced ejection fraction (HFREF) or preserved ejection fraction (HFPEF) in elderly treated hypertensive patients.

METHODS

The occurrence of HFREF and HFPEF was evaluated in 1,191 elderly treated hypertensive patients who underwent clinical and instrumental evaluation, including ambulatory BP monitoring to evaluate daytime, nighttime, and 24-hour BP, dipping status, and morning surge (MS) of BP.

RESULTS

During the follow-up (9.1±4.9 years, range 0.4-20 years), 123 patients developed HF, of whom 56 had HFREF and 67 had HFPEF. After adjustment for other covariates, Cox regression analysis showed that 24-hour systolic BP, but not clinic BP, was independently associated with risk of both HFREF (hazard ratio (HR): 1.36, 95% confidence interval (CI): 1.14-1.63, per 10mm Hg increment) and HFPEF (HR: 1.35, 95% CI: 1.13-1.61, per 10mm Hg increment); moreover, high MS of BP (>23mm Hg) in dippers was independently associated with risk of HFREF (HR: 2.27, 95% CI: 1.00-5.15) and nondipping was independently associated with risk of HFPEF (HR: 2.78, 95% CI: 1.38-5.63).

CONCLUSIONS

In elderly treated hypertensive patients, 24-hour systolic BP is independently associated with future risk of both HFREF and HFPEF, whereas high MS is independently associated with risk of HFREF and nondipping is independently associated with risk of HFPEF.

Blood pressure reverse dipping may associate with stable coronary artery disease in patients with essential hypertension: a cross-sectional study

The dipping variations of circadian blood pressure (BP) correlate closely with target-organ damages and cardiovascular events. The aim of this study was to investigate the relationship between BP reverse dipping and the prevalence of stable coronary artery disease (sCAD) in hypertensive patients. Clinical data and the results of 24-hour ambulatory BP monitoring (ABPM) were obtained from 718 hypertensive patients (390 males, mean age 59.6 ± 13.8 years) in a single centre in Northern China. Reverse dipping pattern was defined as nocturnal systolic BP (SBP) was higher than daytime SBP. A logistic regression model was applied to explore the independent risk factors of sCAD. The patients with BP reverse dipping accounted for 31.5% in sCAD group and 19.5% in control group (P < 0.05). In multivariate analysis, BP reverse dipping remained significantly associated with the prevalence of sCAD (Odds ratio [OR], 1.772; p = 0.027). Furthermore, the circadian decline rate of SBP was independently associated with sCAD (OR, 0.975; p = 0.043). The hypertensive patients with reverse BP dipping were found to be more frequently suffering from sCAD. BP reverse dipping examined with 24-hour ABPM may indicate sCAD.

From Left Ventricular Hypertrophy to Dysfunction and Failure

Left ventricular hypertrophy (LVH) is growth in left ventricular mass caused by increased cardiomyocyte size. LVH can be a physiological adaptation to strenuous physical exercise, as in athletes, or it can be a pathological condition, which is either genetic or secondary to LV overload. Physiological LVH is usually benign and regresses upon reduction/cessation of physical activity. Pathological LVH is a compensatory phenomenon, which eventually may become maladaptive and evolve towards progressive LV dysfunction and heart failure (HF). Both interstitial and replacement fibrosis play a major role in the progressive decompensation of the hypertrophied LV. Coronary microvascular dysfunction (CMD) and myocardial ischemia, which have been demonstrated in most forms of pathological LVH, have an important pathogenetic role in the formation of replacement fibrosis and both contribute to the evolution towards LV dysfunction and HF. Noninvasive imaging allows detection of myocardial fibrosis and CMD, thus providing unique information for the stratification of patients with LVH. (Circ J 2016; 80: 555-564).

Harnessing fetal and adult genetic reprograming for therapy of heart disease

Heart is the first organ formed during organogenesis. The fetal heart undergoes several structural and functional modifications to form the four-chambered mammalian heart. The adult heart shows different adaptations during compensatory and decompensatory heart failure. However, one common adaptation in the pathological heart is fetal reprogramming, where the adult heart expresses several genes and miRNAs which are active in the fetal stage. The fetal reprogramming in the failing heart raises several questions, such as whether the switch of adult to fetal genetic programming is an adaptive response to cope with adverse remodeling of the heart, does the expression of fetal genes protect the heart during compensatory and/or decompensatory heart failure, does repressing the fetal gene in the failing heart is protective to the heart? To answer these questions, we need to understand the expression of genes and miRNAs that are reprogrammed in the failing heart. In view of this, we provided an overview of differentially expressed genes and miRNAs, and their regulation in this review. Further, we elaborated novel strategies for a plausible future therapy of cardiovascular diseases.

Blood pressure reverse-dipping is associated with early formation of carotid plaque in senior hypertensive patients

Nocturnal variations in blood pressure (BP) were associated with carotid intima-media thickness. However, the precise relationship between circadian variations of BP and carotid plaques remains unknown. Therefore, the prognostic value of reverse-dipper pattern of BP for carotid plaque was investigated. In this cross-sectional study, a total of 524 hypertensive patients were recruited and evaluated with ambulatory BP monitoring between April 2012 and June 2013. Carotid plaque was classified into Grade 0 (normal or no observable plaque), Grade 1 (mild stenosis, 1%-24% narrowing), and Grade 2 (moderate stenosis, ≥25% narrowing). Multinomial logistic regression was applied to analyze the relationship between different degrees of carotid plaque and ambulatory BP monitoring results. Reverse-dipper pattern of BP was more common in older patients, smokers, and those with elevated fasting glucose. The incidences of coronary artery disease, lacunar infarction, and diabetes were also higher among hypertensive with reverse-dipper pattern. Multinomial logistic regression analysis showed that reverse dipper (odds ratio [OR] 2.500; 95% confidence interval [CI] 1.320-4.736; P = 0.005), age (OR 1.089; 95% CI 1.067-1.111; P < 0.001), smoke (OR 1.625; 95% CI 1.009-2.617; P = 0.046), and diabetes (OR 1.759; 95% CI 1.093-2.830; P = 0.020) were significantly different between mild carotid plaque and normal. Our results also suggested that mild carotid plaque was closely related to reverse-dipper pattern of BP (2.308; 95% CI 1.223-4.355; P = 0.010). Reverse-dipper pattern of BP may be a risk factor for carotid atherosclerosis and play a crucial role in the early formation of carotid plaque.