Ambulatory arterial stiffness index is associated with impaired left atrial mechanical functions in hypertensive diabetic patients: A speckle tracking study

Association of central arterial stiffness with atrial myopathy: the Atherosclerosis Risk in Communities (ARIC) study

Atrial myopathy-defined as abnormal left atrial (LA) size and function-is associated with an increased risk of atrial fibrillation, heart failure, and dementia. Central arterial stiffness is associated with increased atrial afterload and fibrosis and may be a risk factor for atrial myopathy. We examined the association of carotid-femoral pulse wave velocity (cfPWV) with LA function and assessed potential causal relationships. We included 2825 Atherosclerosis Risk in Communities (ARIC) study participants from Visit 5 (2011-2013). cfPWV was related to echocardiographic LA function continuously per 1-SD and categorically in quartiles. Mendelian randomization (MR) analysis was performed using U.K. Biobank-derived genetic variants associated with arterial stiffness index and cardiac magnetic resonance measures of LA function. When analyzed per SD increment (297.6 cm/s), higher cfPWV was significantly associated with lower LA reservoir and conduit strain (β = -0.53%, 95% CI [-0.81, -0.25] and β = -0.46%, 95% CI [-0.68, -0.25], respectively) after adjusting for demographics, clinical characteristics, systolic blood pressure, and left ventricular (LV) morphology and function. In MR analyses there was a non-significant inverse association of arterial stiffness index with LA total, passive, and active emptying fractions. Higher cfPWV is associated with lower LA reservoir and conduit strain, independent of systolic blood pressure and LV morphology and function. No evidence for a causal relationship between arterial stiffness index and alterations in LA function was found. Future studies should examine the prospective association of central arterial stiffness with LA function alterations.

Exploring the link between blood pressure variability and atrial fibrillation: current insights and future directions

Atrial fibrillation (AF) is the most common heart rhythm disorder, especially in people over the age of 50, which affects more than 40 million people worldwide. Many studies have highlighted the association between hypertension with the development of AF. Blood pressure variability (BPV) is a dynamic size obtained by recording blood pressure oscillations using specific readings and at specific time intervals. A multitude of internal and external factors shape BPV while at the same time constituting a common pathogenetic pathway with the development of AF. Until recently, BPV has been applied exclusively in preclinical and clinical studies, without significant implications in clinical practice. Indeed, even from the research side, the determination of BPV is limited to patients without AF due to doubts about the accuracy of its measurement methods in patients with AF. In this review, we present the current evidence on common pathogenic pathways between BPV and AF, the reliability of quantification of BPV in patients with AF, the prognostic role of BPV in these patients, and discuss the future clinical implications of BPV in patients with AF.

The relationship between ambulatory arterial stiffness index and incident atrial fibrillation

BACKGROUND

The ambulatory arterial stiffness index (AASI) is an indirect measure of blood pressure variability and arterial stiffness which are atrial fibrillation (AF) risk factors. The relationship between AASI and AF development has not been previously investigated and was the primary aim of this study.

METHODS

This was an observational cohort study of adults (aged 18-85 years) in sinus rhythm, who underwent 24-h ambulatory blood pressure monitoring (ABPM) for the diagnosis of hypertension or its control.

RESULTS

Eight hundred and twenty-one patients (49% men) aged 58.7 ± 15.3 years were followed up for a median of 4.0 years (3317 patient-years). In total, 75 patients (9.1%) developed ≥1 AF episode during follow-up. The mean AASI was 0.46 ± 0.17 (median 0.46). AASI values (0.52 ± 0.16 vs. 0.45 ± 0.17; p < .001) and the proportion of AASI values above the median (65.3% vs. 48.4%; p = .005) were greater among the patients who developed AF versus those that did not respectively. AASI significantly correlated with age (r = .49; 95% confidence interval: 0.44-0.54: p < .001). On Kaplan-Meier analysis, higher baseline AASI by median, tertiles, and quartiles were all significantly associated with AF development (X2: 10.13; p < .001). On Cox regression analyses, both a 1-standard deviation increase and AASI > median were independent predictors of AF, but this relationship was no longer significant when age was included in the model.

CONCLUSIONS

AASI is an independent predictor of AF development. However, this relationship becomes insignificant after adjustment for age which is higher correlated with AASI.

Association of Nighttime Systolic Blood Pressure With Left Atrial-Left Ventricular–Arterial Coupling in Hypertension

Objective

Hypertension (HT) induces left atrial (LA) and left ventricular (LV) dysfunction, and an increase in arterial stiffness. In this study, we investigated the association between LA-LV–arterial coupling and nighttime systolic blood pressure (BP) as well as BP circadian rhythm in essential hypertension.

Methods

We enrolled 290 HT patients. All subjects were evaluated by 2- dimensional speckle tracking echocardiography (2DSTE), ambulatory 24 h BP monitoring (ABPM), and brachial–ankle pulse wave velocity (PWV). According to BP patterns, these patients were divided into two groups, which included dippers (n = 111), patients with a >10% reduction in BP at nighttime; non-dippers (n = 179), patients with a <10% reduction in BP at nighttime. 2D-STE based LA and LV strains were studied and the following parameters were measured, LV global longitudinal strain (GLS), LA reservoir strain (LA_S−S), LA conduit strain (LA_S−E), and LA booster pump strain (LA_S−A). LA stiffness index (LASI) defined as the ratio of E/e′ to LA_S−S, and PWV-to-GLS ratio (PWV/GLS) were calculated to reflect LA-LV–arterial coupling. Furthermore, we also explored the correlation between LASI (or PWV/GLS) and ambulatory blood pressure indexes.

Results

Left atrial stiffness index was significantly higher in non-dippers [0.29 (0.21, 0.41)] than in dippers [0.26 (0.21, 0.33)] (P < 0.05). PWV/GLS was significantly higher in non-dippers [−80.9 (−69.3, −101.5)] than in dippers [−74.2 (−60.2, −90.6)] (P < 0.05). LA_S−S, LA_S−E, LA_S−A,and LV GLS were significantly lower in non-dippers than in dippers (P < 0.05). Multivariate linear regression analysis revealed that nighttime systolic BP was independently correlated with LASI and PWV/GLS, even adjusted for multiple clinical risk factors, LVMI, and LVEF.

Conclusions

The dipping pattern of BP was related to the abnormalities of myocardial mechanics and LA-LV–arterial coupling. However, absolute nocturnal systolic BP value maybe more important than BP circadian profile in the progression of abnormal LA-LV–arterial coupling.

Paradoxical association between lipoprotein cholesterol levels and left atrial function in hypertensive diabetic patients: A speckle tracking study

BACKGROUND

Studies have shown that subclinical left atrial (LA) dysfunction can be diagnosed with two-dimensional speckle tracking echocardiography (2D-STE). Although low-density lipoprotein cholesterol (LDL-C) is a risk factor for cardiovascular diseases, recent studies have reported a paradoxical relationship between LDL-C level and atrial fibrillation. In this study, we investigated the relationship between LDL-C levels and LA function.

METHODS

In 168 patients with the diagnosis of hypertension and diabetes, transthoracic echocardiography with LA 2D-STE was performed. The patients were then divided into two groups: normal LA-strain (n = 94) or impaired LA-strain (n = 74). The relationship between LDL-C and LA function was analyzed.

RESULTS

Patients with impaired LA-strain had higher body mass index (BMI) (p = 0.029), higher statin usage (p = 0.003), and lower LDL-C levels (p = 0.001) than patients with normal LA-strain. They also had lower left ventricle ejection fraction (LVEF) (p = 0.047) and higher E-wave velocity (mitral e, m/s) (p = 0.020). Multivariate logistic regression analysis showed that lower LDL-C (p = 0.034), higher BMI (p = 0.004), lower LVEF (p = 0.004), and higher E-wave velocity (p = 0.003) values were independently associated with impaired LA-strain. The area under the receiver operating curve of LDL-C in predicting impaired LA-strain was 0.645 (0.564-0.730, p < 0.05). LDL-C ≤ 112.5 mg/dl was found to be the optimal cut-off value with 74.5% sensitivity and 51.2% specificity in predicting impaired LA strain.

CONCLUSION

In patients with hypertension and diabetes, LDC-C levels are moderately but independently and paradoxically associated with impaired LA function assessed by 2D-STE.

FEV1 is independently related with impaired left atrial strain in chronic obstructive pulmonary disease patients: A speckle tracking study

BACKGROUND

Atrial fibrillation (AF) is common in chronic obstructive pulmonary disease (COPD) patients. It is known that impaired forced expiratory volume in 1 s (FEV1) is one of the risk factors of cardiovascular disease. Two-dimensional speckle tracking echocardiography (2D-STE) can detect deterioration of left atrial mechanical functions in the subclinical stage. We hypothesized that reduced lung functions, measured by FEV1 in COPD patients, may be associated with impaired left atrial (LA) mechanical functions.

OBJECTIVES

Present study included 127 consecutive COPD patients. We divided study population into two groups: patients with normal LA strain (n = 20) or with impaired LA strain (n = 107).

RESULTS

In univariate logistic regression analysis, age (p: 0.001), FEV1% (p < 0.001), FEV1 (p < 0.001), FEV1/forced vital capacity (FVC) (p: 0.014), white blood cell (p: 0.012), LA Max vol (p: 0.026), C-reactive protein (p :0.001), arterial oxygen pressure (PaO₂ ) (p: 0.019), arterial oxygen saturation (SO₂ ) (p: 0.021), left ventricle ejection fraction (LVEF) (p: 0.042), and mitral A-wave velocity (p: 0.017) were associated with impaired LA-strain. In multivariate logistic regression analysis, age (p: 0.043), FEV1 (p < 0.001), LA Max vol (p: 0.004), and LVEF (p: 0.004) were independently associated with impaired LA strain.

CONCLUSION

FEV1 is associated with impaired left atrial strain independently of arterial blood gas and left ventricular diastolic dysfunction parameters in COPD patients with preserved left ventricular systolic function.

Subclinical left ventricular systolic dysfunction by two-dimensional speckle-tracking echocardiography and its relation to ambulatory arterial stiffness index in hypertensive patients

BACKGROUND

Increased arterial stiffness is associated with cardiovascular morbidity and mortality among hypertensive patients.

OBJECTIVES

To assess the relationship between ambulatory arterial stiffness index (AASI) and subclinical left ventricular (LV) systolic dysfunction assessed by 2-D speckle-tracking echocardiography (STE).

METHODS

We enrolled 70 consecutive patients with hypertension. All patients were evaluated for parameters of ambulatory blood pressure monitoring (ABPM) including AASI. From those patients, 51 underwent conventional echocardiography as well as 2-D STE to assess for subclinical LV systolic dysfunction defined by global longitudinal strain (GLS) and global circumferential strain (GCS).

RESULTS

The mean age of the patients (n = 51) was 46.3 ± 12.3 years, women represented 59%. Study population were divided into two groups according to blood pressure control as defined by ABPM; controlled (n = 23), and uncontrolled (n = 28). Baseline characteristics were comparable between both groups. There were significant differences in both daytime and night-time mean ABPM (P < 0.05). Posterior wall thickness, as well as LV relative wall thickness were significantly higher in uncontrolled patients (P < 0.05 for each). AASI was significantly, but moderately correlated to GLS. Most ABPM parameters were elevated with the higher AASI values (AASI ≥0.5). Significantly more uncontrolled hypertensive patients were encountered as well. Interestingly, sex and AASI were predictors of impaired GLS by univariate linear regression analysis; however, AASI was the only independent predictor of impaired GLS on multivariate analysis (Beta = 0.3, CI = 0.2--12, and P = 0.04).

CONCLUSION

AASI might predict subclinical LV systolic dysfunction as assessed by global longitudinal strain. Further wide-scale studies should further explore this intriguing hypothesis.

Impaired left atrial mechanical functions as indicators for increased aortic root diameter in hypertensive and diabetic patients

OBJECTIVES

Previous studies have demonstrated that increased aortic root diameter (ARD) is frequently associated with increased cardiovascular (CV) events and is a predictor of stroke. Two-dimensional speckle tracking echocardiography (2D-STE) provides a better evaluation of left atrial (LA) functions. Left atrial mechanical dispersion is a useful predictor of new-onset atrial fibrillation (AF) independent of LA enlargement and dysfunction. We aimed to investigate the relationship between ARD and LA mechanical functions.

METHODS

The present study included 93 consecutive patients with hypertension and diabetes. The relationships between ARD and LA functions was evaluated.

RESULTS

Study population was divided into two groups according to the mean ARD values: group 1 (ARD ≤30.03 mm, n = 53) and group 2 (ARD >30.03 mm, n = 40). In group 2, age, LA max volume (vol), LA pre A vol, LA min vol, LA emptying fraction, LA active ejection fraction (EF), and LA expansion index were significantly higher compared to group 1. S‑LAs and SR-LAs (peak LA strain and strain rate, respectively, during ventricular systole) and S‑LAe and SR-LAe (peak early diastolic LA strain and strain rate, respectively) were significantly lower in group 2 compared to group 1. Age, LA max vol, LA pre A vol, LA min vol, LA emptying fraction, LA active EF, LA expansion index, S‑LAs, S‑LAe, SR-LAs, and SR-LAe were significantly associated with increased ARD. In multivariate logistic regression analysis, age, LA expansion index, and SR-LAe were independent predictors for ARD.

CONCLUSION

Impaired LA mechanical functions determined by speckle tracking methods are related with increased ARD independent of LV diastolic dysfunction.

Left atrial stiffness index as a marker of early target organ damage in hypertension

This study aimed to evaluate left atrial (LA) mechanics using two-dimensional speckle-tracking echocardiography (2DSTE) and investigate their correlations with measures of target organ damage (TOD) in hypertension. We enrolled 42 healthy controls (Group I) and 286 hypertension patients: Group II (n = 79) had an LA volume index (LAVI) <28 ml/m²; Group III (n = 92) had an LAVI ≥28 ml/m²; and Group IV (n = 115) had hypertension with left ventricular hypertrophy (LVH). We measured the following parameters: LA reservoir strain and strain rate (LA_S-S, LA_SR-S), LA conduit strain and strain rate (LA_S-E and LA_SR-E), and LA booster strain and strain rate (LA_S-A and LA_SR-A). The LA stiffness index (LASI) was defined as the ratio of early diastolic transmitral flow velocity/lateral mitral annulus myocardial velocity (E/e') to LA_S-S. We performed correlation and regression analyses of individual TOD with LA phasic functions, the LASI, and cardiovascular risk factors. Our findings showed that there was a trend toward a gradual increase in the LASI from controls to normal LA and enlarged LA patients and finally to hypertrophic LV patients. The LASI was significantly higher in Group III [0.28 (0.20, 0.38)] than in Group I [0.20 (0.16, 0.23)] and Group II [0.22 (0.18, 0.27)] and was the highest in Group IV [0.33 (0.26, 0.43)]. The LA reservoir and conduit function gradually decreased from Group I to Group IV. Multivariate regression analysis revealed that the LASI was independently correlated with individual TOD. In conclusion, abnormal LA mechanics precede LA enlargement and LVH, and an increased LASI can be used as a marker of early TOD in hypertension.

A cross-sectional study of the ambulatory central artery stiffness index in patients with hypertension

The present study aimed to investigate the characteristics of the ambulatory central artery stiffness index (AcASI) and its related factors. The association between AcASI and the left ventricular mass index (LVMI), and other factors related to atherosclerosis were explored.Patients with primary hypertension were enrolled into this study. Ambulatory central artery blood pressure (CABP) and ambulatory brachial artery blood pressure (BABP) were assessed using a Mobil-O-Graph NG hemomanometer, whereas AcASI and the ambulatory arterial stiffness index (AASI) were determined. LVMI was assessed by echocardiography.A total of 136 patients with primary hypertension were enrolled from May 2011 to January 2013 in Beijing Hospital. AcASI was significantly associated with AASI (r = 0.879, P < .001). AcASI was significantly lower than AASI (0.422 ± 0.302 vs 0.482 ± 0.270; P < .001). AcASI increased with age, ambulatory brachial mean blood pressure (MBP), and fasting glucose. AcASI was significantly associated with office pulse pressure (PP), ambulatory brachial PP, ambulatory central PP, and pulse wave velocity (PWV). AcASI, but not AASI, was significantly associated with LVMI. Receiver operator characteristic analysis indicated that AcASI and AASI could may be a predictor of left ventricular hypertrophy (LVH). Multiple regression analysis indicated that AcASI, chronic kidney disease, and hypertension course were associated with LVMI, but AASI was not.AcASI, which is obtained from ambulatory CABP monitoring, could be a new marker for the evaluation of atherosclerosis. AcASI may be stronger associated with LVH than AASI.

Association of central blood pressure with left atrial structural and functional abnormalities in hypertensive patients: Implications for atrial fibrillation prevention

Aims

Functional and structural abnormalities of the left atrium have been demonstrated to be clinically and prognostically significant in a range of cardiovascular disorders, increasing the risk of atrial fibrillation. Among the potential contributors to these aberrations, central arterial factors remain insufficiently defined. Accordingly, we sought to investigate the determinants of left atrium abnormalities in hypertension, with special focus on central haemodynamics.

Methods

In this retrospective, cross-sectional study, 263 patients (age 63.8 ± 8.0 years) with uncomplicated hypertension underwent echocardiography including left atrium strain (LAS) and volume analysis, and central haemodynamics assessment using radial tonometry.

Results

Patients were grouped depending on LAS and left atrium volume index (LAVI), using externally validated cutpoints (34.1% for LAS and 34 ml/m2for LAVI). The subset with lower LAS ( n = 124) demonstrated higher central (cPP) and brachial pulse pressure (bPP), ventricular- arterial coupling, left ventricular mass index (LVMI) and LAVI, and lower global left ventricular longitudinal strain and early diastolic tissue velocity (e′). Patients with higher LAVI ( n = 119) presented higher systolic blood pressure, cPP, bPP, central augmentation pressure, LVMI and E/e′ ratio and lower LAS. In multivariable analysis, cPP was independently associated with both LAS ( β = –0.22; p = 0.002) and LAVI ( β = 0.21; p = 0.003). No independent associations with left atrium parameters were shown for bPP.

Conclusion

Higher cPP is detrimentally associated with left atrium structural and functional characteristics, thus providing a possible pathophysiological link with the development of substrate for atrial fibrillation. Prophylaxis of atrial fibrillation might be another argument for consideration in the treatment strategy in hypertension targeted measures addressing central blood pressure.

Evaluation of the ambulatory arterial stiffness index in lead-exposed workers

OBJECTIVE

Lead exposure has been associated with various cardiovascular disorders. It may also cause increased inflammation and fibrosis in the arterial system resulting in an increase in arterial stiffness. In this study, the ambulatory arterial stiffness index (AASI), which is a technique that measures arterial stiffness, was evaluated in occupationally lead-exposed workers.

METHODS

In this cross-sectional study, 68 lead-exposed workers without known cardiovascular risk factors and 68 healthy subjects were evaluated according to the 24-hour ambulatory blood pressure monitorization (ABPM) profiles and blood and 24-hour urine lead levels. A regression slope of diastolic over systolic blood pressure (BP) was computed in each participant. AASI was defined as 1 minus the regression slope.

RESULTS

There were no significant differences in terms of baseline demographic, clinical, echocardiographic characteristics, and ABPM profiles between the groups. In lead-exposed workers, the mean age was 34.7±8.1 years, and the median blood and urine lead levels were 40.5 µg/dL and 34.9 µg/L, respectively. AASI was 0.42±0.10 in lead-exposed workers and 0.37±0.10 in control subjects (p=0.007). In correlation analysis, AASI was correlated with both blood (r=0.417, p<0.001) and urine lead (r=0.242, p=0.047) levels. In regression analysis, blood lead level was found to be associated with AASI (ß=0.086, p<0.001).

CONCLUSION

AASI, which is an indicator of arterial stiffness, was found to be higher in lead-exposed workers than in healthy individuals. Increased AASI may be considered an early sign of arterial involvement in case of lead exposure.

Investigation of the arterial stiffness and associated factors in patients with familial Mediterranean fever

Objective:

Because of the ongoing and recurring inflammatory state in familial Mediterranean fever (FMF), patients may experience a high risk of cardiovascular events. Our aim was to investigate the arterial stiffness and associated factors in patients with FMF.

Methods:

Sixty-nine consecutive FMF patients (including 11 females) and 35 controls (including 5 females) were enrolled in the study. The demographical, clinical, and laboratory data and genetic mutations of the patients were recorded. In the study, FMF patients according to the Tel-Hashomer criteria were included, whereas patients with other known inflammatory rheumatologic disease, atherosclerotic cardiovascular disease, hypertension, diabetes, those under the age of 18 years, or those refusing to participate in the study were excluded. Arterial stiffness measurements were performed using the TensioMed device (TensoMed Ltd, Budapest, Hungary).

Results:

The patient and control groups were similar in terms of the mean ages, BMIs, gender, systolic blood pressures, and smoking. FMF patients had a higher pulse wave velocity (PWV) (7.73±1.3 and 7.18±1.1 m/s; p=0.03) and lower brachial and aortic augmentation indexes (–64.6±14.6% and –54.6±25.9%, p=0.041 and 4.9±7.4% and 14.0±11.5%, p=0.025, respectively) compared with the controls. Thirty-one (45%) patients were in the “during-attack” state and had higher PWV (8.17±1.6 and 7.38±0.9 m/s; p=0.027) compared with the asymptomatic patients. PWV was correlated to serum CRP, WBC, ESR, fibrinogen, and neutrophil/lymphocyte ratios (r=0.666, 0.429, 0.441, 0.388, and 0.460, respectively). The genetic mutation and predominant attack type had no effect on arterial stiffness.

Conclusion:

FMF patients have increased arterial stiffness during attacks compared with asymptomatic patients and controls. The impaired arterial stiffness is correlated to the severity of the inflammatory state rather than to the attack type or genetic mutations.